ChanBeDu/relevant_section_length · Datasets at Hugging Face

27,037

105,533

46907+46908

Discharge summary

report+report

Admission Date: [**2137-12-27**] Discharge Date: [**2138-1-17**] Date of Birth: [**2074-12-26**] Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Tomato / Fish Product Derivatives / Peach / Citrus Derived / Egg Attending:[**First Name3 (LF) 1835**] Chief Complaint: Consulted for subdural empyema Major Surgical or Invasive Procedure: 1. Bilateral frontal sinus trephine. 2. Left external ethmoidectomy. 3. Left endoscopic maxillary antrostomy. History of Present Illness: HPI: 63yM with HTN who was transfered from [**Location (un) 620**] after being found down at 5am at his office bathroom. He was intially thought to have a stroke based on [**Location (un) 620**] CT and left sided hemiparesis. MRI done here shows a frontal sinusitis with resulting empyema along the falx cerebri and along the lateral right frontal lobe. Past Medical History: PMHx: HTN Social History: Social Hx: no tobacco, EtOH, drug use, single, lives with sister Family History: Family Hx: father died age 85yo, mother died 85yo w/ CHF, grandfather died of brain tumor Physical Exam: PHYSICAL EXAM: O: T: 101.7 BP: 138/63 HR: 92 R16 O2Sats 97RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs Intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Asleep, easily aroused, somnolent, mostly cooperative with exam, blunted affect. Orientation: Oriented to person, place, and date. Language: Speaks in short sentences with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 2 mm bilaterally. Visual fields are full to confrontation. No anopsia or neglect was noted III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone in bilateral upper extremities. Increased tone in RLE and normal tone LLE. No abnormal movements, tremors. Strength full power [**6-1**] throughout bilateral upper extremities. RLE with full strength thoughout. LLE with IP [**6-1**]; Q [**5-2**]; H [**5-2**]; G, [**Last Name (un) 938**], AT 0/5. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 Toes equivocal left and downgoing on right No Clonus Coordination: normal on finger-nose-finger, rapid alternating movements Pertinent Results: Labs: Coags 14.1/27.4/1.2 CBC 22.4>39.8<401 Diff 88.2/5.5/6/0.1/0.2 Lactate 2.6 Chem 132/3.5/92/23/41/2.0/142 CMP 9.1/2.7/3.3 UA Many bacteria, nitr neg, leuk tr, wbc 21-50, epi 0-2 [**12-27**]: HEAD CT: Again seen are hypodensities involving the bilateral frontal lobe, along the margins of the falx, with the right frontal lobe more severe than the left. There is also suggestion of a right subdural collection along the anterior right frontal lobe convexity. The ifferential diagnostic considerations includes an acute infarct or cerebritis. The ventricles and sulci are normal in caliber and configuration. There is complete opacification of the left maxillary sinus, with opacification of the left ethmoidal sinuses and frontal sinus. CTA: The carotid and vertebral arteries and their major branches are patent with no evidence of stenoses. CT perfusion images reveal slight delayed time to peak involving the right frontal lobe. However, no definite vascular territory abnormality is identified. IMPRESSION: 1) Hypodensity involving bilateral frontal lobes along the falx and the right inferior frontal lobe, with some suggestion of a small subdural fluid collection anterior to the right frontal lobe. Although these findings do not correspond to a major vascular territory and the CTA images do not reveal any vascular abnormalities, the differential diagnostic considerations still includes an acute infarct or may represent cerebritis. 2) Opacification of the left maxillary, ethmoidal, and frontal sinuses. [**12-27**]: MRA Head FINDINGS: There is a small extra-axial fluid collection along the interhemispheric fissure as well as along the anterior right frontal lobe. There is corresponding restricted diffusion involving this fluid collection. Given the restricted diffusion, this is suggestive that this fluid collection may be an empyema. Additionally, there is slight T2 hyperintensity of the frontal lobes bilaterally along the falx, which also exhibit restricted diffusion. These signal abnormalities are not in the expected location of a vascular territory, suggesting that these findings may represent cerebritis rather than an acute infarct. MRA images reveal that the intracranial vertebral and internal carotid arteries and their major branches are normal without evidence of stenosis, occlusion, or aneurysm formation. There is opacification of the left maxillary, ethmoid, and frontal sinuses. On T2- weighted images, there appears to be a linear structure that communicates with the opacified frontal sinus and the fluid collection anterior to the right frontal lobe. This may represent a site of abnormal communication leading to underlying empyema. IMPRESSION: 1. Abnormal small extra-axial fluid collection along the interhemispheric fissure as well as along the anterior right frontal lobe, with associated restricted diffusion. This is concerning for an empyema. 2. Slight T2 hyperintense signal of bilateral frontal lobes adjacent to the falx and inferior frontal lobes bilaterally. These lesions also exhibit restricted diffusion, and may represent cerebritis associated with the overlying empyema rather than an acute infarction. 3. Left maxillary, ethmoidal, frontal sinus opacification with abnormal linear structure connecting the frontal sinus with the abnormal fluid collection, suggestive of a possible source of communication. [**12-27**] SINUS CT: There is complete opacification of the left maxillary sinus with opacification of the left ostiomeatal unit, left anterior ethmoidal air cells as well as left frontal sinus. As seen on prior MR, there appears to be a site of potential abnormal communication involving the posterior aspect of the left frontal sinus with the extra-axial space (series 2, image 52). Additionally, there is mild mucosal thickening of the left sphenoid sinus as well as the right maxillary and anterior ethmoidal air cells. There is also mild mucosal thickening of the right frontal sinus. The right ostiomeatal unit appears to be patent. The cribriform plates are intact. The anterior clinoid processes are not pneumatized. Again seen is hypodensity of the frontal lobes bilaterally, along the margins of the falx as well as a hypodensity involving the inferior frontal lobes. However, this is better appreciated on MRI of the brain on the same day. IMPRESSION: 1. Opacification of the left maxillary sinus, left anterior ethmoidal air cells, as well as left frontal sinus, consistent with an obstructive sinusitis. There appears to be a potential site of communication involving the posterior left frontal sinus with the extra-axial space. 2. Mild mucosal thickening of the right frontal, right anterior ethmoidal, and right maxillary sinus. 3. Hypodensity involving bilateral frontal lobes along the margins of the falx seen on prior MRI, without significant change from earlier in the morning. [**12-28**] CT OF THE HEAD WITHOUT CONTRAST: Motion artifact limits the study. Since prior exam, there has been interval craniotomy. Pneumocephalus is seen, likely related to recent procedure. 4 mm leftward midline shift is noted and unchanged. The right subdural empyema has resolved. Hyperdense subdural collection in the right frontal convexity measuring up to 6 mm in (2 A, I 24) is new and likely represents small subdural hematoma. There is effacement of the right frontal sulci, which is unchanged. Hyperdense material along the falx is noted consistent with subdural hematoma. Unchanged appearance of the paranasal sinuses. IMPRESSION: 1. Interval craniotomy and drainage of right subdural empyema. 2. Hyperdense material along the falx cerebri and right frontal convexity consistent with subdural hematoma. 3. Small pneumocephalus likely related to recent procedure. Unchanged minimal leftward midline shift and effacement of the frontal sulci. [**12-29**] CT OF THE HEAD WITH AND WITHOUT IV CONTRAST: There is no significant change compared to one day prior. Right frontal craniotomy is again seen with a small amount of residual pneumocephalus. Small right subdural hemorrhage layering along the right frontal convexity and falx is unchanged. A 4-mm of midline shift is also unchanged. The ventricles are normal in size and configuration. Hypodensity along the parafalcine frontal cortex may represent subdural fluid and necrosis related to the patient's empyema. The paranasal sinuses again demonstrate diffuse opacification of the left maxillary sinus and the ethmoid air cells, as well as the frontal sinuses, which both contain drainage catheters. Contrast-enhanced imaging does not demonstrate any evidence of dural venous thrombosis. However, this is not a CT venogram, simply a routine post contrast CT scan. If there is concern of sinus thrombosis, an MR venogram, or a CT venogram are suggested. There is again mild hyperenhancement of the right frontal cortex, suggesting persistent cerebritis. IMPRESSION: 1. Relatively unchanged appearance of right subdural hemorrhage/fluid collection. Unchanged hypodensities in the right frontal parafalcine cortex related to the patient's cerebritis. 2. No evidence of dural venous thrombosis on routine post contrast CT. A CT venogram was not performed. 3. Bilateral frontal sinus drainage catheters in situ. [**1-4**] Non-contrast head CT. FINDINGS: Complex hypodensities within the frontal lobes bilaterally are again noted and appear larger in size compared to the previous examination. A large area of hypodensity tracking along the anterior falx measuring approximately 10 x 1.7 cm appears significantly larger compared to the previous examination. Low-attenuation material is seen to extend along the right cerebral convexity into the right middle cranial fossa. There is significant associated mass effect with shift of normally midline structures to the left by approximately 12 mm which is dramatically worse compared to the previous examination. There is significant mass effect on the right lateral ventricle with near-complete compression of the occipital [**Doctor Last Name 534**]. Subfalcine herniation is noted. A component of right uncal herniation is also probably present. Compared to the previous examination, there has been interval removal of bifrontal drains. The frontal sinuses appear nearly completely opacified with just a few areas pneumocephalus. Dense material is again noted within the left maxillary sinus, extending into the left ethmoid air cells. Mucosal thickening is also noted within the sphenoid sinus. Numerous staples overlie the right frontal bone and there is evidence of a right frontal craniotomy. There is also evidence of a right parietal craniotomy. IMPRESSION: Significant interval progression of right cerebral subdural collections, now extending along the anterior falx and into the middle cranial fossa. Significant associated mass effect including leftward shift of normally midline structures as well as subfalcine and uncal herniation. [**1-4**] MRI of the brain and MRV of the head. BRAIN MRI: There is increase in the interhemispheric collection identified, which extends to frontal to the occipital region, also extending along the posterior interhemispheric fissure and along the right side of the tentorium. The previously noted subdural collection along the right side frontoparietal region laterally has also slightly increased. There is now an extensive increased T2 signal seen in both frontal lobes adjacent to the interhemispheric fissure. These signal changes are new. However, previously noted slow diffusion in the brain parenchyma has resolved. This finding indicates development of vasogenic edema. Following gadolinium, extensive enhancement of the meninges is identified along the collections. The collection itself demonstrated an area of low signal in the interhemispheric region on T2 and FLAIR images. The persistent soft tissue changes seen in both frontal sinuses. There is mass effect on the right lateral ventricle, which is partially obliterated. There is also mass effect with partial obliteration of the basal cisterns. Soft tissue changes are seen in bilateral mastoid air cells. IMPRESSION: Increase in size of interhemispheric and convexity subdural collections with extensive enhancement along the margins indicative of empyema. There is persistent slow diffusion seen within these collections. However, presence of low signal intensity areas within the collection also indicatea an associated hemorrhagic component. The mass effect on the right lateral ventricle and obliteration of the right hemispheric sulci has increased since the previous study. There is now extensive vasogenic edema seen in both frontal lobes. MRV OF THE HEAD: The MRV of the head demonstrates slightly narrowed but patent superior sagittal sinus. The right transverse sinus, also demonstrate normal flow signal. The left transverse sinus is not well visualized on the projection images, but on the source images it is partially visualized and could be congenitally small. IMPRESSION: No definite evidence of superior sagittal sinus thrombosis. [**1-8**] CT of the head. FINDINGS: Again identified is an interhemispheric subdural collection along the right side of the falx with high density posteriorly indicative of blood products. Since the previous study the air within the collection has resolved. The collection is now better defined and visualized. Bifrontal hypodensity secondary to brain edema are again noted. A small right-sided frontal parietal convexity collection is also again identified. Compared to the prior study the mass effect has decreased with slight decrease in the midline shift. There is also decreased distortion of the brainstem indicative of improvement in uncal herniation. There is no hydrocephalus identified. There is no new area of hemorrhage seen. IMPRESSION: Decrease in mass effect compared to the prior CT of [**2138-1-5**] with improvement in uncal and subfalcine herniations. There is persistent interhemispheric collection identified better visualized on the current study, possibly secondary to resolution of edema in this right cerebral hemisphere. Convexity, small subdural collection is again identified as before. No new area of hemorrhage seen. [**1-9**] UPPER EXTREMITY ULTRASOUND WITH DOPPLER: Real-time ultrasound evaluation of the left upper extremity deep venous system using grayscale, color, and pulse wave Doppler demonstrates a clot in the cephalic vein extending more peripherally toward the elbow. No flow is identified in the cephalic vein, and the vein is not compressible. The basilic vein, brachial vein, and left internal jugular vein demonstrate normal flow and compressibility. IMPRESSION: Superficial venous clot in the cephalic vein. No evidence of deep venous thrombosis. [**1-10**] BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale Doppler and pulse wave son[**Name (NI) 1417**] of the bilateral lower extremities demonstrate non-compressibility, lack of flow and echogenic thrombus in the right lesser saphenous vein. The bilateral common femoral, superficial femoral, and popliteal veins demonstrate normal compressibility, augmentation, and flow. IMPRESSION: 1. Occlusive thrombus in the right lesser saphenous vein. 2. No evidence of thrombosis in the deep venous structures of bilateral lower extremities. [**1-11**] CT Head without Contrast: FINDINGS: Again identified is an interhemispheric subdural collection along the right side of the falx high-density posteriorly consistent with blood products, unchanged appearance from the prior study allowing for subtle differences in patient positioning. Interval resolution of the postoperative pneumocephalus. Bifrontal hypodensities secondary to edema without interval change. Small right-sided frontoparietal temporal extra-axial collection, not significantly changed. There is persistent 5-mm rightward shift of normally midline structures. Basal cisterns are not effaced. No new foci of hemorrhage. Persistent moderate paranasal sinuses opacification. Calcification of the mastoid air cells persists. The patient is status post right frontal and right posterior parietal craniotomies. Skin staples are in place. IMPRESSION: 1. No significant short interval change in persistent posterior interhemispheric collection and extra-axial collection overlying the right cerebral convexity. 2. Stable bifrontal edema with persistent 5 mm subfalcine herniation. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the ICU for a right frontal subdural empyema. On [**12-27**], he underwent a bilateral frontal sinus trephine, left external ethmoidectomy and a left endoscopic maxillary antrostomy by Dr. [**Last Name (STitle) 1837**] on the ENT service. On [**12-28**], Mr. [**Known lastname **] had three right-sided craniotomies for subdural empyema drainage. He was taken to the ICU postoperatively and was intubated. On [**12-28**] the patient was extubated and put on a face mask with an oral airway. the preliminary cultures on the brain abscess fluid from the drainage revealed streptococcus milleri growing in the sinus tissue samples. On [**12-29**] he started having problems with hypertension requiring a labetolol drip. On [**12-30**], a Dobhoff tube was placed for enteric nutrition. On [**12-31**] a PICC line was placed and the patient opened his eyes spontaneously for the first time after his surgery. On [**1-3**], the infectious diseases team recommended keeping the patient on at least 4 weeks of antibiotics. Mr. [**Known lastname **] became tachypneic to the 40s on [**1-3**] and was reintubated for airway protection. He also had a spike in his temperature at that time to a max of 102 degrees farenheit. On [**1-4**], a repeat CT of the head was worse. An MRI was performed which showed an empyema. An MRV showed no evidence of a venous thrombus in the brain. On [**1-5**], Mr. [**Known lastname **] was taken back to the OR for a sterotactic drainage of the abscess. 40cc of purulent material was drained at that time. On [**1-6**], Mr. [**Known lastname **] was started on Keppra for seizure prophylaxis. On [**1-8**], the patient was taken back to the OR for evacuation of the remaining abscess fluid. The preliminary results of the abscess fluid revealed no growth of any micro organisms. Mr. [**Known lastname **] also had another PICC line placed at this time for antibiotic access. On [**1-9**] a left upper extremity ultrasound revealed a superficial venous clot in the cephalic vein without evidence of deep venous thrombosis. On this same day, Dr. [**Last Name (STitle) **] arranged for a family meeting but the family was not available to meet due to inclement weather. On [**1-11**], purulent material was noted to be coming out from his penis, around the foley catheter. The catheter was removed and a new one was put in place. Also on [**1-11**], Mr. [**Known lastname **] had a bilateral lower extremity ultrasound which revealed an occlusive thrombus in the right lesser saphenous vein but no evidence of thrombosis in the deep venous structures of bilateral lower extremities. The patient was extubated on this day and did well off of the ventilator. Mr. [**Known lastname **] was deemed appropriate to transfer to the floor on [**1-13**]. He was given a bedside swallow study which determined that he could have a thin pureed diet with 1:1 supervision at all times. Subsequent S/S evaluation determined that he was safe to tolerate regular diet, which he tolerated for several days prior to discharge. On [**1-13**] the ID team recommended starting IV flagyl for positive c-diff infection. He will be on the IV form for 14 days and then will be switched back to the PO form of flagyl. The patient's staples were removed on [**1-13**] as well. To date all of the cultures are negative except for the positive clostridium difficile for which the patient is being treated. Pt with slightly elevated BPs upon arrival to floor - lisinopril added, with inmprovement in readings. Family and patient are aware and agree with the transfer to [**Hospital3 **]. Medications on Admission: All: Sulfa Medications prior to admission: Atenolol, ASA Discharge Medications: 1. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours): stop on [**1-26**] then change dose to PO. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**] Drops Ophthalmic PRN (as needed). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 8. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): 1 Q6 hour through [**2138-2-6**] then change to Q8 then stop on [**2138-2-19**]. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: [**1-29**] MLs Intravenous DAILY (Daily) as needed. 12. Ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous twice a day: STOP on [**2138-2-22**]. 13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q 12H (Every 12 Hours): Titrate to trough of 20 will continue to [**2138-2-22**]. 14. Outpatient Lab Work Weekly CBC, BUN, Creatinine, AST,ALT,Alk phos, LDH please fax results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 432**] 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Subdural Empyema Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Follow up in the [**Hospital **] clinic: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2138-2-24**] 9:00 Need head CT on [**1-29**] and [**2-12**] call radiology [**Telephone/Fax (1) 11**] to confirm time Follow up with Dr [**Last Name (STitle) **] in 4 weeks call [**Telephone/Fax (1) 2731**] for an appointment YOU WILL Need a CT with contrast at that time Antibiotic Instructions: vancomycin 1g IV q8h through at least [**2138-2-22**]; goal trough 15-20 ceftriaxone 2g IV q12h through at least [**2138-2-22**] Flagyl 500 mg PO q8h through at least [**2138-2-22**] PO vancomycin 125 mg PO q6h through [**2138-2-6**], then 125 mg PO q8h through [**2138-2-19**], then 125 mg PO q12h through [**2138-2-26**], then stop. Laboratory Monitoring Required weekly safety labs (CBC, BUN/Cr, LFTs) and vanco trough to be drawn and results faxed to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 432**]. All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 6313**]. All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at Completed by:[**2138-1-17**] Admission Date: [**2138-1-18**] Discharge Date: [**2138-1-18**] Date of Birth: [**2074-12-26**] Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Tomato / Fish Product Derivatives / Peach / Citrus Derived / Egg Attending:[**First Name3 (LF) 1835**] Chief Complaint: discharge to rehab - felt too unstable Major Surgical or Invasive Procedure: none History of Present Illness: 63yM with HTN who was transfered from [**Location (un) 620**] after being found down at 5am at his office bathroom. He was intially thought to have a stroke based on [**Location (un) 620**] CT and left sided hemiparesis. MRI done here shows a frontal sinusitis with resulting empyema along the falx cerebri and along the lateral right frontal lobe. Past Medical History: PMHx: HTN Social History: Social Hx: no tobacco, EtOH, drug use, single, lives with sister Family History: Family Hx: father died age 85yo, mother died 85yo w/ CHF, grandfather died of brain tumor Physical Exam: T: 101.7 BP: 138/63 HR: 92 R16 O2Sats 97RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs Intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Asleep, easily aroused, somnolent, mostly cooperative with exam, blunted affect. Orientation: Oriented to person, place, and date. Language: Speaks in short sentences with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 2 mm bilaterally. Visual fields are full to confrontation. No anopsia or neglect was noted III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone in bilateral upper extremities. Increased tone in RLE and normal tone LLE. No abnormal movements, tremors. Strength full power [**6-1**] throughout bilateral upper extremities. RLE with full strength thoughout. LLE with IP [**6-1**]; Q [**5-2**]; H [**5-2**]; G, [**Last Name (un) 938**], AT 0/5. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 Toes equivocal left and downgoing on right No Clonus Coordination: normal on finger-nose-finger, rapid alternating movements Pertinent Results: [**2138-1-18**] 01:15AM GLUCOSE-120* UREA N-13 CREAT-0.9 SODIUM-130* POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-24 ANION GAP-13 [**2138-1-18**] 01:15AM ALT(SGPT)-27 ALK PHOS-70 AMYLASE-76 TOT BILI-0.4 [**2138-1-18**] 01:15AM LIPASE-56 [**2138-1-18**] 01:15AM ALBUMIN-2.8* CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-2.0 [**2138-1-18**] 01:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2138-1-18**] 01:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2138-1-18**] 01:15AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2138-1-17**] 07:15AM GLUCOSE-111* UREA N-13 CREAT-0.9 SODIUM-135 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14 [**2138-1-17**] 07:15AM CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-2.0 [**2138-1-17**] 07:15AM VANCO-20.3* [**2138-1-17**] 07:15AM WBC-10.8 RBC-3.36* HGB-10.7* HCT-32.5* MCV-97 MCH-31.9 MCHC-33.0 RDW-15.3 [**2138-1-17**] 07:15AM NEUTS-71.6* LYMPHS-14.0* MONOS-7.5 EOS-6.1* BASOS-0.8 [**12-27**]: HEAD CT: Again seen are hypodensities involving the bilateral frontal lobe, along the margins of the falx, with the right frontal lobe more severe than the left. There is also suggestion of a right subdural collection along the anterior right frontal lobe convexity. The ifferential diagnostic considerations includes an acute infarct or cerebritis. The ventricles and sulci are normal in caliber and configuration. There is complete opacification of the left maxillary sinus, with opacification of the left ethmoidal sinuses and frontal sinus. CTA: The carotid and vertebral arteries and their major branches are patent with no evidence of stenoses. CT perfusion images reveal slight delayed time to peak involving the right frontal lobe. However, no definite vascular territory abnormality is identified. Brief Hospital Course: Pt was readmitted after patient felt unstable by rehab. pt returned to [**Location **] with above exam - stable from discharge. pt was observed overnight - slept well with return to above exam upon awakening in am. Discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] who felt comfortable with his discharge back to [**Hospital1 **]. Medications on Admission: Discharge Medications: 1. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours): stop on [**1-26**] then change dose to PO. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**] Drops Ophthalmic PRN (as needed). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 8. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): 1 Q6 hour through [**2138-2-6**] then change to Q8 then stop on [**2138-2-19**]. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: [**1-29**] MLs Intravenous DAILY (Daily) as needed. 12. Ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous twice a day: STOP on [**2138-2-22**]. 13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q 12H (Every 12 Hours): Titrate to trough of 20 will continue to [**2138-2-22**]. 14. Outpatient Lab Work Weekly CBC, BUN, Creatinine, AST,ALT,Alk phos, LDH please fax results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 432**] 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: Discharge Medications: 1. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours): stop on [**1-26**] then change dose to PO. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**] Drops Ophthalmic PRN (as needed). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 8. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): 1 Q6 hour through [**2138-2-6**] then change to Q8 then stop on [**2138-2-19**]. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: [**1-29**] MLs Intravenous DAILY (Daily) as needed. 12. Ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous twice a day: STOP on [**2138-2-22**]. 13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q 12H (Every 12 Hours): Titrate to trough of 20 will continue to [**2138-2-22**]. 14. Outpatient Lab Work Weekly CBC, BUN, Creatinine, AST,ALT,Alk phos, LDH please fax results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 432**] 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Subdural Empyema Discharge Condition: stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Follow up in the [**Hospital **] clinic: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2138-2-24**] 9:00 Need head CT on [**1-29**] and [**2-12**] call radiology [**Telephone/Fax (1) 11**] to confirm time Follow up with Dr [**Last Name (STitle) **] in 4 weeks call [**Telephone/Fax (1) 2731**] for an appointment YOU WILL Need a CT with contrast at that time Completed by:[**2138-1-18**]

[ "008.45", "272.0", "348.8", "584.9", "342.90", "324.0", "461.8", "401.9", "348.4" ]

icd9cm

[ [ [] ] ]

[ "22.2", "22.9", "01.31", "22.63", "01.09" ]

icd9pcs

[ [ [] ] ]

33870, 33940

30118, 30508

25927, 25933

34001, 34009

28216, 29279

35395, 35874

26446, 26538

32225, 33847

33961, 33980

30534, 30534

34033, 35372

26553, 26792

21049, 21065

25849, 25889

25961, 26314

27082, 28197

29289, 30095

26807, 27066

26336, 26347

26363, 26430

11,019

194,301

51402

Discharge summary

report

Admission Date: [**2132-5-28**] Discharge Date: [**2132-6-21**] Date of Birth: [**2073-11-30**] Sex: M Service: MEDICINE Allergies: Rofecoxib Attending:[**First Name3 (LF) 12174**] Chief Complaint: Hypotension. Major Surgical or Invasive Procedure: Thoracentesis ([**6-6**] and 18, right and left side, respectively) Pericardial window ([**6-10**]) Intubation ([**6-9**]) History of Present Illness: This is a 58-year-old male with with a history of liver-kidney [**Month (only) **] in [**2124**] for chronic hepatitis C cirrhosis, HL, HTN, emphysema, OSA, and A fib who presented with SOB, lightheadedness, emesis, vague visual hallucinations, finger twicthing, and arm weakness. For the last few days prior to admission, patient reports the following symptoms: dizziness, dropping things due to twitching in both hands, decrease inappetite, decrease fluid intake, more concentrated urine output, mild dull headache, blurry vision, and soreness in the lungs when taking deep breaths. He reports for the last several months he's had SOB when walking even a half block. He needs to stop and rest to catch his breath. Twice in the last two days he's continued to walk despite the SOB and had visual hallucinations (one of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] that was not there and one of a dog that was not there). On arrival to the ED VS were T 96.8 BP 84/48 HR 55 RR 16 02 sat 97% on 3L. While in the ED BP dropped to 71/40 with improvement of SBP to the low 100s after IVF. He had a total of 3L of NS in the ED. His neuro exam was non-focal in the ED and CT of the head was negative. A CT abdomen and pelvis was notable for a moderate pericardial effusion, pulsus was 4, and echo showed no evidence of tamponade. A CXR had some questionable haziness and patient given zosyn 4.6g IV x1 and vancomycin 1g IV x1. Two peripheral IVs were placed. Creatinine was notably 4.5 (up from 1.5) and UA was negative. Nephrology [**Last Name (NamePattern4) **] was consulted and requested a tacrolimus trough and urine lytes. Hepatatology and [**Last Name (NamePattern4) **] surgery were made aware of the admission. Vitals prior to transfer were: 57 104/57 RR14 96% on 3L. Review of systems: Pertinent negative include: no new tingling, no slurring of speech, no one sided weakness in the legs (felt more weak recently), no dysuria, no hematuria, (+) Per HPI, + dull mild headache, + chronic occasional diarrhea, + chronic hip pain (-) Denies fever, chills, night sweats, cough, palpitations, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency. Denies arthralgias or myalgias except per HPI. Denies rashes or skin changes. Past Medical History: 1. S/p liver-kidney [**Last Name (NamePattern4) **] in [**2124**] for chronic hepatitis C cirrhosis. 2. Hypercholesterolemia. 3. Anxiety. 4. Hypertension. 5. History of emphysema, details unclear. 6. Obstructive sleep-disordered breathing, prescribed CPAP. 7. History of atrial fibrillation on flecainide. 8. History of intravenous drug use in the [**2091**]. 9. Tobacco addiction. Social History: Patient is divorced and has an 18-year-old daughter. [**Name (NI) **] lives alone. He previously worked in construction and did some demolition in the past, cutting asbestos pipes without wearing a mask. He has a 40-pack-year smoking history and more recently cut down to half pack per day. He has a history of alcohol abuse, sober since approximately 10 years, and IV drug use and sober since the [**2091**]. Family History: His mother had heart disease and possibly died of emphysema. His father died of an myocardial infarction (MI). He has a brother who died of kidney failure, and a sister who is living with colitis. Physical Exam: PHYSICAL EXAM (Upon evaluation in MICU on [**5-30**]) T: 99.5, BP: 116/67, HR: 70, SP02: 97%2 LPM GENERAL: Alert, oriented, no acute distress SKIN: [**Doctor Last Name **], sallow color HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear NECK: Supple LUNGS: Clear to auscultation bilaterally anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, or gallops ABDOMEN: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, surgical scars well-healed EXTREMITIES: Warm, well perfused, 2+ pulses, feet are tender to palpation (patient states this is chronic and because of his long history of drinking). Pertinent Results: Labs at Admission: [**2132-5-28**] 07:00PM BLOOD WBC-6.4 RBC-4.42* Hgb-12.6* Hct-38.4* MCV-87 MCH-28.5 MCHC-32.7 RDW-15.5 Plt Ct-190 [**2132-5-28**] 07:00PM BLOOD Neuts-70.1* Lymphs-18.9 Monos-9.8 Eos-1.1 Baso-0.3 [**2132-5-28**] 07:28PM BLOOD PT-16.0* PTT-32.9 INR(PT)-1.4* [**2132-6-8**] 01:15PM BLOOD ESR-10 [**2132-5-28**] 07:00PM BLOOD Glucose-142* UreaN-75* Creat-4.5*# Na-133 K-4.5 Cl-93* HCO3-25 AnGap-20 [**2132-5-28**] 07:00PM BLOOD ALT-8 AST-17 AlkPhos-66 TotBili-0.3 [**2132-5-28**] 07:00PM BLOOD Lipase-35 [**2132-5-29**] 05:17AM BLOOD Calcium-8.6 Phos-6.5*# Mg-1.7 [**2132-6-1**] 06:10AM BLOOD calTIBC-307 Ferritn-229 TRF-236 [**2132-6-9**] 04:48PM BLOOD VitB12-466 Folate-10.9 [**2132-5-29**] 05:17AM BLOOD TSH-1.7 [**2132-5-28**] 07:00PM BLOOD T4-4.1* [**2132-5-29**] 05:17AM BLOOD Free T4-0.72* [**2132-5-31**] 06:16PM BLOOD dsDNA-NEGATIVE [**2132-6-8**] 01:15PM BLOOD CRP-113.0* [**2132-6-8**] 01:15PM BLOOD [**Doctor First Name **]-NEGATIVE [**2132-6-19**] 08:46AM BLOOD RheuFac-8 [**2132-6-13**] 03:20AM BLOOD PEP-TRACE ABNO IgG-1074 IgA-135 IgM-27* IFE-TRACE MONO [**2132-5-31**] 04:35AM BLOOD C3-136 C4-26 [**2132-5-29**] 05:17AM BLOOD tacroFK-6.5 Labs at Discharge: [**2132-6-21**] 05:00AM BLOOD WBC-6.2 RBC-3.96* Hgb-10.7* Hct-33.2* MCV-84 MCH-27.1 MCHC-32.3 RDW-15.8* Plt Ct-330 [**2132-6-18**] 05:18AM BLOOD Neuts-58.7 Lymphs-30.0 Monos-6.6 Eos-4.2* Baso-0.5 [**2132-6-21**] 05:00AM BLOOD PT-16.1* PTT-31.6 INR(PT)-1.4* [**2132-6-21**] 05:00AM BLOOD Glucose-96 UreaN-11 Creat-1.1 Na-139 K-4.7 Cl-104 HCO3-27 AnGap-13 [**2132-6-21**] 05:00AM BLOOD ALT-39 AST-51* LD(LDH)-235 AlkPhos-66 TotBili-0.6 [**2132-6-21**] 05:00AM BLOOD Albumin-2.9* Calcium-8.6 Phos-4.0 Mg-1.6 [**2132-6-18**] 05:18AM BLOOD tacroFK-8.2 Radiology: Transthoracic echocardiogram ([**2132-6-16**]): The estimated right atrial pressure is 0-5 mmHg. Right ventricular chamber size and free wall motion are normal. There is a small-moderate circumferential pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elementswith nearly no free flowing elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2132-6-13**], the findings are similar. Unilateral upper extremity doppler ultrasound ([**2132-6-16**]): Echogenic linear structure, the appearance of which is suggestive of a foreign body or less likely a retracted clot within the right basilic vein in the right upper arm. Further imaging with plain film radiograph is suggested. X-ray, right upper extremity ([**2132-6-17**]): Unremarkable appearance of the right elbow. Vascular calcification. CXR ([**2132-6-18**] --> at discharged): A left subclavian line tip is at the junction of the brachiocephalic vein and SVC. The two endovascular stents: SVC and right subclavian vein catheter are in place. Cardiomediastinal silhouette is grossly unchanged. There is still present left small-to-moderately and right small pleural effusion that appears to be improved compared to [**2132-6-15**]. There is also some improvement in the bibasilar aeration, in particular in the left lower lung. Compared to the study from the beginning of [**Month (only) **] ([**6-3**] or [**6-5**] for example), cardiac silhouette appears to be decreased most likely due to at least partial resolution of pericardial effusion. There is no pneumothorax. Brief Hospital Course: Mr. [**Known lastname 2198**] is a very nice 58-year-old gentleman admitted with SOB, lightheadedness, emesis, and vague visual hallucinations, found to be hypotensive, in acute renal failure, and with pericardial and bilateral pleural effusions. HYPOTENSION: He was mildly fluid responsive in the ED from SBP of 80s to 90s-100s. Lactate was 0.9 and WBC was normal. Urine lytes showed FeNa - 0.89, consistent with a pre-renal picture. Once in the ICU, arterial line was placed and he was given 3L NS with good response. His home dilt, doxazosin, flecainide, methocarbamol, metoprolol, oxycontin were held in the setting of hypotension. His pressures normalized quickly. His home lopressor was kept on-board given his a-fib with RVR (see below). Hypotension was thought to be secondary to hypovolemia. Upon transfer to the floor, patient remained hemodynamically stable, with systolic pressures in the 100s-120s. AFIB WITH RVR: Patient's home meds were initially held on admission given hypotension. He developed a-fib with RVR, which was difficult to control. On the floor, cardiology was consulted who helped titrate his regimen. Upon transfer to the MICU, patient was on: dilt 60mg QID, flecanide 50mg [**Hospital1 **], and metoprolol 50mg [**Hospital1 **]. The metoprolol had been down-titrated in setting of obstructive pulmonary disease, and concern for excessive beta-blockade. Mr. [**Known lastname 2198**] will need to follow-up with Dr. [**Last Name (STitle) **] for outpatient management of afib with RVR. His anti-arrhythmic regimen has been adjusted and current doses inclued metoprolol tartrate 150mg twice daily, flecainide 100mg twice daily, and diltiazem SR 240mg once daily. [**Last Name (un) **]: Patient is s/p kidney [**Last Name (un) **] in [**2124**]. Creatinine of 4.5 up from 1.5 on [**5-5**]. Urine lytes consistent with pre-renal etiology. Creatinine improved with IV fluids (down to 2.4 on [**5-30**]). On the floor, creatinine continued to be in flux, but was usually fluid responsive and trended to baseline of 1.1 at time of discharge. PERICARDIAL EFFUSION / PLEURAL EFFUSIONS: Unclear etiology. Cardiology was consulted who recommended serial echos to evaluate evolution/resolution of effusion. Daily pulsus was checked, usually ranging from 16-22. Pericardial fluid did not seem to affect patient in any signficant manner; differential diagnosis included: malignant, infectious, and rheumatologic. The plan was to perform pericardiocentesis for fluid analysis which unfortunately did not reveal an underlying etiology. Patient also underwent right and left-sided thoracenteses, for diagnostic and therapeutic purposes. Extensive work-up for autoimmune causes, infectious (including TB, by way of serum quantinterferon gold and pericardial fluid mycobacterial culture) causes, and malignant causes (pericarial tissue biopsy, pericardial and pleural fluid cytologies), was negative. The patient will follow-up with his outpatient cardiologist for repeat TTE in 2 weeks. Additionally, he will see Dr. [**Last Name (STitle) 724**] in infectious diseases clinic for follow-up of multiple infectious tests, still pending at time of discharge. Imaging at time of discharge shows a small pericardial effusion with no tamponade physiology on echocardiogram and small right-sided pleural effusion on CXR. VISUAL HALLUCINATIONS/CHANGE IN MENTAL STATUS: No focal neuro deficits. Originally thought to be from medications such as gapapentin, muscle relaxants, and oxycodone. These medications were discontinued upon admission to ICU, and they have continued to be held given concern of over-sedation and hypercarbic respiratory failure. His mental status is back to baseline - AAOx3, no encephalopathy or cognitive or concentration deficits. RIGHT UPPER EXTREMITY SWELLING: patient has known SVC and right subclavian vein stents. Vascular was consulted and recommended for outpatient follow-up for consideration of CT venogram. PROPHYLAXIS: subcutaneous heparin. CODE STATUS: full code. Medications on Admission: -ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - two puffs(s) inhaled every 4-6 hours as needed for SOB/wheezes -DILTIAZEM HCL - 180 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily -DOXAZOSIN - 8 mg Tablet - 1 Tablet(s) by mouth once a day -FENOFIBRATE - (Prescribed by Other Provider: [**Name Initial (NameIs) 3390**]) - 54 mg Tablet 1 Tablet(s) by mouth once a day -FLECAINIDE - 50 mg Tablet - 1 Tablet(s) by mouth twice daily -GABAPENTIN - (Pt has not been taking as prescribed) - 300 mg Capsule - one Capsule(s) by mouth twice a day -GEMFIBROZIL [LOPID] - 600 mg Tablet - 1 Tablet(s) by mouth twice a day -LOVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth qpm -METHOCARBAMOL - 750 mg Tablet - one Tablet by mouth twice daily -METOPROLOL TARTRATE - (Prescribed by Other Provider) - 100 mg Tablet - 1.5 Tablet(s) by mouth twice a day -MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - 1 Tablet(s) by mouth twice a day -OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day -OXYCODONE [OXYCONTIN] - 20 mg Tablet Sustained Release 12 hr - 1 Tablet(s) by mouth three times a day as needed for prn pain -RIFAXIMIN [XIFAXAN] - 200 mg Tablet - 1 Tablet(s) by mouth three times a day X 14 days -SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day -TACROLIMUS [PROGRAF] - 1 mg Capsule - 1 Capsule(s) by mouth twice -ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) -CALCIUM CARBONATE - 500 mg Tablet, Chewable - 1 Tablet(s) by mouth three times a day take 1 hour before or 2 hours after Iron -CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 400 unit Tablet - 1 Tablet(s) by mouth once a day -MULTIVITAMIN [DAILY-VITE] - Tablet - 1 Tablet(s) by mouth once a day -NICOTINE - 14 mg/24 hour Patch 24 hr - one patch to skin daily -Spiriva 18 mcg daily Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-29**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. Diltiazem HCl 240 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 3. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Disp:*120 Tablet(s)* Refills:*2* 4. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Methocarbamol 750 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Metoprolol Tartrate 100 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*2* 7. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 15. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 16. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. 17. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 18. CPAP Mask headgear tubing cushion filters. DOS: [**2132-6-20**] x1 year Diagnosis of obstructive sleep apnea 19. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnoses --acute kidney injury secondary to hypovolemia from diarrhea --atrial fibrillation with rapid ventricular response --bilateral pleural effusions and pericardial effusion, etiology unknown Seconday Diagnoses --chronic hepatitis C cirrhosis s/p liver-kidney [**Hospital **] [**2124**] --hypercholesterolemia --anxiety --hypertension --chronic obstructive pulmonary disease --obstructive sleep apnea --atrial fibrillation --tobacco use Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for low blood pressure and acute injury to the kidneys. During the admission you were noted to have fluid collections around the heart and lungs. These collections were drained, and the fluid was sent for microbiology and tumor markers. Unfortunately, no cause could be found for the fluid collections despite an extensive workup for infectious, autoimmune, and other causes. There are a couple tests still pending at the time of discharge, and these should be followed up by your primary care physician. Your symptoms have improved after the fluid was removed, and we believe that you are well enough to go home. Please note your follow-up appointments below. We made the following changes to your medicines: --we INCREASED the dose of diltiazem to 240mg once daily --we INCREASED the dose of flecainide to 100mg twice daily --we STOPPED doxasozin; please restart this at the discretion of your primary care provider [**Name10 (NameIs) **] STOPPED gabapentin due to concern of oversedation; please restart this at the discretion of your primary care provider [**Name10 (NameIs) **] STOPPED fenofibrate; please restart this at the discretion of your primary care provider [**Name10 (NameIs) **] STOPPED gemfibrozil; please restart this at the discretion of your primary care provider [**Name10 (NameIs) **] STOPPED oxycodone due to concern of oversedation; please restart this at the discretion of your primary care provider Followup Instructions: --ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2132-7-10**] 2:00 --[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 285**] Date/Time:[**2132-7-11**] 10:30 --[**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2132-8-21**] 11:40 --please call the clinic of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] [**Telephone/Fax (1) 457**] to schedule an appointment in infectious diseases clinic in the next one to two weeks --please call the office of Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3121**] to schedule an appointment in vascular surgery clinic to discuss possible venogram for the right arm swelling Completed by:[**2132-6-21**]

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icd9cm

[ [ [] ] ]

[ "38.91", "37.0", "34.91", "88.72", "96.72", "96.04", "37.12" ]

icd9pcs

[ [ [] ] ]

15717, 15775

7918, 11307

285, 410

16271, 16271

4498, 5670

17907, 18770

3577, 3775

13882, 15694

15796, 16250

11989, 13859

16422, 17884

3790, 4479

2260, 2725

233, 247

5690, 7895

438, 2241

16286, 16398

2747, 3130

3146, 3561

17,784

171,221

28332

Discharge summary

report

Admission Date: [**2123-10-4**] Discharge Date: [**2123-10-11**] Date of Birth: [**2065-9-27**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: L1-2 corpectomy with T12-L3 fusion Posterior fusion T10-L4 History of Present Illness: Ms. [**Known lastname **] was seen previously in the hospital for L1-2 osetomyelitis. At that time she underwent a laminectomy with subsequent IV antibiotics. Her back pain continued and it was planned to have a two level corpectomy with posterior stabilization in addition to long term antibiotics. She presents for this surgicla intervention. Past Medical History: 1. Depression 2. Anxiety 3. Right toe cellulitis s/p debridement in [**5-27**] 4. Osteoarthritis 5. s/p dental surgeries 6. s/p tonsillectomy 7. s/p laminectomy L1-2 Social History: Lives with husband, no children. Retired from teaching English after 30 years. Smoked 1ppd for approx 24 years, but quit in [**2106**]. No IV drug use. Drinks approx. 2 glasses of wine each night. Family History: Noncontributory Physical Exam: NAD RRR CTA B Abd soft NT/ND BUE- good strength at biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics; sensation intact in all dermatomes; reflexes intact at biceps, triceps and brachioradialis BLE- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact distally; reflexes intact at quads and achilles; + pain to palpation lumbar spine Pertinent Results: [**2123-10-8**] 04:15AM BLOOD WBC-8.6 RBC-2.93* Hgb-9.6* Hct-27.4* MCV-94 MCH-32.8* MCHC-35.0 RDW-16.5* Plt Ct-300 [**2123-10-6**] 10:25PM BLOOD WBC-13.5* RBC-3.44* Hgb-11.3* Hct-31.7* MCV-92 MCH-32.8* MCHC-35.6* RDW-16.8* Plt Ct-286 [**2123-10-6**] 06:24AM BLOOD WBC-13.8* RBC-2.92* Hgb-9.6* Hct-28.7* MCV-98 MCH-33.1* MCHC-33.6 RDW-15.9* Plt Ct-320 [**2123-10-4**] 08:07PM BLOOD WBC-13.1*# RBC-3.17* Hgb-10.5* Hct-31.6* MCV-100* MCH-33.2* MCHC-33.4 RDW-16.2* Plt Ct-329 [**2123-10-8**] 04:15AM BLOOD Plt Ct-300 [**2123-10-6**] 10:25PM BLOOD Plt Ct-286 [**2123-10-4**] 08:07PM BLOOD Plt Ct-329 [**2123-10-8**] 04:15AM BLOOD Glucose-148* UreaN-5* Creat-0.3* Na-137 K-3.5 Cl-106 HCO3-24 AnGap-11 [**2123-10-6**] 06:24AM BLOOD Glucose-137* UreaN-6 Creat-0.3* Na-134 K-3.9 Cl-102 HCO3-25 AnGap-11 [**2123-10-8**] 04:15AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.6 [**2123-10-6**] 10:25PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.7 Brief Hospital Course: Ms. [**Known lastname **] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a two level corpectomy at L1-2 with posterior stabilization. She was informed and consented for the procedures and elected to proceed. Please see Operative Notes for procedure in detail. Post-operatively she was administered antibiotics and pain medication. She was fitted for a TLSO brace and was required to place the brace while in a supine position. Physical therpay saw her and recommended rehabilitation. She had a PICC line placed during her previous hospitalization and chest x-rays were obtained to document the line was in the appropriate position. Intravenous antibiotics were administered and intraoperative cultures were watched. The Infectious Disease service was consulted and recommendation were followed. Her catheter and drain were removed POD 3 and she was able to take PO's. Her pain was well controlled and she remained afebrile throughout her hosptial course. She will return to clinic in ten days. She was discharged in good condition. Medications on Admission: Iron Metoprolol Loperamide Thiamine Folic acid Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 6 weeks. 12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 13. Outpatient Lab Work The following labs must be drawn weekly: 1.CBC with diff 2.LFTs 3.BUN/Creatinine 4.Vanco trough Please fax result [**Telephone/Fax (1) 1353**] Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 4047**] Discharge Diagnosis: Osteomyelitis L1-2 Post-operative anemia Discharge Condition: Good Discharge Instructions: Please continue to take your pain medication with an over the counter laxative. Call the clinic if you notice any redness or discharge from the incision site. Call the clinic for any additional concerns. Physical Therapy: Activity: Activity as tolerated Pneumatic boots TLSO brace for ambulation. Must place brace on while patient in supine position. Treatments Frequency: Please continue to change the dressings daily with dry, sterile gauze. Followup Instructions: Please follow up in the Orthopaedic Spine clinic during your previously scheduled appointments. Please follow up with the Infectious Disease clinic on [**11-2**] at 9am with Dr. [**Last Name (STitle) 9404**]. Call ([**Telephone/Fax (1) 4170**] for directions. Please draw weekly CBC with diff, LFTs, Vanco trough, BUN/Creatinine and fax the results to [**Telephone/Fax (1) 1353**]. Completed by:[**2123-10-11**]

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icd9cm

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53375

Discharge summary

report

Admission Date: [**2202-7-30**] Discharge Date: [**2202-8-12**] Date of Birth: [**2117-12-10**] Sex: F Service: MEDICINE Allergies: Aspirin / Nitrate Analogues Attending:[**First Name3 (LF) 2071**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 109788**] is a pleasant 84yo, Spanish-speaking female with a history of coronary artery disease (s/p RCA stent [**2191**]), severe TR, pulmonary hypertension, atrial fibrillation, diastolic heart failure, chronic kidney disease, DM2, HTN who presents with acute on chronic dyspnea. She has had significant dyspnea on exertion, orthopnea, and PND for the past two months, but it has acutely worsened over the past 10-20 days. She occasionally gets pain in the sternal and lower neck area over that same time period, but it is unclear if she is interpreting that symptom as shortness of breath. She struggles to sleep, and needs to be upright to do so. She has worsening edema of the lower legs as well, with a departure from her dry weight of 200 to 210. She has been taking all meds and diuretics. She denies salt loading. She denies exertional chest pain or pressure. She was instructed to present to the ED by her PCP after her [**Name9 (PRE) 269**] found her sats to be 88% on RA this afternoon. In the ED, initial vs were 98.2 60 120/62 28 98% 8L Mask. She was in Afib with a rate of 60. Labs notable for elevated BNP to 2654, and Ddimer>1000. She did not get CTA due to renal failure, which is chronic. CXR showed pulmonary vascular congestion, which is chronic. On arrival to the floor, initial vitals were T98.1 BP106/62 HR71 RR22 100/2L. She is resting. She has minimal shortness of breath right now, and no chest pain or pressure. She complains of general weakness and malaise. Notably, she was admitted to [**Hospital1 18**] [**6-/2202**] with toe pain due to ingrown nail, and had a course complicated by hypoxia and hypoxic respiratory failure necessitating MICU transfer. She improved with a multifocal regimen of diuretics, antibitoics, and steroids and was eventually liberated from oxygen. She has had multiple admissions for CHF according to her cardiologist. Efforts to reduce lower extremity edema and mild dyspnea with exertion are thwarted by worsening renal performance, and she is allowed to remain modestly overloaded at baseline. Most recent dry weight appears to be around 200lb. REVIEW OF SYSTEMS: Positive otherwise for constipation. Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. Diabetes mellitus, type 2, poorly controlled, last HbA1c 9.0 [**1-15**] 2. Atrial fibrillation, on coumadin 3. Coronary artery disease s/p stent to the RCA 09/[**2191**]. 4. Congestive heart failure, EF 70% [**12/2198**] 5. Hypertension. 6. Hypercholesterolemia. 7. Seizures 8. Parkinson's disease 9. Hx. PUD and gastritis 10. Hx. abnormal pap smears 11. Status post bilateral total knee replacement. 12. Low back pain 13. Chronic kidney disease with baseline creatinine 1.3-1.9 diastolic CHF Social History: Patient lives with her husband in [**Location (un) 686**], daughter lives nearby. Patient is a former smoker, but none in recent years. No alcohol. She walks with the aid of a cane. She was born in [**Male First Name (un) 1056**]. She is spanish speaking only. Grandson, [**Name (NI) **], is primary communicator for the family. Family History: Brother with DM. No CAD or COPD. Physical Exam: ADMISSION PHYSICAL EXAM: VS T98.1 BP106/62 HR71 RR22 100/2L. GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, oral thrush noted NECK JVD to the tragus PULM crackles halfway up back bialterally CV irregularly irregular, varibable intensity S1 S2, 3/6 SEM at the right lower sternal border ABD soft NT ND normoactive bowel sounds, no r/g EXT 2+ edema extending to the mid thigh bilaterally NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Pertinent Results: [**2202-7-30**] 08:59PM K+-4.5 [**2202-7-30**] 07:36PM PT-51.5* PTT-45.9* INR(PT)-5.1* [**2202-7-30**] 06:40PM GLUCOSE-61* UREA N-29* CREAT-1.8* SODIUM-143 POTASSIUM-6.0* CHLORIDE-102 TOTAL CO2-37* ANION GAP-10 [**2202-7-30**] 06:40PM estGFR-Using this [**2202-7-30**] 06:40PM cTropnT-<0.01 [**2202-7-30**] 06:40PM D-DIMER-1432* [**2202-7-30**] 06:40PM proBNP-2654* [**2202-7-30**] 06:40PM WBC-8.4 RBC-3.82* HGB-9.0* HCT-31.8* MCV-83 MCH-23.5* MCHC-28.2* RDW-18.2* [**2202-7-30**] 06:40PM NEUTS-71.1* LYMPHS-18.9 MONOS-6.9 EOS-2.1 BASOS-0.9 [**2202-7-30**] 06:40PM PLT COUNT-162 BLOOD GAS: [**2202-7-31**] 07:29PM BLOOD Type-ART Temp-37.4 pO2-72* pCO2-89* pH-7.23* calTCO2-39* Base XS-6 Intubat-NOT INTUBA [**2202-7-31**] 10:45PM BLOOD Type-ART Rates-/20 PEEP-5 FiO2-50 pO2-91 pCO2-81* pH-7.27* calTCO2-39* Base XS-7 Vent-SPONTANEOU [**2202-8-2**] 02:31PM BLOOD Type-[**Last Name (un) **] pO2-82* pCO2-79* pH-7.36 calTCO2-46* Base XS-14 Comment-GREEN TOP [**2202-8-3**] 07:03PM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-52* pCO2-85* pH-7.40 calTCO2-55* Base XS-22 [**2202-8-4**] 02:59AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-86* pH-7.41 calTCO2-56* Base XS-24 [**2202-8-4**] 10:58AM BLOOD Type-ART pO2-74* pCO2-79* pH-7.43 calTCO2-54* Base XS-22 Intubat-NOT INTUBA CXR [**2202-7-30**] Pulmonary vascular congestion without frank edema, not likely changed given lower inspiratory effort on the current exam. CXR [**2202-7-31**] There are low lung volumes. Moderate-to-severe cardiomegaly and tortuous aorta are unchanged. Mild pulmonary edema is increased from prior. There is no pneumothorax. If any, there are small bilateral pleural effusions. There is no evidence of lobar pneumonia. [**2202-8-7**] CT chest IMPRESSION: 1. No effusion or consolidation. 2. Scattered pulmonary nodules and ground glass opacities requiring follow-up chest CT in 6 months. 3. Mild lower lobe bronchial wall thickening could reflect a chronic small airways disease. 4. Mild-to-moderate cardiomegaly with prominent coronary artery calcifications. DISCHARGE LABS [**2202-8-11**] 06:50AM BLOOD WBC-11.0 RBC-3.90* Hgb-9.5* Hct-32.3* MCV-83 MCH-24.3* MCHC-29.3* RDW-19.7* Plt Ct-243 [**2202-8-12**] 05:43AM BLOOD PT-15.7* INR(PT)-1.5* [**2202-8-12**] 05:43AM BLOOD Glucose-281* UreaN-53* Creat-2.0* Na-133 K-4.7 Cl-91* HCO3-33* AnGap-14 [**2202-8-11**] 06:50AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.3 Brief Hospital Course: Ms. [**Known lastname 109788**] is a 84yoF with [**Hospital 7133**] medical problems including diastolic heart failure (EF 70%), DM2, CKD, TR here with shortness of breath likely caused by decompensation of CHF. . # RESPIRATORY DISTRESS: likely related to obesity hypoventilation and sleep apnea complicated by decompensated heart failure. Seen by Pulm and Sleep who recommend BiPAP at night and at day as needed. Improved with BiPAP qHS and diuresis. Pt continued nebulizer treatments and inhaled steroids throughout admission. She did not receive systemic steroids. Pt's respiratory status improved with diuresis approximately 9L, BiPAP at night, and was successfully weaned off oxygen. She is set up for outpatient follow-up for pulmonary function tests, sleep study, and urgent care pulm clinic. . # [**Hospital1 **]-VENTRICULAR HEART FAILURE: Pt presented with worsening dyspnea over several days. ACS ruled out: troponins negative x2, EKG unchanged from prior, and symptom onset was insidious, and the patient says her chest pain is close to baseline. Likely SOB [**1-7**] acute diastolic heart failure, with superimposed COPD component. The patient was clinically volume overloaded on admission with worsening lower extremity edema, desaturations, and increased weight. Lasix drip and fluid restriction was started on the floor. The patient was placed on supplemental O2 on the floor. Albuterol nebs were given. The patient had a persistently altered mental status on the floor, with increased sleepiness and confusion from baseline accoringing to discussions with her family. Blood gas was obtained, which showed the patient to be in hypercapnic respirtaroy failure, and the patient was tranfered to CCU for BIPAP. In the CCU, pt continued diuresis with lasix drip (approximately 9L) and was intermittently on Bipap. Lasix gtt was stopped and she was transitioned back to PO torsemide on the cardiology service, and maintained at approximately ins = output. PO torsemide was decreased from 80mg to 60mg daily as she developed acute kidney injury and hypotension. Dry weight is 84.3kg. . # ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE: Pt had elevated cr to 2.7 from baseline of 1.5. Cr downtrended with diuresis. Most likely secondary to venous congestion. Creatinine rose again in the setting of aggressive diuresis and hypotension, but improved upon discharge after gentle bolus (500cc) of IVF. . # ATRIAL FIBRILLATION: On admission, pt had supratheraputic INR to 6.2 and coumadin was held. She was given 1mg vitamin K to reverse INR so that patient could go on to right heart catheterization, she did not end up getting procedure, INR normalized and coumadin was restarted. Pt's carvedilol was held for hypotension in CCU and uptitrated to home dose as BP tolerated, then changed to metoprolol to minimize bronchospastic component. . # CORONARY ARTERY DISEASE: Admission EKG at her baseline. Cont simvastatin. Lisinopril held in setting of hypotension and elevated cr, restarted at 20mg, but ultimately discontinued because she became hypotensive to as low as 80/palp. Carvedilol changed to metoprolol. . # HTN: Continued home meds (clonidine,carvedilol) as BP tolerated. Lisinopril initally held, restarted at 20mg on [**8-10**], discontinued because she became hypotensive. # BLOOD PRESSURE: Normotensive with SBP in 110-120s on discharge. HYPERTENSION: - Continued clonidine at reduced dose - Changed carvedilol to metoprolol for redued bronchospasm in the setting of reactive airway disease - Torsemide dose decreased - Lisinopril held on admission, attempted to restart on [**8-10**] at 20mg (half of home dose), but pt developed symptomatic hypotension, so it was discontinued indefinitely HYPOTENSION: Normotensive on discharge. Developed hypotension [**2202-8-10**] in setting of restarting [**12-7**] of home lisinopril 20mg and increasing torsemide to 80mg. Gave gentle fluid bolus 500cc IVF, with appropriate improvement in BP and orthostasis. - No evidence of infection to suggest septic shock - developed mild transient leukocytosis to 12.1, which resolved the follwowing day. # FEVER of 100.5: The patient had a low grade fever on the floor initially. Has had some urinary symptoms, and was post void bladder scan showed 400 ccs of urine, so Foley was placed. The patient also says she has had some cough recently but none has been noted yet by staff on the floor. No consolidation visible on CXR. UCx on admission showed no growth. [**2202-7-31**] urine cx showed 10,000-100,000 Enterococcus. Bcx showed no growth and WBC downtrended. CHRONIC ISSUES # DM2: Continued NPH, QACHS Humalog SS. . # PARKINSONS: Continued Sinemet. . # THRUSH: Likely from fluticasone. Encouraged rinsing mouth after administration. Given nystatin SS. Fluticasone discontinued (replaced with spiriva and advair) . # GERD: Continued omeprazole. . # Seizure disorder: Continued Keppra. . # Sleep: Continued trazadone. TRANSITIONAL ISSUES - Follow-up chest CT in 6 months - pulmonary nodules and ground-glass opacities - Outpatient pulmonary function tests - Outpatient sleep study - DRY WEIGHT: 84.3kg - [**Month (only) 116**] consider tapering off clonidine as tolerated MEDICATION CHANGES - STOP fluticasone inhaler, being replaced with Spiriva and Advair inhalers - START spiriva 1 inhalation twice a day - START advair inhaler - DECREASED clonidine from 0.3 to 0.1mg twice a day - DECREASED torsemide from 80mg daily to 60mg daily - STOP carvedilol, being replaced with metoprolol - START metoprolol succinate 200mg DAILY Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. albuterol sulfate *NF* 1-2 puffs Inhalation q4-6hr SOB, cough, wheezing 2. Carbidopa-Levodopa (25-100) 1 TAB PO TID 3. Carvedilol 50 mg PO BID 4. CloniDINE 0.3 mg PO TID 5. Clotrimazole Cream 1 Appl TP [**Hospital1 **] 6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 7. LeVETiracetam 500 mg PO BID 8. Lisinopril 40 mg PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Simvastatin 40 mg PO DAILY 11. Torsemide 80 mg PO DAILY 12. TraMADOL (Ultram) 50 mg PO BID pain 13. Warfarin 5 mg PO DAILY16 7.5mg on Fridays 14. Docusate Sodium 100 mg PO BID 15. HumuLIN 70/30 *NF* (insulin NPH & regular human) 32 units in the AM, 20 units at dinner Subcutaneous twice a day 16. Milk of Magnesia 15-30 mL PO DAILY constipation 17. Psyllium 1 PKT PO Frequency is Unknown Discharge Medications: 1. Carbidopa-Levodopa (25-100) 1 TAB PO TID 2. Clotrimazole Cream 1 Appl TP [**Hospital1 **] 3. Docusate Sodium 100 mg PO BID 4. LeVETiracetam 500 mg PO BID 5. Omeprazole 40 mg PO DAILY 6. Psyllium 1 PKT PO TID 7. Metoprolol Succinate XL 200 mg PO DAILY hold for sbp < 90, hr < 55 RX *metoprolol succinate 200 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*3 8. CloniDINE 0.1 mg PO BID hold for SBP<100 RX *clonidine 0.1 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 9. Simvastatin 40 mg PO DAILY 10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 11. Warfarin 5 mg PO DAILY16 7.5mg on Fridays 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1 INH twice a day Disp #*1 Inhaler Refills:*0 13. HumuLIN 70/30 *NF* (insulin NPH & regular human) 32 units in the AM, 20 units at dinner Subcutaneous twice a day 14. albuterol sulfate *NF* 1-2 puffs Inhalation q4-6hr SOB, cough, wheezing 15. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 IH DAILY Disp #*30 Capsule Refills:*3 16. Milk of Magnesia 15-30 mL PO DAILY constipation 17. Outpatient Lab Work Please check Chem7 by [**2202-8-17**]. Discharge Cr: 2.0 Send results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4026**], MD. Fax: [**Telephone/Fax (1) 3382**]. 18. Torsemide 60 mg PO DAILY Start [**2202-8-12**] RX *torsemide 20 mg 3 tablet(s) by mouth DAILY Disp #*90 Tablet Refills:*3 19. BiPAP Home BiPAP 10/5 with heated humidification Indication/Diagnosis: Hypoventilation leading to hypercarbia Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: PRIMARY: Hypercarbic respiratory failure, acute on chronic biventricular heart failure (hypertensive cardiomyopathy, tricuspid regurgitation, pulmonary hypertension) SECONDARY: Obstructive sleep apnea, obesity-hypoventilation disease, reactive airway disease, coronary artery disease, atrial fibrillation, acute on chronic kidney disease, diabetes mellitus, Parkinson's disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mrs. [**Known lastname 109788**], It was a pleasure caring for your during your hospitalization for shortness of breath. You were cared for by lung and heart specialists as your shortness of breath is likely due to a combination of heart failure, lung disease, and sleep apnea. Your breathing improved with diuretic medications to remove fluid from your lungs, nebulizers, and BiPAP machine at night. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You should continue getting your INR checked and warfarin dose adjusted at the [**Hospital3 **] Anticoagulation [**Hospital 9085**] clinic as before. MED CHANGES: - STOP fluticasone inhaler, being replaced with Spiriva and Advair inhalers - START spiriva 1 inhalation twice a day - START advair inhaler - DECREASED clonidine from 0.3 to 0.1mg twice a day - DECREASED torsemide from 80mg daily to 60mg daily - STOP carvedilol, being replaced with metoprolol - START metoprolol succinate 200mg DAILY Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2202-8-13**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], NP [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage We are working on a follow up appointment for your hospitalization in Cardiology with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] or NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. It is recommended you be seen within 2 weeks of discharge the office will contact you at home with the appointment information. If you have not heard within 2 business days please call the office at [**Telephone/Fax (1) 62**]. We are working on a follow up appointment for your hospitalization in Pulmonary. It is recommended you be seen within 1 week of discharge the office will contact you at home with the appointment information. If you have not heard within 2 business days please call the office at [**Telephone/Fax (1) 612**]. We are working on a follow up appointment for your hospitalization in Sleep Medicine. It is recommended you be seen within 2 weeks of discharge the office will contact you at home with the appointment information. If you have not heard within 2 business days please call the office at [**Telephone/Fax (1) 612**]. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**] Completed by:[**2202-8-15**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2106-3-20**] Discharge Date: [**2106-4-23**] Service: MEDICINE Allergies: Penicillins / Quinine / Sulfonamides Attending:[**First Name3 (LF) 317**] Chief Complaint: Dyspnea and Hypotension. Major Surgical or Invasive Procedure: Intubation and Mechanical Ventilation. History of Present Illness: Mrs [**Last Name (STitle) **] was an 84 year-old lady with a history of ESRD on hemodialyis, CAD/CABG/Recent NSTEMI, Iscuemic CHF (EF 20%) who presented from her nursing home with dyspnea and hypotension. She was recently admitted (from [**2106-2-24**] to [**2106-3-12**]) for a right hip reconstructive hemiarthroplasty. Her post-op course was complicated by hypotension, requiring vasopressors (neo-> levophed). She was transferred to the CCU, where CEs were negative; she was briefly on the medical floor, but was transferred to the MICU for hypotension and respiratory arrest requiring intubation. An inferiorlateral NSTEMI was then diagnosed. She underwent cardiac cath ([**2106-2-27**]) at which time a LCX instent stenosis was noted; a Taxus stent placed. Given her EF 20-25% on follow-up TTE, she was started on digoxin and warfarin. Her course was also complicated by C. diff colitis, which resolved with Flagyl. She was then relatively well, until 3PM on the day prior to her current admission when she became acutely dyspnic. She reported associated [**9-4**] central aching chest pain, worsened with inspiration. There was no radiation or associated palpitations, presyncope, nausea, vomiting. The pain resolved spontaneously after 15 minutes. At the NH, her VS were: T100.4, HR118, BP84/55. She received 40 mg IV lasix with minimal response. She received two albuterol nebulizers with some improvement. Given her SBPs to the 60s-80s (with a baseline BP in the 90s), she was transferred to the [**Hospital1 18**] ED for further evaluation. In the ED, she received Levofloxacin 500 mg IV and 1 liter of NS. She reported improved dyspnea upon transfer to the floor and had no current chest pain, palpitations, nausea, vomiting, lightheadedness, or diaphoresis. ROS: no headache, rhinorrhea, sore throat, (+) non-productive cough, no fevers, chills (+) diarrhea (incontinent of multiple BM/day). No dysuria. Past Medical History: 1. CAD - s/p CABG '[**81**], multiple stents total of 9 (SVG-LAD [**10/2096**], [**Doctor First Name 10788**] [**8-/2099**], [**2105-9-18**] 2 stents, [**11-28**] 1 stent) s/p NSTEMI [**2-27**] 2. HOCM 3. CRF (creatinine 3.0) s/p fistula placement rt. arm 4. HTN 5. CHF/ischemic cardiomyopathy - EF 20-25% in [**11-28**] 6. HTN 7. Gout 8. LLL lung resection for carcinoid 9. s/p cholecystectomy [**10**]. s/p abdominal hysterectomy 11. s/p rt ant tib surgery [**12**]. rt. hip fracture [**10-28**], now with artificial hip and reconstruction as discussed in HPI Social History: Pt is a nonsmoker, does not use alcohol, is retired and lives with her husband. Family History: Extensive CAD. Physical Exam: Gen: elderly female, A&OX3, although slightly confused, mildly uncomfortable [**1-27**] sacral decubitus ulcer HEENT: [**Month/Day (2) 2994**], EOMI, anicteric, nl conjunctiva, OMM dry, OP clear, JVP to jawline, no carotid bruits, neck supple Cardiac: tachy, regular, II/VI SM at apex Pulm: Crackles up 3/4, decreased LS at bases bilaterally w/ dullness to percussion Abd: hypoactive BS, soft, NT/ND, no masses Ext: 2+ LE edema to thighs, sacral edema, and UE bilaterally. Right radial AVF w/ thrill and bruit. Back: 4 cm Grade 3 sacral decubitus ulcer w/ necrotic center and surrounding erythema Neuro: CN II-XII grossly intact and symmetric bilaterally, [**3-30**] strength throughout, 2+ DTR symmetric bilaterally. Sensation intact to light touch proximally and distally in upper and lower extremities bilaterally Pertinent Results: Admit Labs: [**2106-3-20**] 05:20AM BLOOD WBC-16.8* RBC-3.81* Hgb-11.5* Hct-36.6 MCV-96 MCH-30.2 MCHC-31.4 RDW-18.0* Plt Ct-335 [**2106-3-20**] 05:20AM BLOOD Neuts-92.5* Bands-0 Lymphs-4.6* Monos-2.7 Eos-0.1 Baso-0.2 [**2106-3-20**] 05:20AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL [**2106-3-20**] 05:20AM BLOOD PT-17.7* PTT-31.7 INR(PT)-2.0 [**2106-3-20**] 05:20AM BLOOD Glucose-148* UreaN-43* Creat-4.4* Na-136 K-4.8 Cl-101 HCO3-22 AnGap-18 [**2106-3-20**] 05:20AM BLOOD ALT-15 AST-29 LD(LDH)-320* CK(CPK)-37 AlkPhos-114 Amylase-271* TotBili-0.3 [**2106-3-20**] 05:20AM BLOOD Lipase-112* [**2106-3-20**] 05:20AM BLOOD CK-MB-NotDone cTropnT-2.01* [**2106-3-20**] 05:20AM BLOOD Albumin-2.6* Calcium-9.7 Phos-4.7* Mg-1.8 [**2106-3-20**] 10:19AM BLOOD Type-ART Temp-36.6 pO2-151* pCO2-31* pH-7.36 calHCO3-18* Base XS--6 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2106-3-20**] 10:19AM BLOOD freeCa-1.22 [**2106-3-20**] 07:10AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.014 [**2106-3-20**] 07:10AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [**2106-3-20**] 07:10AM URINE RBC->50 WBC->50 Bacteri-MANY Yeast-MOD Epi-[**2-27**] Admit Reports: * EKG: ST @ 137 bpm, LBBB, prolonged QT. * CXR AP: enlarged heart, bilateral perihilar haziness and upper zone redistribution, bilateral pleural effusions, LLL opacity (atelectasis vs PNA) * CTA: no PE, c/w CHF and pulm edema, LLL consolidation ?pna, multiple small nodules throughout the lungs ?septic emboli vs metastatic dz, multiple rib fractures, some acute Brief Hospital Course: Mrs [**Known lastname 23**] was admitted with an end-stage ischemic cardiomyopathy (LVEF 20%), ESRD and new-onset dyspnea from a presumed CHF exacerbation. She was in persistent borderline cardiogenic shock, with difficult to manage CHF and hypotension throughout her course. She had a prolonged hospital stay, including ICU transfers. Given the lack of success in treating her CHF and hypotension, the patient and her family change their goals of care to comfort. After withdrawal of dialysis and aggressive measures to treat her cardiovascular condition, the patient passed away comfortably. Hypotension and CHF: She had a known extensive CAD history, with prior CABG and recent NSTEMI, and thus an ischemic cardiomyopathy with a LVEF of 20%. Her baseline SBPs were in the 90s, but ranged from the 50s to 80s for most of her course. Initial success was had with diuresis, but renal failure ensued. She thus required HD/Ultrafiltration for fluid removal. The medical and ICU teams walked a fine line between comfort, hypotension with lack of cerebral perfusion, oliguria and flash pulmonary edema. Thus, her course included multipe admissions to ICU (after suffering marked dyspnea and hypoxia while on the floor and hemodialysis units) and bouts of intubation and mechanical ventilation. Extubation trials had relative success for short periods of time, but she would develop rapid progression of her dyspnea and have episodes of flash pulmonary edema. Despite her poor prognosis, which was well known to both the patient and the family, the patient wanted to continue pursuing aggressive measures early in her course. Later on, she decided to make comfort her primary goal. Thus, hemodialysis and mechanical ventilatory support trials were not pursued. She was continued on ace-inhibitor and beta-blocker to prevent pulmonary edema. As hemodialyis was not pursued, she slowly became less reponsive, but never seemed uncomfortable for the last week of her course. She passed away from presumptive kidney failure and heart failure. Medications on Admission: 1) Protonix 40 mg PO daily 2) [**Known lastname **] 325 mg PO daily 3) [**Known lastname **] 75 mg PO daily 4) Colace 150 mg PO BId 5) Atorvastatin 40 mg PO daily 6) Gabapentin 100 mg PO qhs 7) Zinc sulfate 220 mg PO daily 8) Vitamin C 500 mg PO BID 9) MV1 1 tab PO daily 10) coumadin 1 mg PO qod 11) dgoxin 0.0625 mg PO daily (received [**Date range (1) 10649**]) 12) Metronidazole 500 mg PO BID (completed [**3-18**]) 13) Trazodone 50 mg PO qhs 14) Coreg 3.125 mg PO BID (just started [**3-19**]; received no doses) 15) Captopril 6.25 mg PO TID (just started [**3-19**]; received no doses) 16) NTG SL prn 17) oxycodone prn 18) Tylenol prn 19) dulcolax prn 20) Toprol XL 12.5 mg PO daily 21) Lisinopril 2.5 mg PO daily Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: 1) Ischemic Heart Failure. 2) End-Stage Renal Disease. Secondary Diagnosis: 3) Sacral Decubitus Ulcer. Discharge Condition: Deceased. Discharge Instructions: None. Followup Instructions: None.

[ "785.51", "274.9", "403.91", "707.03", "518.84", "263.9", "428.23", "414.8", "286.7", "V45.81", "410.72", "V43.64" ]

icd9cm

[ [ [] ] ]

[ "00.17", "96.6", "38.93", "96.72", "96.04", "39.95", "86.28", "86.22" ]

icd9pcs

[ [ [] ] ]

8327, 8342

5491, 7526

268, 308

8508, 8519

3836, 5468

8573, 8581

2967, 2983

8298, 8304

8363, 8363

7552, 8275

8543, 8550

2998, 3817

204, 230

336, 2257

8459, 8487

8382, 8438

2279, 2854

2870, 2951

22,064

169,250

2241

Discharge summary

report

Admission Date: [**2196-11-4**] Discharge Date: [**2196-11-8**] Date of Birth: [**2156-9-2**] Sex: F Service: SURGERY Allergies: Bactrim / Compazine Attending:[**First Name3 (LF) 3127**] Chief Complaint: Infected AV graft site Major Surgical or Invasive Procedure: Endotracheal intubation Cardiopulmonary resuscitation Removal of infected AV graft History of Present Illness: Ms. [**Known lastname 11863**] is a 40 yo female with a history of HIV (last CD4 89 on [**2196-10-18**]) , also with ESRD on hemodialysis s/p left AV fistula in [**2189**] converted to AV graft in [**2191**], with a history of multiple prior infections requiring excision and revision. She presented to the ED on [**2196-11-4**] with c/o fever and pus oozing from AV graft. In the ED, she was found to be febrile to 103. Past Medical History: 1. HIV 2. End-stage renal disease on hemodialysis 3. Status post AV fistula in [**2189**] 4. Status post AV graft in [**2191**] 5. Status post AV pseudoaneurysm resection in [**4-/2196**] 6. History of prior exposure to TB. Social History: Non-contributory Family History: Non-contributory Physical Exam: Physcial examination per Transplant Surgery admission note: VITALS: T 103, BP 180/131, HR 130, RR 26, Sat 95% on room air. GEN: A&O X 3. In NAD. RESP: CTAB. CV: RRR. Normal S1, S2. No S3, S4. GI: Abdomen soft and non-tender. EXT: Left upper arm AV graft tender, erythematous, pus oozing. Pertinent Results: Relevant laboratory data on admission: CBC: WBC-5.0# RBC-3.08* HGB-11.1* HCT-33.2* MCV-108* MCH-35.9* MCHC-33.3 RDW-16.0* (NEUTS-86.5* LYMPHS-8.6* MONOS-4.2 EOS-0.6 BASOS-0) ANISOCYT-1+ MACROCYT-3+ PLT COUNT-159 Chemistry: GLUCOSE-76 UREA N-34* CREAT-9.6* SODIUM-132* POTASSIUM-5.0 CHLORIDE-94* TOTAL CO2-25 ANION GAP-18 LACTATE-1.5 K+-8.4* Brief Hospital Course: 40 year-old female with HIV, ESRD on HD admitted with an infected left upper arm AV graft. Her hospital course will be briefly reviewed. Ms. [**Known lastname 11863**] was taken directly to the OR where she had excision of her left AV graft and placement of a temporary right groin dialysis catheter. She was empirically started on Vancomycin on admission. Cultures from the AV graft eventually grew MSSA. She was extubated in the OR, but subsequently developed respiratory distress in the PACU requiring reintubation. She became hypoxic and developed asystole/PEA arrest (approximately 7 minutes). She was resuscitated. Post-code, when weaned off sedation, she was noted to be minimally responsive with posturing. A CT head was performed and showed diffuse effacement of the sulci throughout the cerebral cortex suggestive of generalized edema, without hemorrhage, hydrocephalus or shift of midline structures. A subsequent MRI revealed slow diffusion in bilateral basal ganglia, caudate nuclei and the cerebral cortex suggestive of watershed infarction and consistent with anoxic brain injury. Neurosurgery and neurology were consulted. BP was kept under tight control with Nicardipine, and hypertonic saline was administered to bring Na up to 140, then D/C'd. No surgical intervention. Unfortunately, in the ensuing days, Ms. [**Known lastname 11863**] showed no signs of meaningful functional recovery. She was transferred to the MICU team on [**11-6**] for further management. She continued to be febrile while on the MICU service, and antibiotics were changed to Oxacillin. From a neurological standpoint, she had no meaningful recovery following the event. Given the patient's grim prognosis, a meeting was held with the patient's mother, who expressed her wishes of "letting her daughter go". The goals of care were confirmed with the patient's husband, who was incarcerated at the time. Arrangements were made for the husband to be granted a leave and come visit his wife prior to withdrawal of care. She was started on pressors briefly. Care was withdrawn on [**2196-11-8**] at 20:00. She was pronouced dead on [**2196-11-8**] at 23:05. Medications on Admission: Patient expired Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired Completed by:[**2197-2-19**]

[ "427.5", "403.91", "348.1", "038.11", "995.92", "996.62", "042", "583.9", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "39.43", "96.04", "39.95", "99.60" ]

icd9pcs

[ [ [] ] ]

4098, 4107

1841, 3992

301, 386

4167, 4184

1475, 1500

4249, 4296

1134, 1152

4058, 4075

4128, 4146

4018, 4035

4208, 4226

1167, 1456

239, 263

414, 837

1514, 1818

859, 1084

1100, 1118

21,880

162,843

21358

Discharge summary

report

Admission Date: [**2152-3-24**] Discharge Date: [**2152-4-5**] Date of Birth: [**2074-6-7**] Sex: F Service: MEDICINE Allergies: Vioxx Attending:[**First Name3 (LF) 9554**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Swan placement with central venous line History of Present Illness: This is a 77 y.o. female with CAD s/p CABG, CHF secondary to AS ([**Location (un) 109**] 0.7), s/p ICD/PM, AFib presenting s/p D/C to rehab on [**2152-3-15**] with dyspnea. She was evaluated for AVR/MVR by Dr. [**Last Name (STitle) **] during her admission last week and it was determined that she would benefit from rehab prior to surgery. She was doing reasonably well at rehab until [**2152-3-23**] when she noted gradual dyspnea on exertion, even with walking a few feet. ROS: + 10 pound weight gain and peripheral edema. Mild nausea with one episode of vomiting this AM. Profound weakness. No CP/Palp/C/D/Weakness/numbness/HA/lightheadedness. She was transferred to the CCU for tailored therapy with swan. Past Medical History: 1. CAD s/p CABG (LIMA-LAD, SVG-PDA/RPL, SVG-OM) s/p recent PCI of SVG-PDA/RPLV 2. CHF EF 35% due to valvular disease 3. Valvulvar Disease: Aortic stenosis - valve area 0.9 cm2 - 4. Carotid stenosis s/p bilateral CEAs 5. [**Doctor Last Name 933**] disease 6. CRI 7. Cataract surgery 8. PAF s/p VVI/ICD placement 9. PVD 80% RCIA lesion 10. Emphysema Social History: 1. Lives at home with her husband2. 2 children. Currently non-smoker but smoked 1 ppd since age 154. Non-drinker Family History: Father and brothers with cardiac disease Physical Exam: Temp: 96.8 BP:110/33, HR:72, RR:20, O2: 93 RA, 98 2L Gen: NAD. Lying at 30 degrees. A/O x 3. Speaking in full sentences. HEENT: JVD at 15. PEARLA. EOMI. OP: dentures top and bottom CV: RR. III/VI SEM at RUSB heard throughout with mild radiation to carotids. Non-displaced PMI. Pulm: Dullness at bases w/o wheezes/rales. ABD: Distended. +pulsatile liver. soft/NT. No bruits. No HSM. Ext: 2+ pitting edema b/l. 1+DP/PT b/l Neuro: Motor [**5-25**] at all joints. [**Last Name (un) **]: GI to LT. CN II-XII GI. Pertinent Results: [**2152-3-14**] 134 96 72 ----------- < 4.8 32 1.4 Ca: 9.3 Mg: 2.7 P: 3.5 WBC:10.2, Hct: 32.3, Plt:306 PT: 13.5 PTT: 39.2 INR: 1.2 CXR: pending ECG: pending Dobutamine echo [**2-2**]: The patient received intravenous dobutamine in 5 min (low dose 5mcg/kg/min) and 3 minute stages (>5mcg/kg/min) to a maximum of 40mcg/kg/min plus 0 mg atropine. The ECG was uninterpretable due to the presence of a paced rhythm. There was a blunted heart rate response to stress (heart rate 65 paced throughout). Resting images were acquired at a heart rate of 65 bpm and a blood pressure of 110/70 mmHg. These demonstrated moderate regional left ventricular systolic dysfunction with anteroseptal and apical akinesis. Doppler demonstrated mild aortic regurgitation and moderate severe mitral regurgitation with severe aortic stenosis ([**Location (un) 109**] 0.7 cm2). Peak aortic valve velocity 3.9 m/sec, peak gradient 61 mmHg and mean gradient 38 mm Hg. There is severe tricuspid regurgitation with at least mild pulmonary artery systolic hypertension. Right ventricular free wall motion appears preserved (although intrinsic function may be depressed given severity of tricuspid regurgitation). At low dose dobutamine [5mcg/kg/min; heart rate 65 bpm, blood pressure 108/p mmHg], there was mild augmentation of all left ventricular segments except the anterior septum and apex. The peak aortic valve velocity was 3.9 m/sec, peak gradient 62 mmHg with a mean gradient 36 mmHg. At low dose dobutamine [10mcg/kg/min; heart rate 65 bpm, blood pressure 100/p mmHg], there was mild augmentation of all left ventricular segments. The peak aortic valve velocity was 3.9 m/sec, peak gradient 60 mmHg with a mean gradient 33 mmHg. At mid dose dobutamine [15mcg/kg/min; heart rate 65 bpm, blood pressure 104/p mmHg], there was mild augmentation of all left ventricular segments except the anterior septum and apex. The peak aortic valve velocity was 4.2 m/sec, peak gradient 69 mmHg with a mean gradient 42 mmHg. At mid dose dobutamine [20mcg/kg/min; heart rate 65 bpm, blood pressure 106/p mmHg], there was mild augmentation of all left ventricular segments except the anterior septum and apex. The peak aortic valve velocity was 4.2 m/sec, peak gradient 71 mmHg with a mean gradient 43 mmHg. At mid dose dobutamine [25mcg/kg/min; heart rate 65 bpm, blood pressure 122/60 mmHg], there was mild augmentation of all left ventricular segments except the anterior septum and apex. The peak aortic valve velocity was 4.5 m/sec, peak gradient 81 mmHg with a mean gradient 48 mmHg. At mid dose dobutamine [30mcg/kg/min; heart rate 65 bpm, blood pressure 114/68 mmHg], there was mild augmentation of all left ventricular segments except the anterior septum and apex. The peak aortic valve velocity was 4.5 m/sec, peak gradient 80 mmHg with a mean gradient 46 mmHg. At mid dose dobutamine [35mcg/kg/min; heart rate 65 bpm, blood pressure 102/60 mmHg], there was mild augmentation of all left ventricular segments except the anterior septum and apex. The peak aortic valve velocity was 4.6m/sec, peak gradient 85 mmHg with a mean gradient 51 mmHg. At high dose dobutamine [40mcg/kg/min; heart rate 65 bpm, blood pressure 98/40 mmHg], there was continued augmentation of all left ventricular segments except the anterior septum and apex. The peak aortic valve velocity was 4.6m/sec, peak gradient 84 mmHg with a mean gradient 53 mmHg. IMPRESSION: Moderately depressed left ventricular systolic function with significant augmentation of function with dobutamine stress. No evidence of ischemia seen to workload attained (submaximal HR; no HR response to pharmacologic stress). Severe aortic stenosis with increase in gradient with dobutamine stress. Severe tricuspid regurgitation with preserved right ventricular free wall motion. Aortic valve area - 0.7 Echo [**2152-3-6**]: "The left atrium is moderately dilated. A secundum type atrial septal defect is suggested, but could not be confirmed. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis with focal septal dyskinesis (dysnchrony?). The apex is mildly aneurysmal and dyskinetic. No intraventricular thrombus is seen (but apical views are technically suboptimal). Right ventricular chamber size is dilated with preserved free wall motion. [Intrinsic function may be depressed given the severity of tricuspid regurgitation]. The aortic valve leaflets (?#) are moderately thickened. There is moderate aortic valve stenosis with no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2151-10-21**], the right ventricle is now mildy dilated (free wall motion remains preserved) and severe tricuspid regurgitation is now present. The severity of aortic valve stenosis and left ventricular systolic function are similar." Cardiac catheterization [**2152-2-2**]: 1. 3VD 2. Patent SVG to PDA and rPL 3. Patent LIMA to LAD 4. Tricupsid regurgitation 5. Moderate pulmonary hypertension Urine cx [**2152-2-27**]: enterococcus Urine cx [**2152-2-28**]: enterococcus (3000/ml), beta-strep (1000/ml) -------------------- Renal U/S [**2152-3-3**]: 1. No evidence of hydronephrosis, renal stones or other intrinsic renal abnormalities. 2. Huge right subhepatic contained fluid collection. The etiology of this is unclear from the study. Possibilities could include retroperitoneal or mesenteric cysts. [**Last Name (un) **] CT [**2152-3-3**]: 1. Extremely large right-sided peritoneal fluid collection, probably outside of Gerota's fascia, which displaces both the right kidney and the liver. On ultrasound, this had an essentially anechoic appearance, and on the current examination, it has attenuation values of fluid (15 [**Doctor Last Name **]). It is entirely homogeneous in appearance, and could represent a retroperitoneal cyst. Viewing the ultrasound from [**2152-2-5**], this finding was present. 2. Marked cardiomegaly and marked vascular calcifications. 3. Bibasilar atelectasis with mild right lower lobe consolidation. Brief Hospital Course: 77 y.o. female with CAD s/p CABG, Afib s/p ICD/pacer, CHF with EF 30% secondary to AS (VA of 0.7-1.0 on Echo [**3-6**]), 2+ MR, 4+TR presenting with mild nausea and dypsnea. 1) CHF with EF 30% secondary to AS and MR (See DATA for dobutamine echo results) -CT surgery evaluated the patient and felt that the patient was not a candidate for surgical valve correction which Dr. [**Last Name (STitle) 1290**] agreed with. - Thus the utility of aortic valvuloplasty did not validate surgical correction due to the patient's relatively large valve area (0.9-1.0) -The patient was originally placed on a Dopamine gtt, lasix gtt, and dobutamine gtt and a swan was placed for further hemodynamic monitoring. - She was also continued on a low dose digoxin (0.125mg QOD). - However, when surgery no longer was an option, the patient and her family decided to withdraw aggressive medical measures and the patient was made comfort measures only. She passed away peacefully without further events. 2) CAD s/p CABG: - The patient was on ASA, Coreg, and a Statin. 3) EP Issues: s/p VVI pacer and ICD. H/O Afib. - We held her coumadin in light of possible biventricular pacer placement and covered with lovenox. In addition, we hoped increased pacing HR to 80 bpm would improve her overall cardiac function but this proved to have no added benefit. 4) DM: - She was maintained on glargine and ISS. Medications on Admission: 1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Pravastatin Sodium 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Cyclobenzaprine HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) asdir Injection four times a day: sliding scale. 10. Maalox 200-200-20 mg/5 mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for heartburn. 11. Furosemide 40 mg IV DAILY Start: In am 12. glargine Sig: Fifteen (15) units once a day. 13. coumadin 3 qhs Discharge Medications: None. Discharge Disposition: Extended Care Discharge Diagnosis: Severe mitral and tricuspid regurgitation Discharge Condition: Death. Discharge Instructions: Death. Followup Instructions: None. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "398.91", "518.81", "286.9", "396.2", "V53.32", "V45.81", "584.9", "397.0", "280.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "00.13", "89.68", "00.17", "89.64", "38.93" ]

icd9pcs

[ [ [] ] ]

10994, 11009

8495, 9883

272, 313

11094, 11102

2188, 8472

11157, 11291

1588, 1630

10964, 10971

11030, 11073

9909, 10941

11126, 11134

1645, 2169

225, 234

341, 1060

1082, 1442

1458, 1572

75,241

175,261

51698

Discharge summary

report

Admission Date: [**2177-6-28**] Discharge Date: [**2177-7-4**] Date of Birth: [**2108-9-9**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2009**] Chief Complaint: Fatigue and worsening hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 68 year old female with PMH significant for DM2 on insulin complicated by chronic left great toe ulcer requiring frequent debridement and peripheral neuropathy, renal cell carcinoma s/p nephrectomy in [**2175**] at [**Hospital1 2025**], HTN, hyperlipidemia, obstructive sleep apnea (noncompliant with CPAP), and [**Doctor Last Name 933**] Disease s/p radioactive iodine treatment twice presenting for further evaluation of fatigue and worsening hyperglycemia. She has noted polyuria with urinary urgency, but no dysuria. She thinks that she has had elevated blood sugars for quite some time, but is unsure because she has not been really checking her sugars at home. She reports taking Levemir and Humalog for sugar control. She has also noted flushing of her skin and dizziness over the last several days. . In the ED, initial vs at triage were: T=94.6, HR=106, BP=72/34, RR=17, POx=100% RA. She was therefore triggered for hypotension/hypothermia and per report her skin was cool, clammy, and appeared mottled. Her blood pressures increased to 128/87 upon second measurement without any intervention being made. Her subsequent temperature also increased to 96.6 without any intervention. Her finger stick was critically high and her blood glucose returned at 588. She was given 8 units of regular insulin. Upon repeat testing 3 hours later, her blood glucose had increased to 672 and she was given another 10 units of regular insulin. It was then decided to start her on an insulin drip to better control her sugars despite no anion gap being present. A UA showed moderate leukocyte esterase positivity and 15 WBCs. Blood cultures and a urine culture was sent. CXR reportedly did not show any acute process. An EKG reportedly showed NSR at a rate of 82 with T-wave flattening in lead III which was consistent with prior EKGs. She was therefore given vancomycin and Levaquin to cover infections from a skin and urinary source. Of note, the patient developed a pink rash all over her body which was most notable on her palms, shins, chest, and back before she received the vancomycin and it was thought that the rash was due to hyperemia from re-perfusion after initially being mottled. She was also bolused with 3 Liters of NS with a 4th Liter hanging upon transfer and her lactate decreased from 2.8 to 2.2. She has an 18 gauge peripheral for access. Transfer vitals were T=100.8, HR=88, BP=112/52, RR=16, POx=100% RA. . On the floor, the patient is alert and oriented, but inattentive and slow to answer questions. She admits to being confused and reports seeing [**Doctor Last Name **] hair pasta on the walls and believes she heard that [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] has killed little children on TV. She remembers not feeling well when she first arrived in the ED. She denies any localizing symptoms at this time. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -Renal cell carcinoma s/p nephrectomy in [**2175**] -DM2 complicated by chronic left great toe ulcer requiring frequent debridement and peripheral neuropathy -HTN -hyperlipidemia -Restless Leg Syndrome -obstructive sleep apnea (noncompliant w/cpap) -[**Doctor Last Name 933**] Disease s/p radioactive iodine treatment twice and surgical thyroid cystectomy greater than 40 years ago -Thrombocytopenia -Vitamin D deficiency -Osteoporosis -H/O ectopic pregnancy -s/p hysterectomy in [**2156**] -s/p surgical hernia repair Social History: She lives with her dog but is otherwise by herself at home. She has 2 sons and 1 daughter. She quit smoking 20 yrs ago, but did smoke 1 ppd for greater than 20 yrs, occasional alcohol use but none recently, denies IVDU. Family History: Mother- lung cancer and still alive after surgical resection; Father also had cancer Physical Exam: Admission Exam: Vitals: T: 97.9, BP: 103/51, P: 89, R: 16, O2: 97% RA General: Pleasant female, alert and oriented, but at times confused and in no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, large ventral hernia noted in RLQ GU: Foley Skin: Flushing is noted over back, bilateral knees, and hands Ext: warm, well perfused, no clubbing, cyanosis or edema; chronic left great toe ulcer not erythematous, no warmth or active drainage Psychiatric: Inattentive, visual and auditory hallucinations, but otherwise alert and oriented times three . Discharge exam: Vital Signs: BP 131/77 HR 63, RR 18, 98% RA BS: 117/237/203/226/250 Gen: In NAD. HEENT: Mucous membranes moist. Neck: Supple. Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal respiratory effort. CV: RRR, no murmurs, rubs, gallops. Abdomen: soft, NT, ND, NABS, no HSM. Obese. Reducible surgical hernia. Extremities: warm and well perfused, no cyanosis, clubbing, edema. Left great toe with ulcer, s/p debridement. Pertinent Results: On Admission: [**2177-6-27**] 11:18PM WBC-8.2# RBC-4.84# HGB-14.0# HCT-41.5# MCV-86 MCH-28.9 MCHC-33.7 RDW-15.8* [**2177-6-27**] 11:18PM NEUTS-77.1* LYMPHS-15.6* MONOS-3.1 EOS-3.2 BASOS-1.0 [**2177-6-27**] 11:18PM PLT COUNT-147* [**2177-6-27**] 11:18PM GLUCOSE-588* UREA N-37* CREAT-1.4* SODIUM-126* POTASSIUM-5.4* CHLORIDE-87* TOTAL CO2-25 ANION GAP-19 [**2177-6-27**] 11:25PM GLUCOSE-GREATER TH LACTATE-2.8* NA+-128* K+-5.2 [**2177-6-28**] 01:55AM CK(CPK)-128 [**2177-6-28**] 01:55AM CK-MB-6 cTropnT-<0.01 [**2177-6-28**] 01:55AM OSMOLAL-318* [**2177-6-28**] 01:55AM TSH-2.4 [**2177-6-28**] 12:02AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2177-6-28**] 12:02AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [**2177-6-28**] 12:02AM URINE RBC-11* WBC-15* BACTERIA-FEW YEAST-NONE EPI-6 TRANS EPI-<1 . [**2177-6-29**] 04:11AM BLOOD Ret Aut-1.7 [**2177-6-28**] 06:05AM BLOOD %HbA1c-15.1* eAG-387* . CXR: FINDINGS: The lungs are clear, and hyperinflated. There is minimal blunting of the right costophrenic angle, the result of hyperinflation. There is no pneumothorax. The heart size is normal, the mediastinal contours are notable for top normal pulmonary artery size, and mild prominence of the right hilus, which is unchanged since [**2173**]. The pulmonary vasculature is normal. There is degenerative change of the spine. IMPRESSION: No acute chest pathology. parvovirus Igg/Igm negative urine cx [**6-28**] contaminated ESR 45, CRP 5.1 . Discharge labs: [**2177-7-4**] 07:18AM BLOOD WBC-3.3* RBC-3.77* Hgb-10.6* Hct-33.2* MCV-88 MCH-28.2 MCHC-32.0 RDW-15.5 Plt Ct-100* [**2177-7-4**] 07:18AM BLOOD Plt Ct-100* [**2177-7-4**] 07:18AM BLOOD Glucose-257* UreaN-14 Creat-0.9 Na-137 K-4.6 Cl-105 HCO3-25 AnGap-12 Brief Hospital Course: To briefly summarize: 68 yo woman with diabetes complicated by neuropathy, renal cell cancer sp nephrectomy, obesity, hypertension, transferred from ICU after admission there with possible confusion, feeling sick and hyperglycemia. She is a poor historian. It appears that she may have had a rash several days prior, felt like she was getting the flu. She had been out on Tuesday, but not clear what happened on Wed/thurs. Her family brought her in to the hospital for evaluation. She was admitted to the ICU after initially being found to be hyperglycemic, hypotensive and hypothermic. . In the ED, she was found to be hyperglycemic but without a gap. She was treated in the ED with IV insulin, with modest control, but then transferred to the ICU on an insulin gtt. She also received a dose of vancomycin and levofloxacin in the ED. In the ER, she developed a considerable rash on her knees and hands. There was a question of joint swelling. . In the ICU, her infectious workup to evaluate for the hyperglycemia revealed a possible UTI. She remains on levofloxacin. She was also found to have recurrence of an ulcer on the base of her right great toe. She was restarted on long acting insulin, with moderate control, and observed overnight in the ICU. Her mental status progressively cleared to close to baseline. She was found to be pancytopenic today. Her rash improved. Her blood sugar control improved with sliding scale and increased levimir dosing. She had an acute encephalopathy in the setting of acute illness. . By problem: . #. Type II diabetes mellitus, poorly controlled, with complications - The patient's blood sugars were elevated as high as 672 and requried insulin drip and ICU admission. quickly weaned off. Her initial serum osm was 318. The precipitant was unclear, but was thought viral infection and a UTI. She seemed taking good POs without indiscretions or medication changes. Her AIC returned at 15. The [**Last Name (un) **] was consulted, and she was started on an aggressive sliding scale and increased long acting insulin (lantus instead of levemir). She was advised to continue QID blood sugar check, and attempt better compliance. She will require ongoing teaching. . #. Possible Urinary tract infection- The patient's UA is mildly positive with moderate leukocyte esterase and 15 WBCs. She was treated with 3 days of levofloxacin 500 mg daily. Her urine culture was contaminated. . #. [**Last Name (un) **]- Patient's creatinine was up to 1.4 on admission with last baseline in [**2175**] being 0.7. Likely prerenal etiology given profound volume depletion related to uncontrolled hyperglycemia plus lab interference given ketones. She received IVF and improved back to her baseline. . #. Skin rash - She had noticeable warmth and erythema over her bilateral knees, hands, and back. Her TSH was within normal limits (2.2). Parvovirus was negative. She was seen by rheumatology, but they did not believe there was concern for rheumatologic illness. . #. Pancytopenia - She initially had WBC of 8, HCT 34, PLT 117 and after IVF and correction of her glucose went down to 3.1, 31 and 59 respectively. She was seen by hematology. A smear was unremarkable. Workup revealed likely multifactorial etiology, with exacerbation of chronic thrombocytopenia, and leukopenia in setting of viral syndrome. . #. Acute encephalopathy, on admission. Likely related to hyperglycemia and infection. Treated with supportive care. . #. Diabetic foot ulcer. Debrided by podiatry. Will require wound care. . #. history of renal cell cancer, now with abnormal CXR - per pt, awaiting biopsy at [**Hospital1 2025**], in the next ten days. . Chronic issues: Restless legs syndrome, depression, peripheral neuropathy, hypertension: Continued on home medications, with gradual reintroduction back to home doses. . Transitional issues: 1. Pancytopenia: should have repeat CBC at follow up. 2. Abnormal CXR : follow up scheduled at [**Hospital1 2025**]. 3. Poorly controlled diabetes: Needs aggressive teaching and compliance assessment. Medications on Admission: -gabapentin 600 mg by mouth qam, 1200 mg q noon, 1200mg qhs -insulin detemir [Levemir] 50 units [**Hospital1 **] -Humalog sliding scale up to 62 units daily -lisinopril 40 mg by mouth once a day -metformin 1000mg [**Hospital1 **] -nortriptyline 25 mg by mouth at bedtime -pramipexole [Mirapex] 1 mg at 4PM -pramipexole [Mirapex] 2 mg before bed -raloxifene [Evista] 60 mg by mouth once a day -cholecalciferol (vitamin D3) 1,000 units once a day -multivitamin by mouth once a day -Crestor 10mg daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. pramipexole 1 mg Tablet Sig: Variable Tablet PO twice a day: 1 mg at 4pm, 2 mg qhs. 5. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 600 mg Tablet Sig: Variable Tablet PO three times a day: 600 mg po in the am, 1200 mg at 2 pm, and 1200 mg qhs. 8. insulin detemir 100 unit/mL Solution Sig: Fifty Six (56) units Subcutaneous twice a day. 9. Humalog 100 unit/mL Solution Sig: Sliding scale units Subcutaneous QAC and QHS: See sliding scale. 10. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO at bedtime. 11. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day. 12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 13. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pancytopenia Hypotension Poorly controlled type II diabetes mellitus, with neuropathy. Acute confusion and delirium Diabetic foot ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with high blood sugars and low blood pressure. With insulin and IV fluids, your symptoms improved. You did have low blood counts probably related to this illness, which are improving. One of your main problems is not taking your insulin - and you need to take the insulin and follow up with the [**Last Name (un) **] as scheduled. You also had a foot ulcer, that one of Dr. [**Last Name (STitle) 11738**] colleagues debrided. . Medication changes: Increase LEVEMIR insulin to 56 units twice daily Follow the sliding scale insulin as written No other medication changes. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] S. Location: [**Hospital3 **] HEALTHCARE AT [**Hospital1 **] Address: [**Apartment Address(1) 86994**], [**Hospital1 **],[**Numeric Identifier 26419**] Phone: [**Telephone/Fax (1) 86995**] Appt: [**7-8**] at 11:15am Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] (works with [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ) Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] Appt: [**7-8**] at 3:30pm Department: PODIATRY When: WEDNESDAY [**2177-7-9**] at 11:40 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "86.28" ]

icd9pcs

[ [ [] ] ]

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306, 312

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192,839

11397

Discharge summary

report

Admission Date: [**2131-1-12**] Discharge Date: [**2131-1-21**] Date of Birth: [**2060-8-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14964**] Chief Complaint: +ETT as outpt, s/p cath Major Surgical or Invasive Procedure: [**1-12**]- cardiac catheterizations, no complications History of Present Illness: 70 year old man with h/o HTN, hyperlipidemia, 6 months of chest pain and an abnormal ETT referred for cardiac catheterization. Pt c/o approximately six months of exertional dyspnea and left sided chest tightness (non-radiating, "not very bad" but could not put on [**1-15**] scale). He denies symptoms at rest but notes that he becomes acutely SOB while shoveling/inc exercise which persistently resolves with rest. + occ diaphoresis. no nausea/dizziness. no peripheral edema. On [**2131-1-10**] he underwent an ETT where he exercised 3 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, stopping d/t intense fatigue and shortness of breath (no chest pain). EKG revealed 2-2.[**Street Address(2) 1755**] depression in leads II, III, avF, and 1-1.5mm ST depression in leads V4-V6. Referred to [**Hospital1 18**] for cardiac cath which showed: LAD with 95% ostial stenosis, LMCA with diffuse disease at 30% blockage, LCA/RCA with mild dz. Given severity of LAD, he is admitted awaiting CABG on Monday. After cath, pt remained pain free and no complaints. * Past Medical History: Hyperlipidemia Mild diverticulosis Appendectomy Kidney stones Gout Social History: Lives with his wife in [**Name (NI) 620**]. Hx of smoking but quite 30yrs ago. Family History: no family cardiac hx Physical Exam: s/p cath BP: 153/65 HR: 58 RR: 16 O2: 98% GEN: Mr [**Known lastname 36444**] is an eldery male, appears younger than stated age of 70, resting comfortably flat s/p cath, NAD HEENT: PERRL, EOMI, sclerae anicteric, OP - pink/clear - no lesions neck: supple - could not assess JVD as pt flat CARDIAC: rrr, nml S1/S2, no m/g/r LUNGS: ant lung exam - clear, no wheezes/crackles; nml work of breathing ABD: obese, soft, nt/nd EXT: no c/c/e; 2+ DP pulses; warm/dry Neuro: alert and oriented X3, responding appropriately Pertinent Results: [**2131-1-12**] 12:00PM GLUCOSE-119* UREA N-21* CREAT-1.0 SODIUM-139 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-12 [**2131-1-12**] 12:00PM ALT(SGPT)-31 AST(SGOT)-20 ALK PHOS-66 AMYLASE-46 TOT BILI-0.5 [**2131-1-12**] 12:00PM ALBUMIN-4.2 [**2131-1-12**] 12:00PM WBC-9.2 RBC-4.30* HGB-12.1* HCT-36.4* MCV-85 MCH-28.1 MCHC-33.2 RDW-14.0 [**2131-1-12**] 12:00PM NEUTS-68.4 LYMPHS-25.3 MONOS-3.2 EOS-2.4 BASOS-0.6 [**2131-1-12**] 12:00PM PLT COUNT-204 [**2131-1-12**] 12:00PM PT-13.6 PTT-28.6 INR(PT)-1.2 Brief Hospital Course: Mr. [**Known lastname 36444**] is a 70 yo male with h/o HTN, hyperlipidemia with +ETT, s/p cath showing which demonstrated critical stenosis of the LAD. He has initially admitted to the medical service, and subsequently underwent OP CAGBx1 on [**2131-1-15**]. His postoperative course was fairly routine. He was transferred from the CSRU to the cardiac floor on POD#1. He did develop post-op atrial fibrilation requiring amiodarone, which chemically cardioverted him to NSR. He recovered from that point on and his chest tubes were d/c'd on POD#2. He ambulated with physical therapy and was deemed ready to be discharged home on POD#6. Medications on Admission: lisinopril - 5mg lipitor - 10mg daily allopurinol - asa - 81mg daily folic acid Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take for three months post surgery. Disp:*30 Tablet(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Take 400mg po TID for 3 weeks After 3 weeks take 400 po BID. Disp:*180 Tablet(s)* Refills:*0* 12. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD s/p Off Pump Coronary Artery Bypass Graft x1 Post-Op Atrial Fibrilation Hyperglcemia Peri-op Hyperlipidemia Diverticulosis s/p Appendectomy H/O Nephrolithiasis Discharge Condition: Excellent Discharge Instructions: Call Dr.[**Name (NI) 27686**] office if you develop fever, chills, recurrent chest pain, increased drainage from your incision, or if your incision appears red around the edges. Followup Instructions: Call Dr.[**Name (NI) 27686**] office for an appointment in 2 weeks Follow-up with your cardiologist Folow-up with Dr. [**First Name (STitle) 24344**] [**Name (STitle) **] with Dr. [**Last Name (STitle) **]

[ "272.4", "V13.01", "V15.82", "413.9", "427.31", "274.9", "414.01", "997.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.53", "99.29", "36.15", "88.56", "99.69" ]

icd9pcs

[ [ [] ] ]

5279, 5328

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347, 403

5536, 5547

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1,944

171,620

7608

Discharge summary

report

Admission Date: [**2108-11-8**] Discharge Date: [**2108-11-15**] Date of Birth: [**2055-5-19**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 348**] Chief Complaint: urosepsis, tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: 53 yo male with DM1 s/p kidney and pancreatic transplant in [**2094**], atonic bladder who self caths and recurrent UTI's, who initially presented [**11-8**] with inability to pass catheter. He has had difficulty passing the catheter all week and has felt the urge to urinate every hour. He usually only needs to self cath 4 times per day. He also complains of lower abd pain, chills and nausea adn diarrhea. He denies back pain. He was seen by a urologist (Dr. [**Last Name (STitle) 770**] and started on prophylactic nitrofurantoin on [**10-25**]. He is using strile technique. In ED given vanco and ceftriaxone. Of note K was 5.8 and given kayexalate and bicarb. . On the floor, blood cultures from [**11-8**] came back (2/4 bottles) with E. coli, resistant to quinolones but sensitive to everything else. Antibiotic coverage was changed to Zosyn on [**11-10**] (was on CTX, vanco). Azithro was added on [**11-9**] for ?pna/retrocardiac density. He had multiple negative blood cultures and initially had some improvement. [**Month/Day (2) 2793**] US was obtained that did not show any perinephric abscess or other complication of this infection. . He began to spike/be tachypneic on [**11-10**] with preserved oxygenation. He was given 1 dose of 80 mg IV lasix for ?volume overload. He was transferred to MICU on [**11-11**] for closer monitoring given these persistent fevers and tachypnea. On transfer, he had no significant complaints. He stated that his breathing felt at baseline, and he reported only mild LLQ pain. Past Medical History: Past Medical History: 1. Type 1 diabetes for 30+ years - last A1c of 5.5. 2. Coronary artery disease - status post multiple MIs, - status post CABG [**2104**]; LIMA to LAD, SVG to r PDA, SVG to SVG to OM - VT status post pacer/AICD placement was followed by Dr. [**Last Name (STitle) 284**] - ECHO [**2-11**] EF 20% . 3. Peripheral vascular disease status post fem-[**Doctor Last Name **] bypass, subclavian stenosis bilat. 4. Status post kidney and pancreatic transplant 12 years ago 5. CKD. Baseline Cr 1.9-2.8 6. Multiple UTI, history of self caths. 7. Chronic diarrhea 8. HTN Social History: Lives in [**Location **] MA with his wife and 30 year old daughter. Quit smoking cigarettes 20 years ago, + cigars, no EtOH or recreational drugs. He is currently on disability. Family History: Mother - DM, died of MI Father - died of stomach cancer Siblings - DM Daughter - DM Physical Exam: PE VS: 102.3 144/86 109 24 98% 2L Gen: pleasant male, speaking in short sentences, mildly uncomfortable, mild distress HEENT: PERRL, OP clear Neck: no JVD appreciated Lungs: some decreased BS at bases, mild crackles/wheezing diffusely CV: RRR, nl s1/s2, no m/r/g, with well-healed midline scar Abd: protuberant, mild tenderness in LLQ but no reb/guard, nabs Extr: no c/c/e, weak peripheral pulses bilat, sensation intact to LT in LE Skin: multiple bruises/ecchymotic regions, esp on upper extremity Pertinent Results: HEME: . [**2108-11-8**] 02:30AM BLOOD WBC-20.4*# RBC-4.80 Hgb-14.8 Hct-42.6 MCV-89 MCH-30.7 MCHC-34.6 RDW-15.6* Plt Ct-157 [**2108-11-8**] 02:50AM BLOOD WBC-19.3* RBC-4.90 Hgb-15.1 Hct-43.3 MCV-88 MCH-30.9 MCHC-35.0 RDW-15.5 Plt Ct-152 [**2108-11-8**] 08:30AM BLOOD WBC-16.6* RBC-4.11* Hgb-12.7* Hct-36.5* MCV-89 MCH-30.8 MCHC-34.8 RDW-15.5 Plt Ct-135* [**2108-11-13**] 05:10AM BLOOD WBC-10.7 RBC-3.58* Hgb-10.9* Hct-31.9* MCV-89 MCH-30.4 MCHC-34.1 RDW-15.7* Plt Ct-136* [**2108-11-14**] 04:57AM BLOOD WBC-10.5 RBC-3.42* Hgb-10.7* Hct-30.6* MCV-90 MCH-31.1 MCHC-34.8 RDW-15.6* Plt Ct-152 [**2108-11-15**] 04:55AM BLOOD WBC-9.1 RBC-3.80* Hgb-11.4* Hct-35.3* MCV-93 MCH-30.0 MCHC-32.4 RDW-15.6* Plt Ct-197 [**2108-11-8**] 02:30AM BLOOD Plt Smr-NORMAL Plt Ct-157 [**2108-11-8**] 02:50AM BLOOD PT-14.9* PTT-30.2 INR(PT)-1.5 [**2108-11-8**] 02:50AM BLOOD Plt Ct-152 [**2108-11-14**] 04:57AM BLOOD Plt Ct-152 [**2108-11-15**] 04:55AM BLOOD Plt Ct-197 . CHEM: . [**2108-11-8**] 12:52AM BLOOD UreaN-71* Creat-3.2* Na-127* K-6.8* Cl-96 HCO3-11* AnGap-27* [**2108-11-8**] 02:30AM BLOOD Glucose-102 UreaN-72* Creat-3.3* Na-128* K-6.1* Cl-97 HCO3-9* AnGap-28* [**2108-11-8**] 02:50AM BLOOD Glucose-106* UreaN-72* Creat-3.3* Na-129* K-5.8* Cl-98 HCO3-15* AnGap-22* [**2108-11-13**] 09:40AM BLOOD Glucose-113* UreaN-61* Creat-2.9*# Na-133 K-4.1 Cl-100 HCO3-17* AnGap-20 [**2108-11-14**] 04:57AM BLOOD Glucose-91 UreaN-74* Creat-3.1* Na-132* K-4.3 Cl-102 HCO3-15* AnGap-19 [**2108-11-15**] 04:55AM BLOOD Glucose-76 UreaN-69* Creat-2.9* Na-136 K-3.9 Cl-106 HCO3-13* AnGap-21* [**2108-11-15**] 04:55AM BLOOD Calcium-8.4 Phos-4.5 Mg-1.8 . CARD ENZYMES: . [**2108-11-11**] 06:35AM BLOOD CK-MB-3 cTropnT-0.10* [**2108-11-11**] 12:44PM BLOOD CK-MB-2 cTropnT-0.14* [**2108-11-12**] 04:13AM BLOOD CK-MB-2 cTropnT-0.08* . MISC . [**2108-11-11**] 12:44PM BLOOD Hapto-200 [**2108-11-10**] 06:55AM BLOOD TSH-1.2 [**2108-11-12**] 04:13AM BLOOD Cortsol-22.0* . ABG . [**2108-11-10**] 11:40AM BLOOD Type-ART Temp-38.9 O2 Flow-2 pO2-116* pCO2-30* pH-7.40 calHCO3-19* Base XS--4 Intubat-NOT INTUBA Comment-NOTIFIED D [**2108-11-11**] 09:53AM BLOOD Type-ART Temp-36.8 pO2-68* pCO2-30* pH-7.50* calHCO3-24 Base XS-0 [**2108-11-11**] 09:06PM BLOOD Type-ART O2 Flow-4 pO2-65* pCO2-36 pH-7.42 calHCO3-24 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] . UA . [**2108-11-8**] 02:00AM URINE RBC-0-2 WBC-[**10-28**]* Bacteri-MANY Yeast-NONE Epi-[**5-18**] [**2108-11-15**] 05:29AM URINE RBC-2 WBC-0 Bacteri-OCC Yeast-NONE Epi-<1 RenalEp-<1 . Recent Micro history: [**2108-10-18**] enterococcus pan [**Last Name (un) 36**] [**2108-8-10**] Klebsiella R to bactrim [**7-12**] E Coli I to amp/sulb, cefuroxime pip; R to cipro, levo, gent, bactrim, amp; S to ceftriaxone, [**Last Name (un) 2830**], nitrofurantoin, tobra, pip/tazo , EKG: sinus tach 109, RBB morphology, nl axis, no significant change from prior . [**Last Name (un) **] US . TECHNIQUE: [**Last Name (un) 2793**] ultrasound including Doppler son[**Name (NI) 867**]. FINDINGS: The transplanted kidney is identified in the left lower quadrant. The transplanted kidney measures 12.5 cm. There is no evidence of hydronephrosis or peritransplant fluid collection. The main [**Name (NI) **] artery and vein are patent. The arterial resistive indices obtained in the upper, mid, and lower portions of the [**Name (NI) **] parenchyma reveal minimal diastolic flow and range between 0.91 and 1. Arterial waveforms reveal a sharp upstroke, however, minimal diastolic flow is seen. These findings are significantly worse than prior study on [**2108-8-6**], which revealed resistive indices ranging between 0.66 to 0.82. IMPRESSION: Significantly worsened resistive indices, concerning for rejection. No evidence of hydronephrosis or peritransplant fluid collection . CXR . PA AND LATERAL CHEST RADIOGRAPHS: A pacemaker is seen overlying the left hemithorax, with the leads positioned within the right atrium and ventricle. Mediastinotomy wires can be seen from prior CABG. Several of these appear to be broken. Again seen is a left pleural effusion, with a rounded associated opacity, representing either atelectasis or a mass. The remainder of the lung fields are clear. The soft tissue and osseous structures are stable. IMPRESSION: There is a rounded opacity at the left lower lung zone with an associated left pleural effusion. The differential includes atelactasis or a mass lesion. This is probably not changed in comparison to the prior study. . CT chest /abd / plevis . IMPRESSION: 1. Multifocal ground glass opacities in the upper lobes, right greater than left. This appearance could represent infection, correlate clinically, fluid overload could also have this appearance. 2. Bilateral pleural effusions. 3. Unchanged ovoid soft tissue opacity in the left lower lobe, that might represent round atelectasis, an occult neoplasm cannot be excluded. 4. Unusually large cystic area extending from the pancreas transplant to the bladder with fluid content and small bubble of air, this could represent some kind of stenosis in the distal anastomosis, correlate with surgical history. . ECG . Sinus rhythm Right bundle branch block Left atrial abnormality Inferior infarct, age indeterminate Anterior myocardial infarct, age indeterminate Clinical correlation is suggested Since previous tracing of [**2108-11-12**], ventricular ectopy absent and ST-T wave changes less prominent Brief Hospital Course: BRIEF SUMMARY: This 53 year old male presented with signs and symptoms of urniary tract infection / inability to pass self catheter. He was found to have an E.coli UTI and bacteremia. He was treated with broad antibiotics. He became tachypnic on the floor, and azithromycin was added for coverage of a possible retrocardiac density on CXR. He was transferred to MICU when he became tachypnic and alkalotic for closer monitoring. He returned to the floor more comfortable. His culture data cleared, and foley was kept in until discharge. . . 1. Fever/SIRS: He had pus / E.coli in urin on admission, with subsequent [**1-13**] positive blood cultures. He was started on CTX in ED, and was changed to zosyn on admission. He had an extensive history of quinolone resistant bugs, as well as recurrent pan-sensitive enterococcus infections. He was also started on azithromycin for a presumed pneumonia, as he was coughing with a possible density seen on CXR.He was c.dif negative, and his blood cultures cleared. Infectious disease was consulted. There was not felt to be an infection around his pacer site. His cortisol level was adequate (22). . DIFFICULTY PASSING CATHETER: This was felt to be most likely from repeated attempts and localized tissue swelling and edema. He is followed by urology, who consulted on patient while in hospital. They placed foley, and recommended that it stay in place until follow up. He was draining adequate urine. CT scan was reviewed and they felt the catheter was adequately placed and changes in bladder were due to pacnreatic conduits and not any bladder pathology. Of note, he self-removed his foley catheter prior to discharge against medical advice. He did demonstrate before he was discharged that you could successfully self-catheterize. . 2. Tachypnea: he delveloped tachypnea on day two of admission. His ABG showed pH 7.5. He was treated for underlying pneumonia. He also has EF of 20%, but appeared to be euvolemic at the time. Lasix was dosed as needed, given [**Month/Day (4) **] failure. His elevated pH was felt to be due to NaHCO3 in fluids, which was added given anion gap and low bicarb. His CT scan was negative for PE, but with ground-glass opacities in upper lobes and other old findings. He was ruled out for MI with enzymes. His breathing status improved, and was not requiring oxygen the last 24 hours of his admission. He completed a course of abx for pneumonia, lasix dose returned to baseline. His bicarb was felt to be chronically low, and recommendations on repletion were done by [**Month/Day (4) **] team. . 3. Metabolic Acidosis: He had an AG acidosis, which was felt to be due to [**Month/Day (4) **] failure. His lactate was marginally elevated, and returned to [**Location 213**] by discharge. It was also possible due to his bacteremia. He was treated with antibiotics, and his reanal function gradually returned to baseline. . 4. Transplant: does not require insulin [**1-11**] pancreas transplant, kidney with some signs of rejection on US; b/l cr =1.5-2.8. [**Month/Day (2) 2793**] and transplant surgery following. We continued prednisone/rapamune, ck daily [**Last Name (un) **] levels which were adequate. [**Last Name (un) 2793**] and transplant followed closely. . 5. CV: -Rhythm - on amiodarone, sinus on tele, kept lytes adequate, without AICD firing. -Pump: EF of 20% - received lasix intermittently and then returned to op regimen on dicahrge. His aldosterone was held on admission due to hyperkalemia. he was kept on imdur / hydral. -CAD: Continued [**Last Name (un) 4532**], lopressor, statin, hydral/nitrate. Daily EKGs without ischemic chages. He ruled out for MI with enzymes. . 6. PVD: no active sx, cardiac rx as above . 7. Anemia: b/l 36-40, with drop to 32 today, no obvious source. His hematocrit stabilized. His stools were guaiac negative, and hemolysis labs were unrevealing.. 8. FEN: [**Last Name (un) **] diet, monitor lytes carefully . 9. PPX: Sq hep, taking POs, bowel meds if necessary . 10. Code: Full . 11. Communication: daughter . Medications on Admission: Meds at home: Reglan 5 mg 4 times a day Hydralazine 25 mg 4 times a day isorbide Moni ER 30 mg daily Rapamune 1 mg daily Loressor 75 mg [**Hospital1 **] Prednisone 5 mg daily Rocatrol 0.25 mcg daily Loperamide 2 mg TID Potassium Chloride 20 meq daily Lipitor 80 mg daily Aldactone 25 mg daily [**Hospital1 **] 75 mg daily Bicitra 15 cc TID AMiodarone 200mg daily Neutra phos valium 5 mg PRN Prosom 2 mg PRN Lasix 80 mg [**Hospital1 **] Macrodantin 50 mg daily . All: NKDA (>cipro) . Meds on transfer: Combivent Amio 200 mg Lipitor 80 mg Bicitra 15 ml TID Azithro 250 mg started [**11-9**] Zosyn 2.25 QID started [**11-10**] (changed from CTX) Calcitriol 0.25 mcg daily Valium PRN Halcion qhs SQ hep TID Hydralazine 25 mg Q6H Imdur 30 mg daily Lopressor 75 mg [**Hospital1 **] Reglan 10 mg QID Prednisone 5 mg Sirolimus 1 mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 3. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 11. Sirolimus 1 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Forty Five (45) ML PO TID (3 times a day). Disp:*qs * Refills:*2* 14. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day for 15 days. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Urinary tract infection Bacteremia Congestive heart failure End stage [**Hospital1 **] disease s/p kidney transplant Discharge Condition: Stable, ambulating, afebrile, tolerating PO diet, able to self-cath himself adequately prior to discharge Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please keep your follow up appointments as scheduled. You are to continue your antibiotics until you see your urologist. Please continue to take all medications as prescribed. You will continue to take you antibiotic for 15 more days. Your bicitra dose has been increased to 45 three times per day. YOu should now take 1.5 rapamune pills instead of 1. If you experience chest pain, difficulty breathing, high fever, shaking chills, decreased urination, please seek immediate medical attention. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2108-11-22**] 1:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2108-11-29**] 2:50 Please call Dr. [**First Name (STitle) 805**] for a follow up appointment next week at [**Telephone/Fax (1) 3637**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14932, 14938

8760, 12845

295, 301

15099, 15207

3311, 8737

15852, 16212

2682, 2768

13727, 14909

14959, 15078

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15231, 15829

2783, 3292

235, 257

329, 1866

1910, 2470

2486, 2666

13373, 13704

45,193

195,471

4839

Discharge summary

report

Admission Date: [**2187-9-21**] Discharge Date: [**2187-9-29**] Date of Birth: [**2132-1-31**] Sex: F Service: MEDICINE Allergies: Ceclor / E-Mycin / Penicillins Attending:[**First Name3 (LF) 898**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Mrs [**Known firstname 2411**] [**Known lastname 16232**] is a 55 yo F w no significant PMH, who was on azthromycin for outpatient treatment of LLL pneumonia for 5 days and who p/w worsening cough, fever, malaise and dyspnea on exertion. The patient sx started two weeks ago when she felt she had caught a cold or a sinus infection. She had a dry cough, and fullness in her head.-- of note the patient is the director of a nursery home and many children and parents have been sick recently. On [**9-17**], she was started on a course of azythromycin and diagnosed with LLL pneumonia later that week. 5 days later, her sx had worsened, the pt was complaining of productive cough, DOE and pleuritic chest pain and temperature of 101.5 taken orally. On a follow up appt on [**9-21**], the pt was found to be tachy in the 130s and sating 85% on RA. She was advised to go to the ED. The pt did not complain of bloody sputum, N/V, HA, neck stiffness, bloody stool or dysuria. Past Medical History: # Headache # Sinusitis # TMJ # Raynauds - takes nifedipine in the wintertime # s/p partial thyroidectomy for nodules, on levothyroxine Social History: The patient lives in [**Location **] with her husband and two daughters. She is a nursery school director and is regularly in contact with many young children. Family History: [**Name (NI) 20238**], father. Asthma-mother. Father died for renal failure. Physical Exam: VS: 100.8 HR111 BP 127/61 RR32 95% 5LNC GEN: pleasant middle aged female in NAD, comfortable. HEENT: NC/AT. MMM. O/P erythematous, no exudates, + submandibular LAD. NECK: supple. No JVD. CV: regular tachycardia, nlS1, S2, [**1-31**] HSM throughout precordium. RESP: bronchial BS with inspiratory crackles in LLL, RML, and occasianl scattered rhonchi which clear with coughing. No accessory muscle use. Egophony E-->A LL, LM lobe and RML. Dullness to percussion L middle and base and R middle. ABD: S/NT/ND, + BS EXT: WWP, no c/c/e NEURO: AOx3. Non focal. Pertinent Results: [**2187-9-21**] 01:46PM LACTATE-1.2 [**2187-9-21**] 01:38PM PT-14.0* PTT-32.8 INR(PT)-1.2* [**2187-9-21**] 12:57PM K+-4.3 [**2187-9-21**] 10:40AM GLUCOSE-119* UREA N-18 CREAT-0.8 SODIUM-133 POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-25 ANION GAP-18 [**2187-9-21**] 10:40AM IRON-19* [**2187-9-21**] 10:40AM calTIBC-165* FERRITIN-575* TRF-127* [**2187-9-21**] 10:40AM WBC-13.9*# RBC-3.43* HGB-11.2* HCT-32.0* MCV-93 MCH-32.6* MCHC-34.9 RDW-12.9 [**2187-9-21**] 10:40AM NEUTS-88.9* LYMPHS-7.1* MONOS-3.7 EOS-0.2 BASOS-0.1 [**2187-9-21**] 10:40AM PLT COUNT-394 [**2187-9-21**] 10:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2187-9-21**] 10:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2187-9-21**] 10:40AM URINE RBC-[**2-28**]* WBC-[**6-5**]* BACTERIA-MOD YEAST-NONE EPI-0-2 Microbiology: [**1-29**] blood cx from [**9-22**] - coagulate neg Staph Sputum GS shows moderate OP flora. GPC in pairs, chains and clusters. Urine cx negative for legionella. . Studies CXR [**9-21**] PA and lateral views of the chest are obtained. There is dense air space consolidation noted in the right middle lobe and left lower lobe with air bronchograms. There is silhouetting of the left hemidiaphragm and right heart border. Findings are compatible with right middle lobe and left lower lobe pneumonia. There has been significant interval progression over the last four days. Heart size is difficult to assess but appears grossly unremarkable. Mediastinal contour is normal. No pneumothorax is seen. Osseous structures appear intact. IMPRESSION: Dense consolidation in the right middle lobe and left lower lobe compatible with pneumonia. Significant interval progression over the last four days. Chest CT [**9-22**] Multifocal pneumonia in both lower lobes and posterior segment of RUL w/ small bilateral pleural effusions. Brief Hospital Course: Vitals in the ED were 99.8 106 117/69 16 94%RA. She desatted to 88% on 2L NC with tachypnea to 23. CXR showed worsening pneumonia w/ dense consolidation on LLL. Blood cx were drawn. She was started on levo, vanc, gent and nebs. She was transfered to the MICU because of increasing O2 requirements. In the MICU, her abx regimen was changed to levaquin and aztreonam and she received 1L NS. Pneumonia Multifocal azithromycin-resistant community acquired pneumonia, responded to antimicrobial therapy and afebrile for 72hours. Although the pt was in no resp distress, she stilled requiring 2 L O2. Most likely organism is drug-resistant S. pneumoniae. Legionella urine test negative and blood cultures grew coag neg Staph. The patient has no comorbidity and no risk factors for pseudomona infx. Further, no known prior influenza infx. Had CXR and CT chest during hospital course indicating presence of small bilateral pleural effusions. Per pulmonary, effusions were too small to tap for diagnostic thoracocentesis. Furthermore, possibility of empyema or parapneumonic effusion less likely as the pt began to clinically improve on antibiotics. - treated with vancomycin 1g IV daily for 5 days due to GPC on intial blood culture. Once speciation indicated coag neg, discontinued vancomycin. Treated with levofloxacin and aztreonam. Will send home to complete 14 day course of Levaquin (day [**6-9**] on [**9-27**]). - we administered PRN nebs for wheezing and shortness of breath - we administerd nasal NaCl for dry nares - O2 was given as tolerated to target O2 sat >93-94% Depression - administered home dose of citalopram . Hypothyroid - administered home dose of levothyroxine, deferred checking TFTs in setting of acute illness. Last normal was approximately 1 year ago. . Anemia - mild, Iron studies consistent w anemia of acute disease - infection/inflammation. - we follwed hct, which was stable. Thrombocytosis - likely acute phase reactant Completed by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 20239**], MS4 Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-27**] Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pneumonia Secondary Diagnosis: Headache Sinusitis TMJ Raynauds - take nifedipine in the wintertime s/p partial thyroidectomy for nodules, on levothyroxine Discharge Condition: Stable, afebrile and shortness of breath improved. No clinical instability. Discharge Instructions: You were admitted with complaints of fever and chest pain. Chest xray showed that you had a pneumonia. You were given antibiotics, which resolved you fever and improved your symptoms. You will need to complete your home course of Levaquin for the next week. It is important that you take 1 dose each morning. It is important that you take every dose and do not miss a day. Otherwise we did not make any changes to your outpatient medication regimen. Please call your doctor or return to the emergency if you experience any of the following: high fever, shaking chills, worsening cough with sputum production, worsening short of breath, or worsening chest pain. Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week. Completed by:[**2187-9-29**]

[ "443.0", "473.9", "244.9", "311", "285.9", "486", "511.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6640, 6646

4270, 6311

298, 305

6865, 6943

2326, 4247

7656, 7777

1656, 1734

6334, 6617

6667, 6667

6967, 7633

1749, 2307

251, 260

333, 1305

6718, 6844

6686, 6697

1327, 1463

1479, 1640

32,743

113,825

10122

Discharge summary

report

Admission Date: [**2200-3-22**] Discharge Date: [**2200-3-27**] Date of Birth: [**2124-1-13**] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Allopurinol Attending:[**First Name3 (LF) 1646**] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD and colonoscopy History of Present Illness: Mr. [**Known firstname 12056**] [**Known lastname 174**] is a very nice 76 year-old gentleman with PAFib on coumadin, DM2, HTN, severe PVD, anemia, stomach ulcers, duodenitis who comes with shortness of breath and melena. He was in his prior state of health until [**2200-2-27**] when he came with shortness of breath and melena and was admitted to our hospital with UGIB. He required 3 RBC units and underwent EGD, which showed duodenitis, erythema of the antrum with an ulcer that was injected and clipped. He was treated for H. pylori and was discharged home on [**2200-3-1**] with an HCT of 26. He was doing well, followed with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2200-3-11**] who rechecked his HCT and found it at 27. He had been taking his [**Year (4 digits) **] [**Hospital1 **], which was continued as well as his H. pylori treatment (amox/clarithro/omeprazole). . Over the past three days he has noticed melanotic stools, some mild shortness of breath with activity and back pain. . In our ED his initial VS were: T 98.7 F, HR 66 BPM, BP 97/65 mmHg, RR 18 breaths per minute, SpO2 100% on RA. On physical exam he looked comfortable, no abdominal pain and had guaiac positive stools. His NG lavage showed 2 clots, but no bright red blood. He had placed 2 18G. His initial labs showed INR of 4.0 with a HCT of 18 from his last one ~10 days ago of 27. Interestingly, his WBC showed leukocytosis of 11.7 with 1,895 eosinophils. Pt got reversed with 2 FFP, 10 mv of IV vitamin K and got 1 unit of blood. His VS were stable throughout his ER stay (per ED sign out). His most recent vital signs were HR 65 BPM, HR 130/52 mmHg, RR 20 breaths X', RpO2 100 RA. GI was called and is aware, but have not seen him yet. Past Medical History: -PVD: s/p peripheral angiography & angioplasty L peroneal and anterior tibial [**1-/2200**] -CAD s/p CABG on [**9-/2198**] -Right LE cellulitis at vein harvest site (admission [**Date range (3) 33634**]), cx grew Pseudomonas, on cipro and linezolid until [**10/2198**] -Diabetes Mellitus -Hypertension -Peripheral [**Year (4 digits) **] Disease -Chronic Renal Insufficency -Chronic Anemia -Hyperlipidemia -Gangrene of L foot (tips of 4th and 5th digits) -Gout -Osteoarthritis -Cataracts -Carotid stenosis - s/p L CEA [**9-10**] Social History: Daughter lives with patient in his appt, ~60pkyr history, quit [**2182**] Family History: Father: stroke, died in his late 70s Mother: pulmonary embolism after hip fracture, died at age 88 Physical Exam: VITAL SIGNS - Temp 96.6 F, BP 114/45 mmHg, HR 66 BPM, RR 11, O2-sat 100% RA GENERAL - well-appearing man in NAD, comfortable, appropriate, jaundiced (skin, mouth, conjuntiva) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-7**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2200-3-22**] 09:15AM BLOOD WBC-11.7* RBC-1.89*# Hgb-5.6*# Hct-18.4*# MCV-97 MCH-29.5 MCHC-30.4* RDW-18.0* Plt Ct-473*# [**2200-3-22**] 03:11PM BLOOD Hct-18.3* [**2200-3-22**] 07:40PM BLOOD Hct-17.2* Plt Ct-351 [**2200-3-23**] 12:55AM BLOOD Hct-22.8*# [**2200-3-23**] 04:02AM BLOOD WBC-9.8 RBC-2.94*# Hgb-8.9*# Hct-26.6* MCV-91 MCH-30.2 MCHC-33.4 RDW-18.0* Plt Ct-341 [**2200-3-23**] 08:39AM BLOOD Hct-26.0* [**2200-3-22**] 09:15AM BLOOD PT-38.2* PTT-38.4* INR(PT)-4.0* [**2200-3-22**] 03:11PM BLOOD PT-21.6* INR(PT)-2.0* [**2200-3-23**] 12:55AM BLOOD PT-16.7* INR(PT)-1.5* [**2200-3-23**] 04:02AM BLOOD PT-16.0* PTT-30.1 INR(PT)-1.4* [**2200-3-22**] 09:15AM BLOOD Glucose-112* UreaN-120* Creat-5.6* Na-141 K-5.1 Cl-110* HCO3-13* AnGap-23* [**2200-3-23**] 12:55AM BLOOD Glucose-78 UreaN-106* Creat-4.8* Na-144 K-4.1 Cl-113* HCO3-18* AnGap-17 [**2200-3-23**] 04:02AM BLOOD Glucose-76 UreaN-102* Creat-4.8* Na-147* K-4.1 Cl-114* HCO3-17* AnGap-20 [**2200-3-23**] 12:55AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.2 [**2200-3-23**] 04:02AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.2 EGD had erosions in his stomach that showed no evidence of active or recent bleeding. His c-scope had multiple diverticuli and a moderate sized ulcer that may have been the source of bleeding. Brief Hospital Course: Mr. [**Known firstname 12056**] [**Known lastname 174**] is a very nice 76 year-old gentleman with PAFib supratherapeutic on coumadin, DM2, HTN, severe PVD, anemia, stomach ulcers, duodenitis and recent UGIB coming with melena and clots in his NG-lavage. . #. Upper GI Bleed/Anemia. The patient has a recent gastric ulcer which was cauterized and injected on his last admission. Presented again with 10 point Hct drop in setting of supratherapeutic INR. Positive NGL, recent gastric ulcer, and melena suggestive of upper GI bleed. Patient was transfused 3 units of PRBC with an appropriate increase in his hematocrit. Also given vit k and FFP. HCT stabilized. EGD revealed non bleeding erosions in the stomach with the clips still in place from the last procedure. Because no evidence of current or recent bleeding, c-scope with prep revealed diverticuli and an ulcer which was a possible source of the bleed. After much discussion with the patient's outpatient provider and daughter, [**Name Initial (PRE) **] elected to discharge the patient on aspirin/plavix and to avoid coumadin for now. This should be readdressed if the patient does well with no further bleeding issues. #. Back pain: The patient's chief complaint on presentation was actually back soreness. We added standing tylenolol and a lidocaine patch. Oxycodone prn. He has experienced success in the past with PT for back pain, so scheduled this for home. # Coagulopathy. On presentation, INR was 4.0. He was given Vitamin K IV and four units of FFP, with a reversal of his anticoagulation to 1.5. His home coumadin. aspirin and plavix were held. Restarted on discharge. . #. Paroxismal Atrial Fibrillation. H/o PAF. Now in sinus rhythm. Rate controlled with metoprolol. . #. Peripheral [**Name Initial (PRE) 1106**] disease. Patient is s/p peripheral angiography & angioplasty L peroneal and anterior tibial 1/[**2200**]. Restarted ASA/plavix. . #. Coronary artery disease. Patient is s/p CABG in [**9-10**]. BB/statin/asa/plavix. . -Chronic Renal Insufficency - with eGFR of 12 ml/min (MDRD) Stage V CKD with target PTH 150-300 (check every 3 mo). Last Cr check 3.9. . -Chronic Anemia - baseline Hct 28-30. . -Carotid stenosis - s/p L CEA [**9-10**]. Stable. NTD . #. Diabetes mellitus type 2. On glipizide at home. Covered with insulin in hospital. Restarted at discharge. . #. Hyperlipidemia. - continued simvastatin Plan d/w daughter, [**Name (NI) **] [**Telephone/Fax (1) 33635**] Medications on Admission: Amlodipine 10 mg Daily Plavix 75 mg PO Daily EPO [**2190**] U SQ QMWF Furosemide 20 mg PO Daily Glipizide 2.5 mg PO Daily Metoprolol 50 mg PO BID Simvastatin PO Daily Sucralfate 1 g PO QID Coumadin 2 mg PO Daily Aspirin 325 mg PO Daily Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 3. Epoetin Alfa 2,000 unit/mL Solution Sig: [**2190**] ([**2190**]) units Injection MWF. 4. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 10. Percocet 5-325 mg Tablet Sig: 0.5-1 Tablet PO every four (4) hours as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 11. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day as needed for back pain: to low back, 12hrs on and 12 off. . Disp:*5 2* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: 578.9 BLEEDING, GASTROINTESTINAL NOS Secondary Diagnosis: 250.00 DIABETES TYPE II, CONTROLLED, W/O COMPLICATIONS Secondary Diagnosis: 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (15-29) Secondary Diagnosis: 414.05 CAD, BYPASS GRAFT Secondary Diagnosis: 427.31 ATRIAL FIBRILLATION Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN Secondary Diagnosis: 285.1 ANEMIA, ACUTE BLOOD LOSS Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: As we discussed, you were admitted with a intestinal bleed. We have resumed your anticoagulation including aspirin and plavix so you will still be a risk for this happening again. Coumadin has been discontinued for now. Please monitor your stools for any sign of black or bloody bowel movements. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: FRIDAY [**2200-3-28**] at 10:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site

[ "578.1", "272.4", "250.70", "585.4", "285.1", "427.31", "V58.61", "403.90", "V45.81", "440.20", "584.9", "414.00" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.13" ]

icd9pcs

[ [ [] ] ]

8901, 8959

5128, 7595

301, 323

9397, 9397

3844, 5105

9866, 10233

2765, 2866

7882, 8878

8980, 8980

7621, 7859

9546, 9843

2881, 3825

255, 263

351, 2105

9343, 9376

8999, 9036

9412, 9522

2127, 2657

2673, 2749

25,921

184,955

5990

Discharge summary

report

Admission Date: [**2150-11-2**] Discharge Date: [**2150-11-11**] Service: CARD [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 23598**] is an 86 year old woman with a known history of aortic stenosis with a previous hospital admission significant for congestive heart failure. Recently, she became more symptomatic especially more short of breath and more fatigued. She had an echocardiogram on [**11/2149**], which showed a left ventricular ejection fraction of 65%, aortic stenosis with a peak gradient of 42, severe MAC, one plus mitral regurgitation and trivial tricuspid regurgitation. She also had a Persantine MIBI in [**11/2149**], which revealed mild ischemia of the apical segment of the inferior wall and a mild fixed defect of the apical segment of the anterior wall. Her dyspnea significantly progressed since then. Most recently, an echocardiogram showed aortic gradient of 68, and left ventricular hypertrophy with good left ventricular function. The patient was consequently referred for cardiac catheterization for further evaluation. PAST MEDICAL HISTORY: 1. Congestive heart failure. 2. Aortic and mitral valve disease. 3. Hypertension. 4. Hyperlipidemia. 5. Diabetes mellitus. 6. Glaucoma. 7. Peripheral vascular disease. 8. History of cerebrovascular disease with mild right sided weakness. 9. Legally blind. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Partial hysterectomy. 3. Status post left femoral-popliteal bypass graft. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Enteric-coated aspirin 325 mg q. day. 2. Lasix 20 mg p.o. twice a day. 3. Atenolol 25 mg p.o. q. day. 4. Cozaar 50 mg p.o. q. day. 5. Plendil 10 mg p.o. twice a day. 6. Lipitor 10 mg p.o. q. day. 7. Micronase 5 mg p.o. q. day. 8. Xalatan one drop in each eye q. day. 9. Timoptic q. a.m. both eyes. 10. Caltrate. 11. Multivitamins. LABORATORY STUDIES; White blood cell count 7.4, hematocrit 11, platelets 240. Sodium 132, potassium 4.8, BUN 26, creatinine 0.8, glucose 113, magnesium 1.9. SUMMARY OF HOSPITAL COURSE: Given symptomatic disease, the patient underwent cardiac catheterization on [**2150-11-2**]. The findings were 30% distal stenosis of the LMCA, 60 to 70% stenosis of the left anterior descending, mild disease of the left circumflex and 95% stenosis of the right coronary artery. On [**2150-11-3**], the patient underwent aortic valve replacement with 21 millimeter pericardial valve, C-E and coronary artery bypass grafting times two, left internal mammary artery to the left anterior descending, and saphenous vein graft to patent ductus arteriosus. The patient tolerated the procedure well. There were no complications. Please see the full Operative Report for details. She was transferred to the Intensive Care Unit in stable condition. She remained intubated. She remained in sinus rhythm. Given the hematocrit of 23, she was transfused with two units of blood. She continued to make adequate urine. The patient was extubated on postoperative day one which she tolerated well. She remained arousable and responsive. Her heart rate and blood pressure remained stable. Physical Therapy was consulted which followed the patient throughout her hospitalization. The patient was transferred to the Floor on postoperative day three. She was noted to be wheezing and appeared mildly fluid overloaded on examination. A chest x-ray showed atelectasis and right sided pleural effusion. She was diuresed further with good response. Respiratory Care was called which gave the patient nebulizer treatments with good response. She was encouraged to use incentive spirometry. The patient was also noted to be slightly hypertensive and her medications were adjusted accordingly. A repeat chest x-ray showed improvement in both lung fields. The patient was discharged to the [**Hospital3 **] facility on [**2150-11-11**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: [**Hospital3 **] facility. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting times two. 2. Aortic disease status post aortic valve replacement. 3. Noninsulin dependent diabetes mellitus. 4. Hypertension. 5. Hypercholesterolemia. 6. Peripheral vascular disease. 7. Congestive heart failure. DISCHARGE MEDICATIONS: 1. Cozaar 50 mg p.o. q. day. 2. Lopressor 12.5 mg p.o. twice a day. 3. Lasix 40 mg p.o. twice a day times 14 days, then 20 mg p.o. twice a day. 4. Potassium chloride 20 mEq p.o. twice a day with Lasix. 5. Aspirin 325 mg p.o. q. day. 6. Percocet one to two tablets p.o. q. four to six hours p.r.n. pain. 7. Albuterol and Atrovent nebulizers p.r.n. 8. Glyburide 5 mg p.o. q. day. 9. Insulin (regular) sliding scale p.r.n. 10. Lipitor 10 mg p.o. q. day. 11. Micronase. 12. Xalatan one drop to both eyes q. day. 13. Timoptic q. a.m. both eyes. 14. Caltrate. 15. Multivitamin. 16. Plendil 10 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with her surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**], in approximately four weeks. 2. The patient is to follow-up with Dr. [**Last Name (STitle) **], her Cardiologist, in approximately two to three weeks. 3. The patient is to follow-up with Dr. [**First Name (STitle) 216**], her primary care physician, [**Name10 (NameIs) **] approximately one to two weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 1741**] MEDQUIST36 D: [**2150-11-13**] 16:37 T: [**2150-11-13**] 18:45 JOB#: [**Job Number 23599**]

[ "424.1", "443.9", "428.0", "365.9", "414.01", "401.9", "272.4", "250.00", "438.21" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "36.15", "36.11", "37.23", "88.56", "88.53" ]

icd9pcs

[ [ [] ] ]

3989, 4017

4038, 4330

4353, 4971

4995, 5710

1414, 2071

2100, 3931

149, 1103

1125, 1391

3957, 3964

3,435

118,270

7130

Discharge summary

report

Admission Date: [**2148-4-27**] Discharge Date: [**2148-5-2**] Date of Birth: [**2092-8-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6114**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: intubation right internal jugular line EGD Colonoscopy History of Present Illness: 55 year old male with a history of rectal cancer s/p polypectomy '[**41**], EtOH use with history of DTs/seizures, type 1 DM and depression who presented to [**Hospital3 **] on [**2148-4-26**] s/p fall at home. The patient lives alone at home and was brought in by his daughter, an [**Name (NI) 9168**], who received a phone call from her father on [**4-26**] after he experienced an unwitnessed fall at home (?syncope). Patient was orthostatic hypotensive (SBP110>>90 sitting unable to stand) at home. He appeared incoherent on the phone but complained of stomach aches/vomitting with no fevers/chills over the past 7 days. He also expressed that he had not taken his insulin for 3 weeks (reasons unclear). [**Name2 (NI) **] denied any EtOH in the past 10 days and his urine toxicology screen at [**Hospital3 **] was negative, although the pt is a poor historian. - In the ED at [**Hospital3 **], he was found to have a BS of 397 with a gap of 39 and an ABG of 7.02/15/95/95%. His UA was positive for glucose as well as ketones and bilirubin. In addition, his LFTS were mildly elevated at: ALP 183, ALT 97, AST 145. His chemistries were: Na 127/ K 4.2/ Cl 183/ HCO3 4.2/ BUN/Cr 32/1.8 - His CKs, troponins were flat without EKG changes. He had a WBC of 11.75, Hct of 31.6 and Plt 64. His Hct in [**12-12**] was 43. - His CXR on admission showed question of left lower lobe infiltrate and he was started on CTX/Azithro in the ED. This was changed to Flagyl/Unasyn in the ICU. - Overnight on [**4-26**] to [**4-27**], the patient had a witnessed seizure likely attributed to EtOH withdrawal in which he became incontinent of urine with post-ictal confusion for which he received Ativan. He did not have any repeat seizures. - In addition, he has been having guaiac positive stool but no melena/hematemesis with a Hct drop from 31.6 to 22 for which he was transfused 2 units PRBC on [**2148-4-27**] (last Hct before transfer was 25 at 4pm). His SBP dropped from 100s to mid 60-low 70s and a central line was placed on [**2148-4-27**] and he was resuscitated with fluids alone to the 100s without pressors. He also had received at least 6 liters IVF. - Furthermore, on [**2148-4-27**], the patient desaturated to the 80s on 6 liters NC which then became mid 90s on 100% FM. They attempted BIPAP but failed as the patient has a history of ?obstructed airway. They believe his respiratory distress was secondary to volume overload as corroborated with CXR and intubated the patient on [**4-27**] at 5:30pm. His vent settings on transfer are AC 500 x 15, FiO2=0.5, PEEP=5. - His mental status at [**Hospital3 **] on [**4-27**] was somnolent but arousable as he opens his eyes to voice but not able to provide a history. At baseline, he is A&Ox3, but difficutly with higher learning questions. He was placed on an insulin drip, IV PPI, and is receiving IV flagyl/unasyn for his bilateral pulmonary infiltrates. Past Medical History: 1) Rectal adenocarcinoma ca s/p excision [**2142-5-9**]. Colonscopy [**2144-5-13**] at [**Hospital3 **]: Moderate sigmoid diverticulosis. Moderate internal hemorrhoids. No polyps. 2) IDDM diagnosed 6 years ago, sees Dr. [**Last Name (STitle) **] at [**Last Name (un) **]. On Lantus and humalog SS. 3) Depression 4) EtOH abuse with h/o DTs. No known h/o cirrhosis, varices. 5) ? Diastolic CHF, EF >70% with near obliteration of the LV during systole Echo [**12-12**], no AS, trace AI, hyperdynamic LV, trace to mild TR, mild MR. 6) Psoriasis: on devonex Social History: Social: The patient has a history of five to ten to 20 years of alcohol abuse, drinking one pint of vodka a day. Tobacco 1ppd for many years. The patient is a former executive of a bank and was fired after 24 years during a merger of his bank. Had a wife and daughter but now lives alone. Family History: Mother with A.D. Cousins with EtOH abuse. Physical Exam: Tc=98.4 P=89 BP=127/86 RR=15 100% on AC 500 x 15 FIO2 .5 PEEP 5 Gen: Sedated, intubated, awakens to voice, appears older than stated age. HEENT: ETT in place, OGT in place. NC/AT. PERRL, anicteric. OP clear. Neck: Right IJ in place and site C/D/I. JVP not appreciated. Lungs: coarse BS b/l anteriorly. CV: RRR, nml S1S2, no m/r/g Abd: soft, ? TTP in RUQ but no HSM. ND. naBS. no bruits, masses. Ext: tr edema b/l LE. Radial, DP pulses 2+ b/l. Skin: diffuse erthematous plaques with scale. Neuro: sedated and intubated. Opens eyes to voice. Pertinent Results: [**2148-4-27**] 9:32p 89 3.8 \ 10.3 / 44 / 28.1 \ N:72.3 L:21.1 M:4.4 E:0.3 Bas:1.8 PT: 12.9 PTT: 30.7 INR: 1.1 133 104 15 AGap=16 -------------< 136 3.1 16 0.7 Ca: 7.8 Mg: 1.4 P: 1.7 D ALT: 48 AP: 133 Tbili: 1.5 Alb: 3.0 AST: 104 LDH: 247 Dbili: TProt: [**Doctor First Name **]: 81 Lip: 7 Other Blood Chemistry: Hapto: 139 HBsAg: Negative HBs-Ab: Negative HBc-Ab: Negative HAV-Ab: Positive IgM-HBc: Negative IgM-HAV: Negative HCV-Ab: Negative Discharge labs: [**2148-5-2**] 07:55AM BLOOD WBC-3.4* RBC-4.05* Hgb-13.3* Hct-38.2* MCV-94 MCH-32.8* MCHC-34.7 RDW-14.6 Plt Ct-152 [**2148-5-2**] 07:55AM BLOOD Glucose-106* UreaN-4* Creat-0.6 Na-132* K-3.7 Cl-95* HCO3-28 AnGap-13 [**2148-5-2**] 07:55AM BLOOD ALT-21 AST-26 AlkPhos-134* TotBili-1.0 [**2148-4-28**] 07:29AM BLOOD Ret Aut-1.2 [**2148-5-2**] 07:55AM BLOOD Albumin-3.2* Calcium-8.4 Phos-2.0* Mg-1.3* [**2148-4-29**] 04:15AM BLOOD VitB12-1594* Folate-8.5 [**2148-4-29**] 05:45PM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE [**2148-4-27**] 09:32PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2148-4-30**] 10:33 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2148-5-1**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2148-5-1**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [**2148-4-29**] 2:38 pm URINE **FINAL REPORT [**2148-5-1**]** URINE CULTURE (Final [**2148-5-1**]): NO GROWTH. [**2148-4-28**] 4:56 am BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): [**2148-4-27**] 10:40 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [**2148-4-30**]** GRAM STAIN (Final [**2148-4-28**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2148-4-30**]): NO GROWTH. CHEST (PORTABLE AP) [**2148-4-27**] 9:25 PM 1) Tubes and catheters as described. Note that the sidehole of the NG tube appears to be in proximity to the GE junction. This could be advanced several centimeters for better placement. 2) No CHF. 3) Multifocal infiltrates as described. ABDOMEN U.S. (COMPLETE STUDY) [**2148-4-29**] 3:04 PM Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. Cardiology Report ECHO Study Date of [**2148-4-29**] Conclusions: 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is probably normal but the images are not optimal and have limited views of the distal septum. Overall left ventricular systolic function is probably normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6.There is a trivial/physiologic pericardial effusion. Brief Hospital Course: 55 y.o. man with PMHx h/o significant for colon CA, EtOH abuse, type 1 DM now with DKA, multifocal pneumonia on levo/flagyl, possible CHF, hct drop with hypotension. In the [**Hospital Unit Name 153**] he was placed on an insulin drip, IV PPI, and IV flagyl/unasyn for his bilateral pulmonary infiltrates. He was extubated on changed to levo/flagyl. Insulin and versed drips were stopped on [**4-28**] in the afternoon. He was extubated [**4-28**] at 3 pm and called out on [**4-29**]. 1) resolving Diabetic Ketoacidosis: On admission to OSH, the patient had an ABG of 7.02/15/95/95% with a gap of close to 40 with ketones in his urine. The patient is known to Dr. [**Last Name (STitle) **] at [**Last Name (un) **] and was last on Lantus 12 units QHS and Humalog SSI 2-15 units in 9'[**46**] [**First Name8 (NamePattern2) **] [**Last Name (un) **] records. He was not using his insulin for a week prior ot admission because he "felt sick". He was put on an insulin drip and transitioned to sc insulin, glargine 10 QHS and sliding scale. [**Last Name (un) **] followed him in house and he was discharged on 10 of lantus with instructions to continue regardless. 2) Hypoxic Respiratory Failure - The patient was intubated during admission for respiratory failure. Ddx included PNA vs CHF. He had CXR with multilobar PNA, sputum culture with no growth. Blood cultures showed no growth. Possible CHF (Ef 70% in past, but had a LVOT gradient in '[**46**] with no AS and concentric LVH) as the patient was aggressively fluid resuscitated at the OSH, but his echo showed normal EF and no outflow obstruction. He was treated with levaquin and flagyl, and autodiuresed after extubation without lasix. 3) Anemia: The patient was having guaiac positive brown stool with no melena/hematemesis and found to have an acute drop in his Hct from 32 to 22 with aggressive IVF resuscitation at the OSH. His baseline Hct is 43 (1 year ago). The patient was transfused 2 units PRBC at the OSH; now Hct stable and no TF here. GI was consulted and EGD showed a gastric ulcer, grade 1 esophageal varices and duodenitis. He was continued on [**Hospital1 **] PPI. Colonoscopy with diverticulosis and no acute issues. He did not require further transfusion. 4) Blood pressure - He was initially hypotensive and received fluid but then became hyprrtensive and was started on lisinopril. 5) EtOH Withdrawal with seizure - The patient had GTC seizure at the OSH with a negative urine tox screen on presentation on [**4-26**] but a history of heavy EtOH use and depression. He denied drinking in the 10 days per patient which corroborates with EtOh of 0 at OSH. He was put on a CIWA scale with ativan/valium and given folate, thiamine, agressive electrolyte repletion. He had a social work consult and eill receive social work services as an outpatient. His daughter will also help monitor him at home. 6) Transaminitis: rising LFTS; AST>>ALT--likely due to alcoholic hepatitis. Hepatitis serologies were negative and RUQ ultrasound showed fatty liver infiltration. 7) Thrombocytopenia baseline in [**2142**] around 60-80. Most likely etiology is alcholic liver disease. No intervention was necessary. 8) Depression: continued celexa Medications on Admission: Outpt Meds: Neurontin, Insulin, Celexa, Prevacid. - Meds on Transfer: Insulin gtt (1U/hr); SC heparin; Protonix 40mg daily, Thiamine; MVI; Folate; Neurontin 600mg [**Hospital1 **]; Neutraphos; Flagyl 500mg tid; Unasyn 3g q6; prn APAP; versed gtt. Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). [**Hospital1 **]:*30 Cap(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). [**Hospital1 **]:*60 Capsule(s)* Refills:*2* 5. Calcipotriene 0.005 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). [**Hospital1 **]:*1 tube* Refills:*2* 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. [**Hospital1 **]:*21 Tablet(s)* Refills:*0* 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. [**Hospital1 **]:*7 Tablet(s)* Refills:*0* 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 10. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime: may need to be adjusted based on AM blood sugars- please keep in close communication with your [**Last Name (un) **] doctor. [**Last Name (Titles) **]:*1 bottle* Refills:*3* 11. Humalog 100 unit/mL Solution Sig: as directed per sliding scale units Subcutaneous four times a day: please take per [**Hospital1 18**] humulog sliding sacle 4 times a day. [**Hospital1 **]:*1 bottle* Refills:*2* 12. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pneumonia Diabetic Ketoacidosis Anemia Diabetes Type II Hypertension Congestive Heart Failure s/p intubation Hypoxic Respiratory Failure Alcohol Withdrawal and Seizure Thrombocytopenia Depression Transaminitis Discharge Condition: stable. Diabetic Ketoacidosis has resolved. Hypoxic respiratory failure has resolved. Patient with no further seizures. Liver Function tests, and platlet count stable. Patient tolerating a diabetic diet. Patient stable on room air. Discharge Instructions: Please take all medications as perscribed. Please check your insulin 4 times daily or as directed by [**Last Name (un) **]. Please report to your primary care physician with [**Name9 (PRE) **] Sugars persistently above 250, decreased food intake, fevers, chills, nausea, vomiting, abdominal pain, confusion, pai with urination, bright red blood per rectum. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) 26542**] 1 week of discharge. Please stop drinking. Your liver functions are elevated and you have fatty liver changes due to your alcohol abuse. Please follow up with [**Last Name (un) **] in [**1-11**] weeks.

[ "780.39", "276.5", "V58.67", "518.81", "535.41", "486", "250.10", "284.8", "305.01", "V10.06", "291.81", "428.33", "571.1", "428.0" ]

icd9cm

[ [ [] ] ]

[ "45.23", "96.71", "96.04", "38.93", "99.04", "45.16" ]

icd9pcs

[ [ [] ] ]

13407, 13465

8139, 11355

322, 378

13719, 13952

4834, 5302

14359, 14652

4213, 4256

11653, 13384

13486, 13698

11381, 11433

13976, 14336

5318, 6431

4271, 4815

274, 284

6461, 6461

6490, 8116

406, 3313

3335, 3890

3906, 4197

11451, 11630

44,427

112,762

41474+58450

Discharge summary

report+addendum

Admission Date: [**2129-1-21**] Discharge Date: [**2129-1-26**] Date of Birth: [**2051-2-2**] Sex: M Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: IPH Major Surgical or Invasive Procedure: none History of Present Illness: 77 yo M with hx fall in [**2127-8-28**] with left frontal hemorrhage and baseline speech difficulties and subsequent seizure disorder, HTN, HLD, MI with DES in [**2123**], transferred from OSH after found to have two small areas of hemorrhage in left frontal region as well as small layering of IVH. Per wife he was agitated this morning and did not want to get dressed. He walked to the kitchen and appeared to lose his footing, falling on his left side and hitting his head on the ground. After the fall he was breathing heavily and was unresponsive with eyes open and had fine shaking of all extremities lasting for one minute, believed by wife to be consistent with seizure. He went to OSH where he was found to have two areas of left frontal IPH, CT c-spine per report showed degnerative changes but no fracture or dislocation, received 1g dilantin and transferred here for further care. Upon arrival he was agitated and intubated in order to expedite further imaging studies. Prior to intubation he was reported to be awake and alert, not following commands and nonverbal, moving all extremities with good strength. His wife reports at baseline he is agitated at times and he speaks "when he wants to" and is nonfluent. He exercises independently and requires daily supervision by her. He developed seizures shortly after his hemorrhage in [**2126**] and initially was started on dilantin which caused drowsiness. Since he has been on keppra 250 mg [**Hospital1 **] with one seizure approximately four months ago. Past Medical History: -TBI in [**2126**] with left frontal hemorrhage -Post Traumatic seizures -HTN -HLD -MI with DES in [**2123**] -BPH - Vascular dementia Social History: -lives with wife, had worked as a salesman prior to injury. No tobacco, etoh, or drugs Family History: -no history of stroke or seizures Physical Exam: HEENT; ecchymosis over left eye with laceration above eye covered with a dressing. Neck; c-collar in place CV; RRR, no murmurs Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Neuro: Alert. Minimal verbal output. States name, hi, staes when he is hungry. [**Last Name (un) 90230**] in [**12-30**] word phrases. Does not follow commands. Able to feed himself. Moving all four extremities but prefers his right side, likely has some weakness of his left side. Positive jaw jerk. EOMI with jerk saccades. Face appears symmetric. Increased tone in legs b/l. upgoing toes b/l. Pertinent Results: CT head: IMPRESSION: 1. Unchanged left frontal lobe intraparenchymal hemorrhage. 2. Decreased degree of hemorrhage in the occipital [**Doctor Last Name 534**] of the left lateral ventricle. 3. Decreased size of the subdural hematoma overlying the right frontal convexity. MR [**Name13 (STitle) 1093**] (C): 1. Changes of cervical spondylosis as described above without high-grade spinal stenosis but with foraminal narrowing as discussed above. No evidence of ligamentous disruption or acute vertebral edema seen. An endotracheal intubation with a small amount of retained fluid in the oropharynx. Brief Hospital Course: Upon arrival to the [**Hospital1 **], Mr. [**Known lastname **] was agitated and intubated in order to expedite further imaging studies. Prior to intubation he was reported to be awake and alert, not following commands and nonverbal, moving all extremities with good strength. CT revealed a L intraparenchymal hemorrhage with interventricular blood and a R subdural hematoma. He was evaluated by neurosurgery and no intervention was completed; He was transferred to the neuroICU. He was extubated after 24 hours. MRI revealed no c-spine injury. Able to move all extremities, PERRL. After extubation, his vocalization was at his baseline, which per his wife includes saying simple words like "yes" "no" and appropriate nodding and head shaking. He is able to ambulate, eat and drink with supervision. He is incontinent of urine overnight. Cardiac enzymes were negative for MI. Repeat head CT on [**1-22**] was stable. His Keppra was initially increased to 500mg twice daily and changed to 250 qam and 500mg qpm because of concerns for lethargy by wife. [**Name (NI) **] was transferred to the Neurology floor service on [**2129-1-23**]. He was not observed to have seizures while in the hospital. He was assessed by PT/OT and Speech and Swallow, and was cleared to go home with PT and 24h care(per family's request), and self-feed regular solids and thin liquids. Repeat CT on [**1-24**] showed stable L frontal IPH,with decreased hemorrhage in L lateral ventricle and decreased size of subdural hematoma overlying the R frontal convexity. He was discharged at baseline mental status; he did not consistently follow commands and had very minimal verbal output. Medications on Admission: -keppra 250 mg [**Hospital1 **] -plavix 75 mg daily -proscar 5 mg daily -lopressor 25 mg [**Hospital1 **] -lipitor 20 mg daily -iron 325 mg daily Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 3. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: New - Traumatic Left frontal IPH with IVH. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your stay here. You were admitted from an outside hospital after experiencing one of your seizures and suffering a traumatic brain bleed after falling. You had multiple CT scans of your brain which have demonstrated a stable bleed. Because of your seizure we have increased your medication Keppra to 250mg in the morning and 500mg in the evening. We also increased your medication called metoprolol to 37.5mg twice daily. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] in Neurology ([**Telephone/Fax (1) 2574**]) on [**3-16**] at 2:30 in the [**Hospital Ward Name 23**] Building, [**Location (un) 6749**]. You will need to have your primary care doctor fax a referral to his office (fax [**Telephone/Fax (1) 44948**]). Name: [**Known lastname 4138**], [**Known firstname **] Unit No: [**Numeric Identifier 14269**] Admission Date: [**2129-1-21**] Discharge Date: [**2129-1-26**] Date of Birth: [**2051-2-2**] Sex: M Service: Neurology ADDENDUM TO IMAGING: CAT scan of the brain without contrast on [**2129-1-21**], findings: Encephalomalacia in the left frontal lobe was chronic though in this area of encephalomalacia there are discrete areas of parenchymal hemorrhage, the largest of which is seen on series 2, image 16 measuring 12 x 12 mm compared to prior measurement of 10 x 12 mm. A second area of parenchymal hyperdensity seen just superior to this level on series 2, image 19 also similar in size to the outside hospital study. There is a small amount of intraventricular hemorrhage seen in the left lateral ventricle in the occipital [**Doctor Last Name **] which is similar in volume compared with the outside hospital study. Basilar ganglial calcifications are noted. Diffuse cerebral atrophy and ventriculomegaly stable. Impression: Stable hemorrhage in the left frontal lobe and left lateral ventricle compared to the outside hospital study. CAT scan of the brain without contrast on [**2129-1-22**] findings: Left frontal intraparenchymal blood is again identified with surrounding hypodensities. There is blood visualized in the region of fornix as well as in the left occipital lobe which is unchanged. There is moderate prominence of the temporal horns and ventricles which is unchanged from previous study. There is prominence of the right frontal extra-axial space with hypodensity likely due to a small subdural effusion which is new since the prior study and measures approximately 8 mm. There is no midline shift seen. Small vessel disease and brain atrophy are noted. Impression: Since the previous CT of [**2129-1-21**], an 8-mm right frontal hypodense subdural effusion is now visualized. Mild adjacent indentation on the sulci is seen. Left frontal intraparenchymal blood and intraventricular blood are unchanged. Ventricular size is unchanged. CAT scan of the brain from [**2129-1-24**] findings: The area of intraparenchymal hemorrhage in left frontal lobe are not significantly changed compared to [**2129-1-22**]. The quality of intraventricular hemorrhage in the occipital [**Doctor Last Name **] of the left lateral ventricle was decreased. The size of the subdural hematoma overlying the right frontal convexity is decreased compared to [**2129-1-22**]. There is no significant mass effect. Periventricular white matter hyperdensities are consistent with chronic small vessel ischemic disease. ADDITION TO Hospital Course: Although the initial impression of the CAT scan brain report from [**2129-1-21**], reported moderate peri-hemorrhagic edema in the left frontal lobe, the finalized impression of this report stated that this was actually chronic encephalomalacia in the left frontal lobe. This chronic encephalomalacia was not responsible for causing additional neurological deficits for the patient during this hospitalization. By the time of his hospital discharge on [**1-26**], he seemed to have returned to his baseline mental status. [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 55**] [**Last Name (NamePattern1) 14270**], M.D. [**MD Number(2) 4699**] Dictated By:[**Name8 (MD) 14271**] MEDQUIST36 D: [**2129-3-24**] 12:20:43 T: [**2129-3-24**] 12:53:36 Job#: [**Job Number 14272**]

[ "907.0", "E929.9", "E885.9", "600.00", "853.01", "272.4", "V45.82", "290.40", "437.0", "401.9", "412", "345.80" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

5935, 6018

3422, 5095

299, 305

6105, 6105

2795, 2795

6815, 9790

2144, 2180

5292, 5912

6039, 6084

5121, 5269

9808, 10631

6289, 6792

2195, 2776

255, 261

333, 1864

2804, 3399

6120, 6265

1886, 2023

2039, 2128

12,135

197,838

52615

Discharge summary

report

Admission Date: [**2147-9-29**] Discharge Date: [**2147-10-27**] Date of Birth: [**2096-10-8**] Sex: M Service: TRANSPLANT SURGERY CHIEF COMPLAINT: End-stage liver disease. HISTORY OF THE PRESENT ILLNESS: This is a 50-year-old man with a prior history of hepatitis C, abnormal transaminases with probable cirrhosis with ascites, diabetes, increasing jaundice, who presented to the [**Hospital **] clinic with complaints of increasing abdominal pain. The laboratory evaluation showed a marked increase in albumin and the patient was recommended to return to the hospital, [**Hospital1 18**], directly from the clinic. REVIEW OF SYSTEMS: No fever, no nausea, vomiting, no diarrhea. Positive weakness and positive swelling. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Asthma. 3. Migraines. 4. Hepatitis C. 5. Intravenous drug use in the past, currently on methadone. SOCIAL HISTORY: He lives alone. He smokes. He denied alcohol. He currently receives methadone daily from the [**Hospital **] Hospital in [**Location (un) 18293**]. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Aldactone. 2. Flexeril. 3. Fluoxetine. 4. Lasix. 5. Ibuprofen. 6. Levofloxacin. 7. Novolin. 8. Protonix. 9. Rhinocort. 10. Methadone. PHYSICAL EXAMINATION ON ADMISSION: General: The patient is a jaundiced male, awake, alert, and oriented times three. Head and neck: Positive for scleral icterus with no cervical lymphadenopathy. Chest: Clear to auscultation bilaterally. Lungs: Regular rate and rhythm. S1, S2. Abdomen: Distended with active bowel sounds, tympanitic, positive fluid wave, nontender. Extremities: Marked edema bilaterally up to the thighs. Neurologic: Positive asterixis, 2+ reflexes, [**5-29**] muscle strength. LABORATORY/RADIOLOGIC DATA: CBC: White blood cell count 8.5, hematocrit 37.9. His urinalysis showed bilirubin. His K was low at 3.1. His LFTs were as follows: ALT 80, AST 154, alkaline phosphatase 318, total bilirubin 26.4. AST 51.4, CEA 9.7. An ultrasound on admission showed a markedly cirrhotic liver with a distended and sludge-filled gallbladder. HOSPITAL COURSE: It was determined that the patient had end-stage liver disease and he was admitted to the [**Hospital **] Medical Service under Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. On [**2147-9-30**], the patient underwent paracentesis to drain his markedly ascitic abdomen. This was repeated five times over the next few days. On one of these paracenteses, there was a culture that grew out Pneumococcus strep pneumoniae and the patient did have spontaneous bacterial peritonitis. On [**2147-10-2**], the patient underwent an endoscopy examination which failed to reveal any varices. On [**2147-10-5**], the patient received a Psychiatry consult which confirmed that the patient had a pre-existing major depressive disorder. At about this time, the patient was evaluated by the Transplant Surgery Team. After evaluation by the Transplant Surgery Team, the patient was deemed for a transplant and added to the liver donor list. On [**2147-10-10**], a liver was obtained and the patient was pre-opped. On [**2147-10-11**], the patient underwent a transplant operation by Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], and Dr. [**First Name (STitle) **]. Please refer to the previously dictated operative note from [**2147-10-11**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for the specific details of this operation. Immediately postoperatively, the patient was treated with intravenous antibiotics, vancomycin, and Zosyn as well as immunosuppressants, CellCept, Solu-Medrol, and Simulect. He was transferred to the unit where he stayed for the next few days. He was hemodynamically monitored. He received several transfusions for decreasing hematocrit and platelet transfusions for decreasing platelets. During this time, he also developed several bouts of postoperative atelectasis and was eventually diuresed with Lasix. By [**2147-10-18**], postoperative day number seven, the patient was doing much better. His lungs were clear. He was hemodynamically stable. It was decided that he should be extubated and he was. He tolerated this well and on the next day, postoperative day number eight, the patient was stable enough to be transferred to the floors. In addition, it should be noted that during the patient's SICU stay, his nutritional status was maintained with total parenteral nutrition and once extubated he was able to be sustained on an oral diet which was slowly advanced while he was on the floor to a regular diet which he tolerated without nausea, vomiting, or abdominal pain. Once on the floor, the patient was evaluated by Physical Therapy. It was determined that he was stable enough and in good enough condition to be discharged home once he was cleared medically. Several radiologic studies were performed over the final few days of his admission, first on postoperative day number 13, [**2147-10-24**], a cholangiogram was performed through the patient's T tube. This revealed a stricture at the biliary anastomosis. On the next day, the patient underwent ERCP and this previously mentioned stricture was dilated. Later on [**2147-10-25**], a duplex ultrasound of the liver was obtained which showed adequate blood flow through the hepatic arteries and portal veins indicating the transplanted liver was well perfused. Therefore, on [**2147-10-27**], hospital day number 33, postoperative day number 20, the patient is afebrile with stable vital signs. He is tolerating a solid oral diet, making good urine, and having good bowel movements. His abdominal examination is benign and his laboratory work from [**2147-10-26**] is as follows; white blood cell count 13.1, hematocrit 32.3, platelets 304,000. Chemistries: Sodium 137, potassium 4.3, chloride 104, bicarbonate 24, BUN 20, creatinine 1.6, glucose 80. Liver function tests: ALT 43, AST 29, alkaline phosphatase 261, total bilirubin 5.5, albumin 2.9, and his latest cyclosporin level was 351 on a 400 b.i.d. dose. He is being discharged home in good condition with the following discharge diagnoses. DISCHARGE DIAGNOSIS: 1. Major depressive disorder. 2. Hepatitis C. 3. End-stage liver disease. 4. Portal hypertension. 5. Hepatic encephalopathy. 6. Cirrhosis. 7. Ascites. 8. Spontaneous bacterial peritonitis. 9. Insulin-dependent diabetes mellitus. 10. Asthma. 11. Migraines. 12. Chronic myofascial pain (fibromyalgia). 13. Outpatient methadone treatment. 14. Orthotopic liver transplant. 15. Hypovolemia requiring fluid resuscitation. 16. Postoperative atelectasis. 17. Hyperalimentation, TPN. 18. Chronic blood loss anemia requiring red blood cell transfusion. 19. Thrombocytopenia requiring platelet transfusion. 20. Biliary anastomotic stricture. 21. Status post diagnostic paracentesis. 22. Status post endoscopy. 23. Status post intubation and mechanical ventilation. 24. Status post cholangiogram by Interventional Radiology. 25. Status post endoscopic retrograde cholangiopancreatography. DISCHARGE MEDICATIONS: 1. Valcyte 450 mg p.o. q.o.d. 2. Bactrim one single-strength tablet p.o. q.d. 3. Celexa 10 mg p.o. q.d. 4. Fluconazole 400 mg p.o. q.d. 5. Metoclopramide 10 mg p.o. q.i.d. 6. CellCept 1,000 mg p.o. b.i.d. 7. Protonix 40 mg p.o. q.d. 8. Methadone 45 mg p.o. q.d. 9. Metoprolol 25 mg p.o. b.i.d. 10. Hydralazine 10 mg p.o. q. six hours. 11. Prednisone 15 mg p.o. q.d. 12. Colace 100 mg p.o. b.i.d. 13. Dilaudid 2-6 mg q. four hours p.r.n. pain. 14. Dulcolax 10 mg p.r. q.d. p.r.n. constipation. 15. Neoral 400 mg p.o. b.i.d. 16. NPH insulin 20 units subcutaneously q.a.m., 14 units subcutaneously q.p.m. with a regular insulin sliding scale. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) **], and Dr. [**Last Name (STitle) 497**]. As well, he should continue his outpatient methadone treatment and he should be receiving twice weekly laboratory work during which he tests CBC, Chem-20, including liver function tests, and Neoral cyclosporin levels. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2147-10-26**] 02:18 T: [**2147-10-28**] 19:44 JOB#: [**Job Number 108602**]

[ "518.0", "250.01", "997.3", "070.54", "567.2", "789.5", "571.5", "280.0", "572.8" ]

icd9cm

[ [ [] ] ]

[ "51.22", "99.15", "50.59", "96.72", "51.87", "45.13", "96.04", "87.54", "54.91", "51.85", "38.93" ]

icd9pcs

[ [ [] ] ]

7180, 8464

6270, 7157

2178, 6249

1144, 1312

659, 746

166, 639

1327, 2160

768, 898

915, 1121

67,209

183,672

19284+57037

Discharge summary

report+addendum

Admission Date: [**2190-3-8**] Discharge Date: [**2190-3-25**] Date of Birth: [**2112-2-5**] Sex: M Service: CARDIOTHORACIC Allergies: Dicloxacillin Attending:[**First Name3 (LF) 922**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram, left ventriculogram Dental Extractions [**2190-3-18**] Aortic Valve Replacement(27mm [**Company 1543**] Mosaic Ultra Procine), coronary artery bypass grafts x 3(LIMA-LAD,SVG-PDA,SVG-PLV),resection of left atrial appendage [**2190-3-19**] History of Present Illness: 78 yo M w/ dCHF, diet controlled DM 2, HTN and h/o afib w/ RVR presents from [**Hospital1 **] for admit of CP, SOB. Patient was diagnosed with new onset atrial fibrillation in 12/[**2189**]. Esmalol drip and loading dose of digoxin were tried at that time, but patient has severe AS and developed hypotension. The patient was also put on a heparin gtt and coumadin but had expanding hematomas and symptomatic anemia so was discontinued. He was cardioverted and discharged on metoprolol. Since then he has occasional palpitations but these symptoms last 3-4 minutes and resolve w/ rest. One the day of presentation the patient again had palpitations but they did not resolve. He also felt SOB and chest pain. He presented to [**Hospital1 1774**], where he had Afib w/ RVR with HR 130s, started on dilt drip at 15 mg/h (reportedly to 90s). 1st set trop neg <0.01. Became chest pain free (did not get nitro, critical AS). HR dropped to 40s but stabalized to 60s. SBP dropped to 80s but stabalized to 100s. . Of note patient has also been complaining of fatigue for several weeks and dark stools for 1 week. He was guiac negative in the ED. No hematuria noted by patient. . In the ER, vitals were: 96.6 55 101/54 18 100. EKG showed afib w/ RVR with RBBB but now in sinus brady w/ RBBB, no concerning ST-T changes. CXR showed mild hilar fullness. His dilt gtt was weaned down. Was also given ASA, plavis 300, and started on a heparin gtt after repeat labs showed elevated cardiac enzymes. Past Medical History: noninsulin dependent diabetes mellitus Dyslipidemia Hypertension Severe Aortic Valve Stenosis peripheral [**Hospital1 1106**] disease s/p Left axillary bifemoral bypass [**2189-8-28**] s/p left femoral posterior tibial bypass s/p cross-femoral bypass graft s/p abdominal aneurysmectomy [**2168**] h/o Cataracts h/o bladder cancer chronic graft infection Social History: Pt is a pharmacist and lives with his wife -[**Name (NI) 1139**] history: quit 6months ago 1/2ppd x40yrs -ETOH: rare -Illicit drugs: denied Family History: Father MI at 80 Mother with brain tumor No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission: VS: T=96.3 BP=125/59 HR= 66 RR=22 O2 sat= 100 on 2L (for comfort) GENERAL: NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. + Conjunctival pallor but no cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVD to middle of neck CARDIAC: RR, normal S1, S2. No S3 or S4. 2/6 systolic murmur loudest at the apex LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: No edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: 2+ radial Left: 2+ radial Pertinent Results: Conclusions PRE-CPB:1. The left atrium is markedly dilated. No spontaneous echo contrast is seen in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. LVEF = 40%. 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve is bicuspid. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild to moderate ([**1-9**]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The annulus measures 23 mm. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. There is a small pericardial effusion. 8. Moderate bilaterl pleural effusions are seen. Dr. [**Last Name (STitle) 914**] was notified in person of the results. POST-CPB: On infusions of epinephrine and norepinephrine. AV pacing. Well-seated bioprosthetic valve in the aortic position. Minimal AI. Gradient is now 22, 13 mean at CO = 5 L/min. LVEF is now 45%, with inferior hypokinesis. MR is now trace. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2190-3-19**] 13:55 [**2190-3-25**] 05:05AM BLOOD WBC-5.9 RBC-4.04* Hgb-12.2* Hct-36.8* MCV-91 MCH-30.1 MCHC-33.0 RDW-15.1 Plt Ct-78* [**2190-3-25**] 05:05AM BLOOD PT-22.1* PTT-36.1* INR(PT)-2.1* [**2190-3-25**] 05:05AM BLOOD Glucose-86 UreaN-33* Creat-1.3* Na-137 K-4.2 Cl-102 HCO3-26 AnGap-13 [**Known lastname 52523**],[**Known firstname **] [**Medical Record Number 52532**] M 78 [**2112-2-5**] Radiology Report CHEST (PA & LAT) Study Date of [**2190-3-24**] 10:58 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2190-3-24**] 10:58 AM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 52533**] Reason: eval for infiltrate [**Hospital 93**] MEDICAL CONDITION: 78 year old man s/p cabg REASON FOR THIS EXAMINATION: eval for infiltrate Final Report INDICATION: 78-year-old man status post CABG, evaluate for infiltrate. COMPARISON: Chest radiograph from [**2190-3-23**]. PA AND LATERAL CHEST RADIOGRAPH: Again noted is left lower lobe opacification with associated mild pleural effusion. Mild right lower lobe opacification is unchanged. Cardiac silhouette is moderately enlarged, unchanged. The mediastinal silhouette and hilar contours are normal. IMPRESSION: Persistent opacification of the left lower lobe with associated mild effusion may represent atelectasis or pneumonia. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 28398**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Brief Hospital Course: This 78 year old male presents from with chest pain and dyspnea. Initially he had negative cardiac enzymes at another institution, however, after a tachycardic episode, enzymes were positive with no changes on EKG. He was referred for aortic valve replacement and a catherization showed significant three vessel disease. He was continued on ASA 325, a statin and Metoprolol. He was initially started on Plavix but this was stopped once it was decided that he should have valve replacement. He has had atrial fibrillation with a rapid ventricular response. He was rate controlled with Metoprolol and Amiodarone. Preoperative workup included dental extractions and on [**3-19**] he went to the Operationg Room where surgery was performed. See operative note for detasils. He weaned from bypass on Propofol, Levophed, Epinephrine and Vasopressin infusions. He remained stable, pressors were gradually weaned and he was extubated. CTs and temporary pacing wires were removed per protocol. He was diuresed towards his preoperative weight and beta blockers begun. Physical Therapy saw him for strength and mobility. The Lopressor was changed to Carvedilol for heart failure management and Amlodipine and Lisinopril were given as well. He was very debilitated and, therefore, a stay at a rehabilitation facility was recommended. His chronic Doxycycline was resumed for his low grade arterial graft infection. He was discharged with the right staples in place and these will need to be removed a week after discharge. Coumadin was given for his paroxysmal atrial fibrillation. The target INR is 2 to 2.5. This will be followed by Dr. [**Last Name (STitle) 16471**] as an outpatient. Medications on Admission: Finasteride 5 mg Tablet once a day Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr 1 Tablet(s) by mouth QD Simvastatin 80 mg Tablet daily Tamsulosin [Flomax] 0.4 mg Capsule, Sust. Release 24 hr 1 Capsule(s) by mouth once a day Aspirin 325 mg Tablet once a day Niacin 500 mg Capsule, Sustained Release 2 Capsule, once a day Doxycycline 100mg po BID Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Amiodarone 200 mg Tablet Sig: as directed Tablet PO as directed: two tablets twice daily for two weeks then one tablet twice daily for two weeks then one tablet daily. 11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 14. Furosemide 10 mg/mL Solution Sig: 40 mg Injection once a day for 2 weeks: Or until at preop weight (69kg). 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: INR goal 2-2.5. 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks: or while on lasix. Hold for K+>4.5. 18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 20. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML Injection DAILY (Daily) as needed for flush: while IV in. 21. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 24. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 days: Titrate dose for INR goal of [**2-9**].5. Discharge Disposition: Extended Care Facility: lifecare center [**Location (un) **] Discharge Diagnosis: Aortic Stenosis Coronary Artery Disease s/p aortic valve replacement, coronary artery bypass and left atrial appendage resection noninsulin dependent diabetes mellitus dental caries chronic renal insufficiency h/o atrial fibrillation peripheral [**Location (un) 1106**] disease Hyperlipidemia Hypertension Peripheral [**Location (un) 1106**] disease Left axillary bifemoral bypass [**2189-8-28**] s/p left femoral-posterior tibial bypass [**2184**] s/p cross-femoral bypass graft s/p abdominal aneurysmectomy [**2168**] h/o Cataracts h/o bladder cancer Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2190-5-10**] 11:30 Surgeon:Dr. [**Last Name (STitle) 914**] on [**4-20**] at 1pm ([**Telephone/Fax (1) 170**]) Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 16471**] ([**Telephone/Fax (1) 52528**]in [**1-9**]- weeks Cardiology: Dr. [**First Name8 (NamePattern2) 5987**] [**Last Name (NamePattern1) 3236**] in 2 weeks Completed by:[**2190-3-25**] Name: [**Known lastname 9771**],[**Known firstname **] Unit No: [**Numeric Identifier 9772**] Admission Date: [**2190-3-8**] Discharge Date: [**2190-3-25**] Date of Birth: [**2112-2-5**] Sex: M Service: CARDIOTHORACIC Allergies: Dicloxacillin Attending:[**First Name3 (LF) 1543**] Addendum: These are the accurate discharge medications: Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Amiodarone 200 mg Tablet Sig: as directed Tablet PO as directed: two tablets twice daily for two weeks then one tablet twice daily for two weeks then one tablet daily. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO twice a day. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks: or while on lasix. Hold for K+>4.5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML Injection DAILY (Daily) as needed for flush: while IV in. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 days: Titrate dose for INR goal of [**2-9**].5. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Amiodarone 200 mg Tablet Sig: as directed Tablet PO as directed: two tablets twice daily for two weeks then one tablet twice daily for two weeks then one tablet daily. 11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks: or while on lasix. Hold for K+>4.5. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 17. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML Injection DAILY (Daily) as needed for flush: while IV in. 18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 21. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 days: Titrate dose for INR goal of [**2-9**].5. Discharge Disposition: Extended Care Facility: lifecare center [**Location (un) **] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2190-3-25**]

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icd9cm

[ [ [] ] ]

[ "37.36", "88.56", "23.19", "39.61", "36.12", "35.21", "36.15", "37.22", "88.53" ]

icd9pcs

[ [ [] ] ]

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285, 573

11939, 12036

3420, 5910

12578, 13484

2640, 2801

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12060, 12555

2816, 3401

238, 247

6007, 6819

601, 2088

2110, 2466

2482, 2624

11,378

130,429

29315

Discharge summary

report

Admission Date: [**2154-12-10**] Discharge Date: [**2154-12-19**] Date of Birth: [**2110-2-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: found down Major Surgical or Invasive Procedure: mechanical ventilation subclavian line placement History of Present Illness: 47 year old with insulin dependent diabetes mellitus who was found down in a pool of vomitus by his family earlier today. At the OSH he was found to have a glucose of > 1300, pH of 6.8 and a potassium 9.2 at the OSH. He was hypotensive and somnolent and was intubated for airway protection/hypoxia. R femoral CVL attempt was unsuccessful. THe patient also received Levaquin, Flagyl, ASpirin 325, Lovenox sc, protonix at the OSH. He came by [**Location (un) **] for further management. He reportedly was depressed and suicidal for the last days and was drinking high-sugar drinks while being non-compliant wit his medications. He was just recently admitted to [**Hospital3 **] on the [**12-2**] with DKA in the context of Strep pharyngitis. . In the ED here, he was continued on an insulin gtt. He was hypotensive and was started on Levophed. A LSC was attempted unsuccessfully. While attempting a central line to the LIJ the carotid artery was punctured and dilated. A vascular consult was obtained. R carotid US did not show any hematoma or pseudoaneurysm. Finally a L femoral line was successful. An EKG also showed ST changes which were thought to be due to hyperkalemia rather then ischemia. He received 20iv of potassium and 10mg sc Vitamin K in the ED. The patient received a total of 9L of NS while in the OSH and in the ED here Past Medical History: Insulin dependent diabetes, non-compliant, h/o DKA Depression ETOH abuse CAD, MI, s/p stents x5 Hypothyoidism Hypercholesterolemia Social History: excessive tobacco abuse, single dad, lives with his three children who help him out, history of ETOH abuse, no IVDU Family History: n/c Physical Exam: VS T 97.0 BP 126/76 HR 109 RR 16 O2Sat 87% Gen: NAD, intubated and sedated HEENT: NC/AT, PERRLA, mmm, ET in place, NG in place, on suction with coffee ground contents NECK: no JVD visible, L neck without swelling, hematoma, bruit COR: S1S2, positive [**2-3**] SM over precordium, regular rhythm, no r/g PULM: bronchial breath sounds over the left lung and the R lung base, no wheezing or rhonchi ABD: + bowel sounds, soft, nd, nt Skin: cool extremities, no rash, appendectomy scar EXT: 2+ DP, no edema/c/c, R femoral packing, no hematoma, no thrill Neuro: moving all extremities, PERRLA, reflexes 2+ b/l, up-going Babinsky on the R, normal on the L Pertinent Results: [**2154-12-10**] 08:24PM HGB-12.2* calcHCT-37 O2 SAT-96 [**2154-12-10**] 08:24PM GLUCOSE-485* LACTATE-0.9 NA+-139 K+-4.5 CL--113* [**2154-12-10**] 08:24PM TYPE-ART PO2-100 PCO2-41 PH-7.01* TOTAL CO2-11* BASE XS--21 [**2154-12-10**] 09:25PM PT-16.8* PTT-47.5* INR(PT)-1.5* [**2154-12-10**] 09:25PM PLT COUNT-381 [**2154-12-10**] 09:25PM NEUTS-89.0* BANDS-0 LYMPHS-8.5* MONOS-1.5* EOS-0.1 BASOS-0.8 [**2154-12-10**] 09:25PM WBC-23.6* RBC-3.63* HGB-12.2* HCT-35.5* MCV-98 MCH-33.5* MCHC-34.3 RDW-13.5 [**2154-12-10**] 09:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2154-12-10**] 09:25PM CALCIUM-5.7* PHOSPHATE-3.3 MAGNESIUM-2.0 [**2154-12-10**] 09:25PM CK-MB-18* MB INDX-2.0 [**2154-12-10**] 09:25PM cTropnT-0.04* [**2154-12-10**] 09:25PM LIPASE-108* [**2154-12-10**] 09:25PM ALT(SGPT)-20 AST(SGOT)-74* CK(CPK)-904* ALK PHOS-79 TOT BILI-0.2 [**2154-12-10**] 09:25PM GLUCOSE-435* UREA N-40* CREAT-2.2* SODIUM-144 POTASSIUM-4.3 CHLORIDE-114* TOTAL CO2-11* ANION GAP-23* [**2154-12-10**] 11:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: 47 yo male with IDDM who p/w DKA, ARDS from aspiration, hypotension and ARF. . # Hypotension: Mr [**Known lastname 9416**] presentation was consistant with Sepsis/SIRS most likely secondary to aspiration pna, severe acidosis, and dehydration. Mr [**Known lastname 732**] was treated with aggressive fluid resuccitation, levofloxacin and flagyl to cover aspiration. He did not appropriately stim to cosyntropin and was therefore started on hydrocortisone. He was maintained on neosynephrine for several days. His DKA was also treated as below. . # DKA: Mr [**Known lastname 732**] was admitted in DKA and hyperosmolar hyperglycemia with an etiology most likely secondary non-compliance with aspiration pneumonia as a second event (due to unconsciousness). He was treated with agressive IVF recussitation, IV bicarbonate for severe acidosis (pH 7.01), IV insulin until his anion gap closed, with aggressive electrolyte repletion. He was eventually transitioned from insulin drip to Lantus 16U + SSI. [**Last Name (un) **] is following and will aid with future management goals. . # Respiratory failure: Mr [**Known lastname 732**] was admitted with ARDS in the context of aspiration/aspiration pneumonia. He was ventilated as per the ARDS net with low tidal volumes. He was initially very difficult to ventilate requiring high PEEP and recruitment maneuvers, rt-sided positioning, and PRVC mode. He was extubated after 6 days and is currently breathing well on N/C oxygen. He was also treated with 7 days of broad-spectrum antibiotics to treat aspiration pneumonia. All cultures were no growth to date. . # Thrombocytopenia: Mr [**Known lastname 732**] has a baseline platelet count was in the 300's which fell to 100. All heparin products were discontinued; HIT antibody was negative. His platelets rebounded and on last count were 230. He should have further evaluation prior to any consideration of heparin products. . # ARF: Baseline was 0.8; he was admitted with Cr of 2.2 which has come down to 1.3 with hydration. This may represent his new baseline. . # Coffee ground stomach contents: likely in the context of stress reaction. Hct stable from OSH. Was kept on protonix IV bid with resolution and stabilization of his hct. . # Troponin leak/ ST changes: negative MB index, troponin trended down. . # Elevated CK: most likely rhabdomyolysis from being down. CK peaked at 1400 and trended down. . # Coagulopathy: resolved with vitamin K . # FEN: NPO, replete lytes . # Prophylaxis: Heparin sc, PPI [**Hospital1 **], HOB . # Access: L femoral, R EJ . # Code: presumed full . # Communication: [**Name (NI) 1258**] [**Name (NI) 732**], mother > [**Telephone/Fax (1) 70430**] [**Name (NI) **], sister > [**Numeric Identifier 70431**], cell: [**Telephone/Fax (1) 70432**] Family was asked to establish HCP Medications on Admission: Lantus 25 U qam Novalog per sliding scale Non-compliant with beta-blocker, plavix, aspirin, lipitor, Levothyroxine Zantac prn Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*0* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2* 4. Insulin Glargine 100 unit/mL Cartridge Sig: Eighteen (18) units Subcutaneous at bedtime: dose to be adjusted by your doctor. [**Last Name (Titles) **]:*1 month supply* Refills:*0* 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 6. Lancets Misc Sig: Four (4) Miscell. four times a day. [**Last Name (Titles) **]:*200 lancets* Refills:*6* Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic Ketoacidosis Secondary: Adult Onset Type 1 diabetes mellitis Coronary artery disease Discharge Condition: Stable Discharge Instructions: You were admitted with Diabetic Ketoacidosis requiring a stay in the intensive care unit. It is essential you follow a careful diabetic diet, check your blood sugars at home at least four times a day, and maintain your insulin sliding scale. Failure to do so could result in another episode of acidosis and death. Do not stop or change your medications without first speaking to your physician. Call your Doctor or 911 if you experience blurred vision, increased frequency of urination, unusual thirst, nausea or vomiting, fevers, cough, shortness of breath, chest pain, weakness, numbness or tingling or any other concerning symptoms. While you were in the hospital your levothyroxine was doubled from 25 mcg to the new dose: 50 mcg. You will need to have your PCP check [**Name Initial (PRE) **] TSH the next time you see them. Followup Instructions: Call the [**Last Name (un) **] Diabetes Center for a follow up appointment early next week. Please be sure to see their nutritionist. . Please see your primary care doctor early next week.

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icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

7725, 7731

3900, 6724

328, 378

7879, 7888

2738, 3877

8770, 8962

2048, 2053

6900, 7702

7752, 7858

6750, 6877

7912, 8747

2068, 2719

278, 290

406, 1744

1766, 1899

1915, 2032

1,042

165,314

22566

Discharge summary

report

Admission Date: [**2166-4-18**] Discharge Date: [**2166-5-4**] Date of Birth: [**2129-5-22**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 943**] Chief Complaint: Abdominal pain, shortness of breath. Major Surgical or Invasive Procedure: Diagnostic paracentesis History of Present Illness: 36 year old male with Hx of hepatic cirrhosis from HCV and hemochromatosis admitted with SOB, worsening ascites, leakage from past paracentesis, and hyponatremia. He recently saw Dr. [**Last Name (STitle) 497**] on [**2166-4-10**] and was reinstated on the transplant list and his [**Last Name 16423**] problem is worsening ascites/edema and hyponatremia. Pt is being admitted because he has been more SOB since last paracentesis, with difficulty moving around. Denies hematemesis or hematochezia/melena. +BM with lactulose. Denies abdominal pain but notes increasing abdominal girth. Past Medical History: 1)Cirrhosis - Hepatitis C diagnosed in [**2162**] secondary to jaundice. Intolerance to IFN/ribaviran therapy. Genotype 1 2) History of IVDA [**2152**]-[**2159**]. Also cocaine usem last + tox in mid-[**2-6**]) Hemachromatosis - no phlebotomy, and diagnosis uncertain. 4) BCC removed in [**2162**] 5) Hernia repair 6) ADD 7) Recent scalp furuncle ?????? MRSA. Treated with Bactrim 8) SBP [**1-8**]; started cipro ppx 9)Ascites 10)Depresion 11)Hyponatremia 12)Anemia 13)Thrombocytopenia 14)Hypoalbuminemia 15)h/o recent hyperkalemia Social History: Mr. [**Known lastname 46**] was diagnosed w/ HCV cirrhosis and hemochromatosis in [**2162**]. He used IV heroin for [**8-12**] yrs starting at 20, but quit in [**2159**] after multiple incarcerations. When he became acutely ill with jaundice and ascites in [**9-7**], he moved back to [**Location (un) 8973**], MA, and currenly lives with mother who is power of attorney. He quit drinking in [**2160**], and drank heavily intermittently before that. He smoked 1PPD for 10 yrs, but started nicotine patch recently and says no cigarettes for 2 weeks. He uses cocaine and has most recent tox screen positive in mid-[**Month (only) 956**]. Not currently on transplant list as a result of this. Family History: Cousin with hemachromatosis Physical Exam: 98.3 121/74 68 20 95%RA Gen: Bronze colored, overweight caucasian male in mild distress HEENT: Scleral icterus present. OP clear. MMM, nose with ? past surgery. CVS: RR, normal rate, I-II/VI systolic murmur at RUSB without radiation to carotids. LUNGS: Crackles at bases bilaterally- [**1-5**] way up. Abd: NABS, soft, markedly distended- + ascites, diffuse mild tenderness. Back: nontender Extr: 3+ edema in legs past his knees. Neuro: AAOx3. Responds to questions appropriately. No asterixis but Mild bilateral hand tremor. Pertinent Results: [**2166-4-19**] WBC-8.7 Hct-30.8* MCV-98 MCH-32.8* MCHC-33.4 RDW-18.2* Plt Ct-61* [**2166-5-4**] WBC-5.5 Hct-30.5* MCV-96 MCH-32.0 MCHC-33.4 RDW-19.1* Plt Ct-42* [**2166-4-22**] Neuts-58 Bands-0 Lymphs-23 Monos-14* Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2166-5-1**] Neuts-45* Bands-0 Lymphs-32 Monos-8 Eos-3 Baso-0 Atyps-11* Metas-1* Myelos-0 [**2166-4-19**] PT-15.7* PTT-39.3* INR(PT)-1.6 [**2166-4-24**] PT-18.0* PTT-37.7* INR(PT)-2.0 [**2166-4-26**] PT-18.9* PTT-42.7* INR(PT)-2.3 [**2166-5-4**] PT-16.6* PTT-43.6* INR(PT)-1.8 [**2166-4-19**] Glucose-100 UreaN-37* Creat-2.7*# Na-131* K-5.1 Cl-99 HCO3-26 [**2166-4-20**] Glucose-134* UreaN-44* Creat-2.9* Na-135 K-5.0 Cl-102 HCO3-26 [**2166-4-24**] Glucose-138* UreaN-39* Creat-2.0* Na-145 K-4.5 Cl-107 HCO3-28 [**2166-5-4**] Glucose-89 UreaN-15 Creat-1.0 Na-139 K-4.0 Cl-101 HCO3-34* [**2166-4-19**] ALT-40 AST-99* LD(LDH)-457* AlkPhos-142* TotBili-7.9* [**2166-4-25**] ALT-19 AST-35 AlkPhos-66 Amylase-19 TotBili-11.2* [**2166-5-4**] TotBili-5.2* [**2166-4-19**] Albumin-2.6* Calcium-8.7 Phos-5.8*# Mg-2.0 [**2166-5-4**] Phos-3.4 Mg-1.5* [**2166-4-24**] calTIBC-192* Ferritn-1203* TRF-148* [**2166-4-19**] Ammonia-40 [**2166-4-20**] C3-33* C4-12 Urine: [**2166-4-21**] 05:44PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 [**2166-4-20**] URINE Eos-NEGATIVE [**2166-4-22**] URINE Hours-RANDOM UreaN-619 Creat-102 Na-39 TotProt-9 Prot/Cr-0.1 [**2166-4-22**] URINE Osmolal-401 Ascites: [**2166-4-19**] ASCITES WBC-48* RBC-137* Polys-3* Lymphs-19* Monos-62* Mesothe-16* [**2166-4-24**] ASCITES WBC-250* RBC-3700* Polys-3* Lymphs-15* Monos-0 Mesothe-5* Macroph-77* Time Taken Not Noted Log-In Date/Time: [**2166-4-19**] 4:50 pm PERITONEAL FLUID Time not noted on requisition or specimen PERITONEAL FLUID. **FINAL REPORT [**2166-4-25**]** GRAM STAIN (Final [**2166-4-19**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2166-4-22**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2166-4-25**]): NO GROWTH. [**2166-4-24**] 5:58 pm PERITONEAL FLUID **FINAL REPORT [**2166-4-30**]** GRAM STAIN (Final [**2166-4-24**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2166-4-27**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2166-4-30**]): NO GROWTH. OTHER MICRO: [**2166-4-19**] 5:25 pm BLOOD CULTURE **FINAL REPORT [**2166-4-25**]** AEROBIC BOTTLE (Final [**2166-4-25**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2166-4-25**]): NO GROWTH. [**2166-4-19**] 2:46 pm URINE **FINAL REPORT [**2166-4-20**]** URINE CULTURE (Final [**2166-4-20**]): <10,000 organisms/ml. [**2166-4-26**] 6:19 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2166-4-27**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): COLUMNAR EPITHELIAL CELLS. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2166-4-29**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2166-4-28**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): VIRAL CULTURE (Preliminary): No Virus isolated so far. [**2166-4-30**] 12:30 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2166-5-3**]** GRAM STAIN (Final [**2166-4-30**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2166-5-3**]): SPARSE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH. PREDOMINATING ORGANISM. IMAGING: ABD US [**2166-4-18**]: IMPRESSION: 1) Paracentesis, marked. 2) Cholelithiasis, wall edema and thickening commonly associated with cirrhosis. Common bile duct is not dilated. 3) Cirrhotiform liver with all vessels patent. CXR [**4-18**]: The heart is normal in size. The diaphragms are somewhat elevated and there are small effusions and mild bibasilar subsegmental atelectasis. Mediastinal contours are normal. There is no bone destruction. IMPRESSION: There is no significant change in the chest since [**2166-4-3**]. CXR [**4-23**]: PA AND LATERAL VIEWS OF THE CHEST: There are developing bibasilar areas of consolidation. There are likely small bilateral pleural effusions. The heart size is not significantly changed. The mediastinal and hilar contours are stable. No evidence of pneumothorax. The osseous structures are unchanged. IMPRESSION: Bilateral areas of consolidation consistent with multifocal pneumonia. Follow-up study after clinical treatment is recommended to demonstrate complete resolution. MR Abdomen [**4-24**]: IMPRESSION: 1) Patent portal and hepatic veins and IVC. No thrombosis identified. The main portal vein also demonstrates hepatopetal blood flow. 2) Findings consistent with the primary form of hemochromatosis. Clinical correlation is recommended. 3) Liver cirrhosis with portal hypertension. No suspicious liver masses identified. 4) Moderate amount of abdominal ascites. 5) Patchy bibasilar lung opacities. Clinical correlation is recommended, as these opacities may be secondary to dependent atelectasis versus a bibasilar infectious process. CT chest [**4-25**]: IMPRESSION: 1. Bilateral pleural effusion with marked bilateral opacities in the lungs, probably representing pulmonary edema. Superimposed multifocal pneumonia should be considered in this patient with fever. If the patient has hemoptysis, diffuse hemorrhage is also a consideration. 2. Right paratracheal lymph node measuring 12 mm in short axis. 3. Atrophic liver, splenomegaly, ascites and lateral collateral vessels in this patient with end-stage liver disease. CXR [**4-30**]: IMPRESSION: Marked improvement in bilateral lower lobe consolidations with only faint residual reticular opacity seen in these regions. Improved congestive failure compared to the most recent study of [**2166-4-27**]. Brief Hospital Course: Mr. [**Known lastname 46**] is a 36 year old male with cirrhosis secondary to HCV, hemochromatosis, and renal disease, who presented with increasing abdominal girth and abdominal pain x 2 wks. 1) Liver Failure/Ascites: The patient presented with a worsening MELD score pushing him further up the transplant list. An abdominal U/S on admission showed good portal and hepatic vein flow without clot, but severe ascites. An MRI revealed patent vessels. The plan initially was for large volume paracentesis, however he was found to be in acute renal failure as well (see below), therefore he was given albumin and a diagnostic paracentesis was performed instead. There was no evidence for spontaneous bacterial peritonitis. His diuretics (lasix and aldactone) were held given his acute renal failure, and he unfortunately subsequently experienced steady accumulation of peripheral edema and ascites. His renal failure persisted despite holding lasix, and he was eventually transferred to the SICU for initiation of CVVHD and removal of fluid with lasix drip under a more controlled setting. In the SICU he had a therapeutic paracentesis and received CVVHD with massive improvement in his edema and ascites. He was transferred back to the floors after 3 days in the SICU. His renal function had improved back to baseline by the time of transfer (after a peak of 2.9), and he was therefore able to be restarted on diuretics. It was decided to try bumex rather than lasix, and continue aldactone. His MELD remained high because of having received CVVHD, necessitating inpatient monitoring, and his mental status was borderline encephalopathic at times. We continued his lactulose and urosdiol. His MELD dropped precipitously once one week out from CVVHD, and he was able to be discharged from the hospital. He was discharged on 1 mg Bumex daily, and 50 mg spironolatone [**Hospital1 **], as well as cipro 250 mg [**Hospital1 **] for SBP prophylaxis, and lactulose. He will get labs drawn 3 days after discharge, and will call Dr. [**Last Name (STitle) 497**] for an appointment. 2) Acute renal failure: On admission he was noted to have a marked increase in creatinine from a baseline of 1.2 to 2.7. Initially it was thought to be pre-renal from his liver disease and aggressive outpatient diuresis, however his creatinine did not improve with holding diuretics and giving albumin. Additionally, he was never oliguric as would be seen with pre-renal failure or hepatorenal syndrome. Urine lytes were not reliable in the setting of polyuria. Given that hepatorenal syndrome was in the differential, however, he was started on midodrine and octreotide. His creatinine had actually begun to improve prior to transfer to the SICU, down to 2.2, however it was slow and his edema was increasing, therefore he was transfered to the SICU for CVVHD and diuresis. Over the three days in the SICU his creatinine dropped precipitously and on transfer back to the floors his creatinine was back to 1.0. His acute renal failure is thought to have been secondary to ATN, which has resolved. He was restarted on diuretics, and will need to have his renal function monitored to avoid further episodes of ATN (likely secondary to pre-renal state). 3) PNA: Mr. [**Known lastname 46**] presented with dyspnea, thought initially to be secondary to his large ascites - he had dullness at the bases of his lungs, with decreased air entry. However, he became progressively hypoxic, to the point where he required up to 2 L to keep his oxygen saturation above 90%, and a repeat CXR suggested bibasilar infiltrates. He was started on levaquin and flagyl, which were changed to vancomycin and zosyn on transfer to the SICU. He had a BAL in the SICU which unfortunately didn't have any growth, therefore broad spectrum abx were continued. He completed 10 days of vanco/zosyn, as well as azithromycin for atypical coverage, and his oxygenation improved to baseline (98% on RA). He was discharged on cefpodoxime for 3 days (to complete a total antibiotic course of 14 days). 4) Hyponatremia: Secondary to liver disease. His hyponatremia resolved with holding diuretics and giving albumin. 5) Anemia: His hematocrit has fluctuated greatly over the last few months, generally anywhere between 24 and 33. During the hospitalization it also fluctuated. At one point his hematocrit dropped from 33 to 28, and he did report some hematochezia, so a decision was made to scope. An EGD showed possibly a small esophageal varix, and portal hypertensive gastropathy. A colonoscopy showed internal hemorrhoids. His anemia is an anemia of chronic inflammation. 6) FEN: Given his hyponatremia, he was fluid restricted to 1L. He was maintained on a low Na diet. Medications on Admission: 1. Pantoprazole Sodium 40 mg Tablet 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID 3. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H 6. Lasix 40mg daily 7. Spironolactone 150mg daily 8. ursodiol 300 mg TID 9. tylenol 500 QID 10. Tramadol 50 QID PRN pain. Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Tramadol HCl 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day): Please take enough to have at least 3 bowel movements a day - take more frequently if you are not having enough bowel movements. Disp:*1800 ML(s)* Refills:*2* 6. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: This is an antibiotic for your pneumonia which is almost gone. Disp:*6 Tablet(s)* Refills:*0* 9. Outpatient Lab Work Please check CBC, CHEM7, AST/ALT/ALP, Total Bilirubin, PT, PTT, INR. 10. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day: For prevention of infection. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Acute renal failure secondary to Acute Tubular Necrosis Ascites End stage liver disease Hepatitis C viral infection Bacterial pneumonia Discharge Condition: Improved abdominal pain and renal failure resolved. Patient ambulating, having BMs, urinating. O2 requirement at baseline. Discharge Instructions: If you experience any increasing abdominal pain, weight gain of more than a few pounds, increased swelling in your legs, fevers, chills, diziness, feeling as if you are going to pass out you should call Dr.[**Name (NI) 948**] office. We changed some of your medications while you were in the hospital and you should take all of your new medications as prescribed. You will finish your course of antibiotics in 3 days - the antibiotic that you are on is called cefpodoxime and you should pick it up at the pharmacy today - 1st dose tonight. Make sure that you are having at least 3 bowel movements a day - if you are not having at least 3, please increase the frequency of your lactulose to three times a day or four times a day as necessary. Followup Instructions: Please call Dr.[**Name (NI) 948**] office on Monday morning to set up an appointment in the next week or two. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**] Phone:[**Telephone/Fax (1) 673**] You will need to get your labs checked this week, on Tuesday or Wednesday - we have given you a lab slip which you should bring with you to the lab.

[ "070.54", "584.5", "275.0", "572.8", "572.3", "304.21", "789.5", "482.9", "276.1", "511.9" ]

icd9cm

[ [ [] ] ]

[ "38.95", "38.93", "39.95", "54.91" ]

icd9pcs

[ [ [] ] ]

15767, 15773

9184, 13935

304, 330

15952, 16078

2824, 6151

16871, 17263

2228, 2258

14380, 15744

15794, 15931

13961, 14357

16102, 16848

2273, 2805

6184, 6308

6341, 9161

228, 266

358, 948

970, 1504

1520, 2212

2,180

157,981

22664

Discharge summary

report

Admission Date: [**2169-1-31**] Discharge Date: [**2169-2-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11495**] Chief Complaint: Pericardial tamponade Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 80 yo M with h/o aflutter ablation on [**12-16**] and an abdominal mass of unclear etiology s/p gastric biopsy on [**1-27**], transferred from [**Hospital1 **] for cardiac tamponade and cardiogenic shock. He had been having mild DOE for 2-3 months, per wife, but otherwise well. Two days prior to presentation, the pt developed abd pain and vomiting. He did not immediately seek treatment. He then developed CP while shoveling and went to the ED on [**1-30**]; was felt to have MSK pain & was d/c'ed on Toradol and muscle relaxants. On [**1-30**], pt was ascending stairs when he had presyncope and acute periumbilical abd pain. He was taken to [**Hospital1 **] ED where BP 90/60 and EKG showed diffuse ST elevations and PR depression inferiorly. A Chest CT done to r/o dissection showed a large pericardial effusion, and bedside TTE showed signs of tamponade. Because of hypotension, he was started on dopamine and transferred to [**Hospital1 18**] for pericardial drainage. In [**Hospital1 18**] ED he was treated w/ levo/flagyl x1 for potential gut ischemia/ process due to severe abdominal pain and lactic acidosis. Pt had an initial gas: 7.21/18/88 with lactate 7. In cath lab, 560 cc blood drained. At end of procedure, he went into respiratory arrest and was intubated due to resp fatigue and increasing acidosis, then went into PEA arrest and a pacing wire was placed. He rec'd epi and atropine, developed Vfib and was shocked out into NSR but still hypotensive- IABP placed, put on levophed as well as DA. He received 11mg epi, 100 mg lido also, then sent to CCU. Here initially very unstable with pH ~7; received several amps bicarb and serial TTE to r/o accumulation of effusion which showed no increase. He had unstable rapid AF which was cardioverted. In addition: CXR showed a L retrocardiac opacity LFT's rose to several thousand within the first few hours Hct dropped from 37 to 26 Pt had INR of 2.4 from coumadin; was given multiple units of FFP and Vit K 10 mg sq Lactate peaked at 15. Past Medical History: Aflutter s/p ablation [**2168-12-16**] Atrial fibrillation Hypothyroidism S/p TURP S/p Hernia repair S/p bilat TKRs [**2161**] S/p rotator cuff surgery S/p tonsillectomy [**12-28**] - CT abd showing small pericardial effusion and small mass near pancreas. EGD [**1-27**] showed benign gastric musosa. Unclear why the mass was not biopsied. Social History: Married, lives with wife. Family History: NC Physical Exam: On admission: T 92, BP 120s/70s, HR 124 AF, O2 96% on vent Gen: Intubated, sedated HEENT: PERRL, edematous conjunctiva, mmm Neck: Unable to assess JVD Lungs: Clear anteriorly CV: Irreg irreg, tachycardic. Pericardial drain in place with 350 cc blood. Abd: +bs, soft, ND, tenderness unable to be assessed as sedated Extr: 1+ pitting LE edema bilat, very cool to palp, mottled with blue hands and feet Pertinent Results: [**2169-1-31**] 05:40AM WBC-19.4* RBC-3.83* HGB-11.8* HCT-37.1* MCV-97 MCH-30.9 MCHC-31.9 RDW-16.1* [**2169-1-31**] 05:40AM NEUTS-92.3* BANDS-0 LYMPHS-5.3* MONOS-2.2 EOS-0.1 BASOS-0.1 [**2169-1-31**] 05:40AM PLT COUNT-226 [**2169-1-31**] 05:40AM PT-19.6* PTT-42.2* INR(PT)-2.4 [**2169-1-31**] 05:40AM GLUCOSE-162* UREA N-41* CREAT-2.1* SODIUM-142 POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-11* ANION GAP-29* [**2169-1-31**] 07:04AM TYPE-ART O2 FLOW-15 PO2-65* PCO2-48* PH-7.00* TOTAL CO2-13* BASE XS--19 INTUBATED-INTUBATED [**2169-1-31**] 07:04AM LACTATE-14.4* Brief Hospital Course: 1. Tamponade: - S/p pericardial effusion drain placed and removed 2d later when had no output although flushed, and serial TTEs did not show further accumulation of blood. + Small residual effusion but no signs of tamponade and size of effusion stable x several days. . 2. Cardiogenic shock/ Pump - Initially very poor CI due to both tamponade and cardioversion shocks. Initially on levophed/dopa and changed to dopa/dobut to increase CO, but then weaned off x several days with good BPs and CO. - Repeat TTE showed improvement of LVEF several days after admission. - With improvement in CI, had resolution of acidosis with decreased lactate, decreased LFTs, and improved appearance of extremities. - As 12L positive over first 1-2d, was diuresed with lasix aggressively and diuresed well. . 3. Rhythm - Pt has a h/o AF and was cardioverted into NSR initially due to unstable BP. Because then had several episodes of PAF during first 2-3d of hospitalization, was started on procainamide with resolution of his AF (due to elevated LFTs, avoided amio). . 4. Metabolic acidosis - Initially thought to be due to poor forward flow and resulting ischemia to either gut (explaining abdominal pain) and/or extremities (initially cold and blue). Then resolved. . 5. Respiratory failure - As RSBI low, was extubated on [**2-3**] but re-intubated later that evening due to secretions and tachypnea, dropping sats, thought to be d/t mucous plugging vs. volume overload. - Attempt to diurese aggressively over next couple days (was 5L negative on [**2-4**]) to facilitate extubation. . 6. GI - Abdominal pain at home likely not related to very elevated LFTs which are likely due to shock liver, now trending down daily. Has pancreatic tail cystic appearing mass, the etiology of which is unknown. Had gastric biopsy but no bx of this mass. - Some blood initially from mouth, unclear if this was from stomach or just mouth but has not continued- on PPI daily. . 7. Infectious disease - Initially given dose of levo/flagyl in ED and standing Unasyn to cover potential translocation of bowel organisms during ischemic episode. . 8. Thrombocytopenia - Plt dropped in first couple days; stopped heparin sq and sending HIT. Plts were trending up. . 9. Coagulopathy - Though on coumadin at home for AF, had INR of 1.6 day PTA and up to 2.4 after admit here; took several units of FFP and Vit K 10 mg x 1 to bring down, now not on any anticoagulation and INR in 1's. Elevated INR also thought [**2-8**] shock liver. . 10. FEN - Being aggressive about checking K's tid to qid while diuresing so much. Started TPN [**2-5**]. Starting free water through NGT. . 11. Access - Groin lines incl swan pulled; now R IJ (placed [**2-5**]), + peripherals. . 12. Proph - Pneumoboots, protonix qd. . 13. Full code. Family including wife, kids, very involved. ******************* On [**2169-2-6**], the pt had gone for HIDA scan when went into PEA arrest and passed away despite aggressive attempts at resuscitation. The pt's family agreed to an autopsy. Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased

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icd9cm

[ [ [] ] ]

[ "99.62", "00.17", "99.05", "37.23", "37.78", "99.15", "99.04", "99.07", "96.72", "37.0", "38.91", "37.61" ]

icd9pcs

[ [ [] ] ]

6845, 6854

3800, 6822

284, 309

6906, 6917

3205, 3777

2766, 2770

6875, 6885

2785, 2785

223, 246

337, 2344

2799, 3186

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2723, 2750

47,875

163,504

40048

Discharge summary

report

Admission Date: [**2118-12-17**] Discharge Date: [**2118-12-27**] Date of Birth: [**2064-12-17**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p trauma: fall Major Surgical or Invasive Procedure: [**2118-12-17**] T1-T11 fusion History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 53 year old male who complains of S/P FALL. Patient was intoxicated and fell from a balcony, approximately 10 feet to the ground. He landed on a staircase, and rolled approximately 5 feet down that. He is complaining of back pain, and was transported to [**Hospital **] Hospital. There, the patient was found to have a left second rib fracture, and some haziness in the superior portion of the right lung. He is complaining of significant chest and back pain, and was noted to have a differential in the blood pressures between his 2 arms. There was concern for traumatic dissection, and this was heightened by widened mediastinum on the chest x-ray. The patient was then transferred here emergently for further evaluation. Upon arrival, the patient is labile and complaining of significant back pain. Timing: Sudden Onset Severity: Severe Duration: Hours Context/Circumstances: s/p fall Associated Signs/Symptoms: back pain Past Medical History: Past Medical History: HTN Social History: Social History: Positive for Alcohol Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission: [**2118-12-17**] HR:100 BP:140/110 O(2)Sat:100 NRB Normal Constitutional: Boarded and collared Chest: Breath sounds bilaterally, chest wall stable without crepitus Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended Rectal: Normal tone,, Heme Negative Extr/Back: Spine is without step-offs. The patient complains of pain throughout. Neuro: Speech fluent, so 4 extremities Psych: Emotionally labile Physical examination upon discharge: Vital Signs: T=96, hr= 82, bp=130/72, room air 96%, resp.rate=18 GENERAL: Resting comfortably, conversant CV: Ns1,s2, -s3, -s4 LUNGS: Clear ABDOMEN: Soft, non-tender EXTEMITIES: Muscle st. lower ext. +5/+5, upper ext. +5/+5, no pedal edema bil. BACK: DSD cervical to lumbar spine, oozing sero-sanguinous drainage from upper back dressing. DSD to right lower flank Pertinent Results: [**2118-12-20**] 02:31AM BLOOD WBC-13.3* RBC-3.11* Hgb-9.1* Hct-26.2* MCV-84 MCH-29.3 MCHC-34.8 RDW-14.2 Plt Ct-186 [**2118-12-19**] 09:23PM BLOOD Hct-25.4* [**2118-12-19**] 01:26PM BLOOD Hct-24.3* [**2118-12-19**] 01:53AM BLOOD WBC-12.9* RBC-2.84* Hgb-8.6* Hct-23.2* MCV-82 MCH-30.4 MCHC-37.1* RDW-14.1 Plt Ct-164 [**2118-12-20**] 02:31AM BLOOD Neuts-78.0* Lymphs-12.2* Monos-6.1 Eos-3.4 Baso-0.3 [**2118-12-20**] 02:31AM BLOOD Plt Ct-186 [**2118-12-19**] 01:53AM BLOOD Plt Ct-164 [**2118-12-18**] 01:53AM BLOOD Plt Ct-199 [**2118-12-18**] 01:53AM BLOOD PT-13.4 PTT-27.9 INR(PT)-1.1 [**2118-12-17**] 05:23PM BLOOD Fibrino-315 [**2118-12-20**] 02:31AM BLOOD Glucose-133* UreaN-12 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-28 AnGap-11 [**2118-12-19**] 01:26PM BLOOD Glucose-144* UreaN-13 Creat-0.7 Na-138 K-3.8 Cl-103 HCO3-27 AnGap-12 [**2118-12-19**] 01:53AM BLOOD Glucose-175* UreaN-15 Creat-0.8 Na-134 K-3.9 Cl-102 HCO3-26 AnGap-10 [**2118-12-20**] 02:31AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.7 [**2118-12-19**] 01:26PM BLOOD Calcium-7.5* Phos-2.5* Mg-2.0 [**2118-12-19**] 01:53AM BLOOD %HbA1c-6.4* eAG-137* [**2118-12-17**] 04:45AM BLOOD ASA-NEG Ethanol-84* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-12-17**]: Head cat scan: IMPRESSION: 1. The study is suboptimal due to excessive motion-related artifacts. Within this limitation, no acute intracranial process is seen. Possible cerebral edema and nasal bone fracture/deformity at the tip. 2. Mild left sinus disease. [**2118-12-17**]: Cat scan of the c-spine: Prevertebral soft tissue thickening and edema at C2 through C5 is concerning for acute anterior ligamentous injury. MRI should be considered for further evaluation. Lucencies at the anterior osteophytes at C5/6 level and mild splaying at C4/5 level anteriorly can be related to recent trauma. 2. Multiple widely displaced posterior spinous process fractures from C7 to at least the level of T3, with significant soft tissue edema likely represent interspinous ligamentous injury. 3. Bilateral 1st and 2nd rib fractures. Comminuted fracture in the left transverse process/inferior articualr process junction. ( se 402b, im 49) 4. Nondisplaced left scapular fracture. 5. Pulmonary contusions at the apices. Pl. see CT Torso. 6. Fullness in the left piriform sinus, left vallecula and fossae of Rosenmuller can be evaluated with direct ENT examination, when appropriate as also enlarged palatien tonsils and narrow glottis- ? motion. Multiple mildly enlarged nodes are noted and can be correlated clinically [**2118-12-17**]: Cat scan of pelvis and abdomen: IMPRESSION: 1. No aortic injury seen. 2. Bilateral pulmonary contusions 3. Rib fractures: Right [**12-28**] and [**6-30**], and left 1st-5th (left fx better seen on CTA exam performed today). No fractures is seen within the right 6th rib on this examination, but there is one demonstrated on the CTA exam. 4. Left scapular fx. 5. T7 burst fx involving anterior and posterior columns, highly unstable. 6. T8 superior endplate deformity, likely acute. 7. Right T7 transverse spinous fx. 8. C7-T3 spinous process fx with significant posterior distraction of the fragments and a larege soft tissue edema/hematoma in the region. There is likely underlying ligamentous injury. 9. T6 and T7 minimally displaced spinous process fx. 10. No acute intra-abdominal or intra-pelvic process seen. 11. Incidental left pelvic kidney [**2118-12-17**]: CTA neck: CONCLUSION: Technically limited study. No definite signs for vascular injury. Other numerous post-traumatic abnormalities, described above [**2118-12-17**]: Chest x-ray: FINDINGS: As compared to the previous radiograph, the patient has been intubated. The tip of the endotracheal tube projects 6 cm above the carina and should be advanced 2-3 cm. Minimal volume loss at the right lung base. Otherwise, the radiograph is unchanged. No evidence of complications [**2118-12-17**]: MR spine: IMPRESSION: 1. C-SPINE: Moderate-marked of prevertebral soft tissue swelling, from edema&/hematoma extending to the region of the skull base to C4, with lack of visualization of the outline of the anterior longitudinal ligament at C4. In addition, the outline of the anterior longitudinal ligament is not well seen, from C4-T1 level. Injury to ALL at these levels cannot be completely excluded. Possible fracture of the anteroinferior aspect of C4/the osteophyte, given the mild splaying on the CT of the cervical spine. 2. Diffuse disc bulge, with disc osteophyte complex effacing the ventral CSF space and indenting the ventral surface of the cord at C3-4 level. Extensive posterior spinous soft tissue hyperintense areas on the sagittal STIR sequence may relate to edema&/ ligamentous injury, with spinous processes fractures from C7 - extending into the thoracic spine at multiple levels. Some of the areas are more rounded in shape and may relate to focal areas of hematoma. While there are no obvious cord signal abnormalities, subtle edema in the cervical cord cannot be excluded. 3. MR OF THE THORACIC SPINE: Fractures involving the T7 and T8 vertebral bodies, better seen on the prior CT torso study. Areas of marrow contusion/edema noted involving the T6, T7 and T8 vertebral bodies, and the posterior elements of T7, with moderate amount of pre- and para-vertebral soft tissue swelling from edema&/hematoma. Increased signal intensity within the posterior spinous soft tissues in the thoracic spine may relate to edema&/injury to the ligaments in this location as well as injury to the paraspinal muscles. There is mild bulging of the posterior aspect of the T7 vertebral body, with mild displacement of the posterior longitudinal ligament, deformity on the cord at this level, with slightly increased signal intensity which may relate to edema&/contusion in the cord. 4. MR OF THE LUMBAR SPINE: Multilevel degenerative changes as described above along with post-surgical changes at L5-S1 level, with scar tissue noted extending into the right side of the spinal canal in close proximity to the right S1 nerve. Disc bulges, with mild neural foraminal narrowing as described above. Consider spine consult to decide on further management. Followup evaluation can be considered to assess stability/progression of the changes. Please see the dedicated CT torso for additional information including the rib fractures, lung changes and hyperintense foci in the kidneys which may represent cysts. Left kidney ectopic. Largest cyst in the left kidney, measures 5.6 x 4.2 cm. [**2118-12-17**]: Thoracic spine x-ray: FINDINGS: A single lateral radiograph is obtained intraoperatively. The spinal fusion hardware is in expected location [**2118-12-19**]: Chest x-ray: Heart size is normal, decreased since earlier in the day. Small right pleural effusion is stable. Aside from mild right infrahilar atelectasis, improved since earlier in the day, lungs are clear. Right subclavian line ends in the upper SVC. No pneumothorax [**2118-12-21**]: Chest x-ray: IMPRESSION: 1. New right upper lobe opacity may represent focal atelectasis or early pneumonia. Recommend short-term followup to assess for progression or resolution. 2. Improved small right pleural effusion and right lower lobe atelectasis. 3. Unchanged mild cardiomegaly [**2118-12-20**]: Blood culture pending [**2118-12-21**]: Blood culture pending URINE CULTURE (Final [**2118-12-21**]): NO GROWTH [**2118-12-22**]: IMPRESSION: AP chest compared to [**12-21**]: Subject to the technical limitations of bedside radiography, there does appear to be a right suprahilar region of consolidation, possibly pneumonia. Left lung is clear. Obscuration of the right diaphragmatic interface could be due to pleural effusion. Conventional radiography is recommended, when feasible. Heart size is normal. No pneumothorax. Brief Hospital Course: 53 year old gentleman who was admitted to the Acute Care Service after a 10 foot fall. Upon admission, he was made NPO and had intravenous fluids started. He had imaging studies of his head, chest, neck, abdomen and back. As a result of his fall, he sustained bilateral rib fractures, and an unstable burst fracture of his T7 thoracic spine. He was evaluated by the Pain service because of the extent of his thoracic and rib fractures, as well as his history of chronic back pain. He was also evaluated by the Ortho-Spine Service and because of his injuries, he was taken to the operating room on [**12-17**] where he had a spinal fusion of T1-T11. His operative course was notable for a large blood loss necessiating volume repletion. He was monitored in the intensive care unit after his procedure. He was extubated on [**12-19**] and he did have an isolated episode of oxygen desaturation which resolved with nebulizer treatments. He was fitted for the TLSO brace. He was transferred to the floor on [**12-20**]. Since his transfer, he has continued to have pain issues requiring adjustments in his pain medication and recommendations from the Pain Service. His pain is currently controlled with oxycodone and methadone. He had been febrile and has had blood cultures, urine culture, chest x-ray, and line tip cultured. His blood cultures and urine culture have shown no growth of bacteria. His has had no further fever spikes. His chest x-ray on [**12-22**] was reported to have a right upper lobe consolidation. He has resumed his pre-op inhalers. He has been evaluated by both physical and occupational therapy. He has also been seen by Social Services. He has been out of bed into a chair. He does require TLSO brace with cervical attachement when out of bed, but no cervical collar needed while in bed. He is tolerating a regular diet and is voiding and moving his bowels without difficulty. He is preparing for discharge to a rehabilitation facility with folow-up visit with Dr. [**Last Name (STitle) 363**] and with the Acute care service in 2 weeks. Medications on Admission: Medications: simvastin, lisinopril, pro-air, citalopram Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: hold for diarrhea. 2. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 6. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation: hold for diarrhea. 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. HydrALAzine 10 mg IV Q6H:PRN SBP>160 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. gabapentin 600 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 15. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 16. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day. 17. citalopram 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for systolic blood pressure < 110, hr <60. 19. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain: hold for increased sedation/resp. rate <12. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p trauma: fall acute anterior ligamentous injury mult posterior spinous process fx b/l first and second rib fx non displaced scapula fx pulmonary contusions multiple rib fractures T7 burst fracture - highly unstable T8 superior endplate deformity C7-T3 spinous process fractures T6-T7 spinous process fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance, TLSO brace with cervical collar attachment prior to getting out of bed. Uses walker with ambulation Discharge Instructions: *You fell 10 ft off a porch and sustained an unstable T7 burst fracture and underwent a T1-T11 fusion. As a result of the fall, you also sustained rib fractures. You are being discharged to an extended care facility with the following information: Your injury caused multiple rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs You also sustained a T7 burst fracture for which you had repaired with a spinal fusion. Please follow these instructions: *apply the TLSO brace prior to getting out of bed *report any numbness, weakness of upper and lower extremities *report any inabililty to pass your urine Followup Instructions: Please follow-up with the Acute Care Service in [**1-26**] weeks. You can schedule this appointment by calling #[**Telephone/Fax (1) 21962**]. You will also need to follow-up with Dr. [**Last Name (STitle) 363**] in 2 weeks. You can schedule this appointment by callling # [**Telephone/Fax (1) 3573**] Completed by:[**2118-12-27**]

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icd9cm

[ [ [] ] ]

[ "81.05", "77.79", "81.64", "03.53" ]

icd9pcs

[ [ [] ] ]

14361, 14431

10382, 12458

324, 357

14789, 14789

2523, 10357

17004, 17340

1563, 1567

12565, 14338

14452, 14768

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267, 286

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385, 1441

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50,651

133,600

27776

Discharge summary

report

Admission Date: [**2191-11-27**] Discharge Date: [**2191-12-3**] Date of Birth: [**2138-7-23**] Sex: F Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 18369**] Chief Complaint: N/V/D Major Surgical or Invasive Procedure: None History of Present Illness: This is a 53 year old female with past medical history of stage IV breast cancer diagnosed in [**2188**] 12 days s/p cycle 2 of chemotherapy (adriamycin/cytoxan) who presents with 4 days of nausea/vomiting/diarrhea and inability to tolerate PO. THe patient reports that 4 days prior to admission, she began to lose her appetite. She subsequently began vomiting multiple times daily ("innumerable times") and developed loose, watery stools as well. She was unable to take anything by mouth, including fluids. She continued to stay at home thinking her symptoms would improve. Today, as she continued to feel unwell, she called her oncologist who recommended she come into the emergency room for evaluation. The patient denies any problems with prior chemotherapy, and tolerated her first cycle well. She does report that she has had several XRT treatments to her back and her leg recently, and she believes that the combination of this with her chemotherapy may have led to her symptoms. On review of systems, she reports subjective fevers at home, chills, and nausea, vomiting and diarrhea as above. She denies headaches, vision changes, chest pain, shortness of breath, abdominal pain even with her above symptoms, weakness, paresthesias, dysuria, or other symptoms. She denies any hematochezia, melena or hematemesis. She does complain of a sore throat from her vomiting. In the ED, the patient was febrile to 101.8 and initially tachycardic to the 160s. Initial lactate was 7.2. She received approximately 6L of IVF and her heart rate came down to high 90s. Additionally, lactate down to 1.0. She and her family refused a central line in the ED as well. Stool was guaiac positive. She received vancomycin, cefepime, and flagyl and was transfused 2 units prbcs for a Hct of 23.5 prior to being transfered to the ICU. Since arriving, the patient is tearful but states she feels much improved. She denies any pain, and has not be nauseated or vomiting throughout the day. No recent diarrhea. She has a sore throat from wretching but no other complaints. Past Medical History: 1. Stage IV breast cancer (ER+ PR+ Her2/neu- ductal invasive carcinoma) c/b chord compression s/p XRT and spinal fusion T9-L4 on [**2189-5-9**], PE/dvt now on lovenox, posterior laminectomy and fusion T1-T9 in [**8-30**]; course includes arimidex, lupron, xeloda, now adriamycin/cytoxan 2. tubal ligation and uterine fibroid removal 3. severed right 5th digit 4. tonsilectomy 5. HTN Social History: The pt denies past or present tobacco. Denies EtOH, IVDU, other rec drugs. She is a housewife. Lives with husband and 2 children (in college). Family History: Denies family history of breast CA or other malignancy Physical Exam: On presentation: Vitals: T: 98.8 BP: 127/78 HR: 106 RR: 23 O2Sat: 97% on RA GEN: Well-appearing, tearful, NAD HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, erythema of posterior oropharynx without tonsilar exudate, +alopecia NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: tachycardia, regular rhythm, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, bibasilar rales, no wheezes or rhonchi ABD: Soft, NT, ND, +BS, + ecchymoses of lower abdomen, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. Pertinent Results: IMAGING: CT A/P 1. Significantly limited study given lack of contrast administration. No definite findings of acute intra-abdominal pathology such as colitis, diverticulitis, or obstruction. 2. Diffuse permeative osseous metastases with little change over the interval. Intrathecal detail is limited, especially in the region of hardware and if tumoral extension is suspected in the spinal canal, MRI spine is warrented. 3. Decreased size of right inguinal adenopathy although not well evaluated given lack of IV contrast. 4. Soft tissue nodules within the subcutaneous tissues of the anterior pelvis. Please correlate with injection history. 5. Axial hiatal hernia. Brief Hospital Course: This is a 53 year old female with a history of stage IV breast cancer with 4 days of nausea, vomiting, diarrhea and neutropenic fever. She was treated with broad spectrum antibiotics. Additionally, she had A fib with RVR which responded well to iv lopressor. # Neutropenic fever/sepsis: Met SIRS criteria on admission. Was likely source is GI given loss of appetite, nausea, vomiting, diarrhea, and inability to tolerate PO. Patient was profoundly dehydrated with tachycardia, elevated lactate, all improved with aggressive hydration. Started on vanc/cefepime/flagyl for broad coverage including GI source/anaerobes, which can narrow based on cultures and clinical source Blood cultures sent which are NGTD, UA negative/ucx pending. CXR without evidence of infiltrate and CT abd/pelvis pending, with prelim read negative for infection. Patient was started on a 7 day course of neupogen per heme/onc rec, to complete on [**2191-12-5**]. However, her WBC was 5.1 on day 3 so neupogen was stopped. Patient spiked to 100.4 on morning of [**2190-11-28**] and was cultured. No additional antibiotics were started. Patient remained afebrile and was transferred to the floor on [**2191-11-30**]. Flagyl was stopped. The patient remained afebrile and she started taking POs. Vanco was D/C'd and she was discharged on 10 day course of cefpodoxime. . # Tachycardia/Atrial Fibrillation with RVR: Patient became tachy to 190's morning of [**2191-11-29**], 12-lead EKG showed it was atrial fibrillation. Patient has no prior history of this. Arrythmia broken with IV lopressor she was transitioned to metoprolol 25mg [**Hospital1 **] with good effect. Patient was anticoagulated with lovenox (see below) which she was on for her portal vein thrombosis. She continued to have episodes of SVT from 100-120, which was treated with IV fluids. On the floor, the patient had sinus tachycaria into the 140s. She was asymptomatic. No underlying cause was found, likely [**12-26**] chemo, cancer, recovering from acute illness, anxiety. Her BB was uptitrated to metoprolol 50 TID. She was seen by physical therapy and was tachycardic to the 130s while walking but not dizzy or SOB, so she was d/c'd home with close follow up. Metoprolol can be downtitrated as an outpatient. . # Nausea/vomiting/diarrhea: Resolved with fluids and anti-emetics. Was likely gastroenteritis, though given neutropenia, was initially more concerning for occult cause. Diet was advanced to clears which patient tolerated and nausea was treated with anti-emetics. C. diff was negative x2. Stool cultures were negative and patient was given low dose of immodium. . # Anemia: Admission hct 22 on admission. In the MICU, received 2 units PRBC without appropriate bump. Recevied an addition 2 units with bump to 29. Remained stable 28-32 for the length of stay. . # Metastatic Stage IV breast Ca: Admitted 14 days post cycle two of adriamycin/cytoxan - last dose [**2192-11-14**]. Continuing to get XRT to back and leg, last [**10-18**]. Per OMR appears next XRT is due in [**Month (only) 956**]. Dr. [**Last Name (STitle) **] is primary oncologist and is aware of admission. She has a follow up appointment with Dr. [**Last Name (STitle) **] three days after discharge. . # Anxiety: Patient was quite tearful and anxious intermittenly. Notes that she uses ativan at home for this prn. We continued ativan prn. Social work was consulted for patient coping. . # Portal Vein Thrombosis: Was on lovenox on admission which was held for 36 hours as patient was anemic and thrombocytopenic. Restarted on lovenox 120mg sq qd as anemia responded well to tranfusion and was stable. . # Hypertension: Patient came in hypotensive, so we held her atenolol and lisinopril. She was normotensive on discharge so her medications were not restarted (on metoprolol 50 TID). She was advised to call her primary care doctor to have her blood pressure medications titrated as needed. . Medications on Admission: Lisinopril 10 mg daily Atenolol 50 mg daily Lovenox 120 mg daily Ativan 1 mg QHS, prn Q6H Multivitamin Calcium Carbonate Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q24H (every 24 hours). 4. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 9 doses: Last dose will be PM on [**12-7**]. Disp:*18 Tablet(s)* Refills:*0* 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary Diagnosis: Sepsis Neutropenic Fever Metastatic Breast Cancer Hypokalemia Discharge Condition: Stable Discharge Instructions: You came to the hospital with neutropenic fever, diarrhea and hypotension. We believe this was from an infections, but we were not able to find the bacteria that caused it. We treated you with IV fluids and IV antibiotics in the ICU. You were stable and transferred to the regular floor and switched to PO antibiotics. We also noticed that your potassium was low and replaced it. . We made the following changes to your medications: ADDED Cefpodoxime (this is your antibiotic) Stopped Atenolol Started Metoprolol 50mg TID Stopped Lisinopril . Please follow up with your doctors as below. . IF you have worsening diarrhea, abdominal pain, fevers, chills, nausea, weakness, confusion, or any other symptom that is concerning to you, please call your doctor or come to the emergency room. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 17688**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2191-12-7**] 12:30. Please have your blood pressure and heart rate checked at this time and consider decreasing your metoprolol dose if needed. . Provider: [**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2191-12-7**] 2:00 . Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to make an appointment. You should have your blood pressure and potassium checked and discuss restarting your lisinopril.

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

9211, 9282

4476, 8427

275, 282

9407, 9416

3783, 4453

10254, 10888

2954, 3011

8599, 9188

9303, 9303

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3026, 3764

9877, 10231

230, 237

310, 2369

9322, 9386

2391, 2777

2793, 2938

28,671

125,868

32586

Discharge summary

report

Admission Date: [**2151-3-4**] Discharge Date: [**2151-3-10**] Date of Birth: [**2093-3-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Left lung cancer. Major Surgical or Invasive Procedure: Flexible bronchoscopy, left thoracoscopy, left thoracotomy and left pneumonectomy, mediastinal lymph node dissection. History of Present Illness: Mr. [**Known lastname 75909**] is a 57-year-old gentleman with a proximal left lung cancer which had obstructed the distal left mainstem. He also had a positive 4L lymph node on TBNA. He received neoadjuvant chemotherapy and radiation and had an excellent response radiographically. We restaged him with cervical mediastinoscopy which was negative for any persistent mediastinal nodal disease. There was evidence of sterilized tumor in the 4L lymph node station. Past Medical History: 1. T3N2 squamous cell carcinoma of the left main stem bronchus diagnosed [**11-21**]. The initial tumor was a large, necrotic, friable mass that completely occluded the left mainstem bronchus; it was associated with left lung collapse and bilateral hilar and right paratracheal adenopathy. The tumor was debrided and a stent was placed in early [**11-21**]. Treatment with combination chemotherapy and XRT was started on [**2150-11-30**]. 2. Pulmonary embolism [**11-21**]. 3. Post-obstructive pneumonia [**11-21**]. 4. Chronic obstructive pulmonary disease. 5. Latent tuberculosis. 6. Pneumonia [**11-21**]. Social History: 70-pack-year smoking history. He is living with his daughter, [**Name (NI) **]. [**Name2 (NI) **] has three children, two daughters and one son, and he has grandchildren. He has not been smoking for one month. He occasionally drinks alcohol and denies illicit drug use or abuse. He was born in [**Country 5881**] and came to the U.S. roughly forty years ago. Family History: Father died of laryngeal cancer. Physical Exam: General: 57 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: Resp: GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr warm trace edema Incision Neuro: non-focal Pertinent Results: [**2151-3-9**] WBC-5.5 RBC-3.83* Hgb-11.7* Hct-34.3 Plt Ct-274 [**2151-3-4**] WBC-9.9# RBC-4.05* Hgb-12.4* Hct-36.7 Plt Ct-216 [**2151-3-9**] Glucose-117* UreaN-10 Creat-0.7 Na-140 K-3.8 Cl-101 HCO3-32 [**2151-3-4**] Glucose-109* UreaN-9 Creat-0.8 Na-143 K-4.1 Cl-107 HCO3-27 [**2151-3-4**] Echocardiogram: Conclusions The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). with moderate global free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque . The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Pathology Examination SPECIMEN SUBMITTED: Left Lung, Lymph node level 9, lymph node level 10, Level 5 Lymph Node, Level 6 lymph node, Level7 lymph node. Procedure date Tissue received Report Date Diagnosed by [**2151-3-4**] [**2151-3-4**] [**2151-3-8**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/vf Previous biopsies: [**Numeric Identifier 75964**] 4L LYMPH NODES, 2L LYMPH NODES, 2R LYMPH NODES, 4R LYMPH [**-6/4756**] Left mainstem tumor. DIAGNOSIS: 1. Lung, left, pneumonectomy (A-K): Lung with focal area of necrosis, histiocytes, foreign body giant cell reaction and necrotic keratinocytes consistent with treated tumor. No lymphovascular invasion is identified. Bronchial and vascular resection margins are free of tumor. Ten lymph nodes with no malignancy identified. 2. Lymph node(s), level 9 (L): Three lymph node fragments, no malignancy identified. 3. Lymph node(s), level 10 (M): Three lymph node fragments, no malignancy identified. 4. Lymph node(s), level 5 (N): Two lymph node fragments, no malignancy identified. 5. Lymph node(s) level 6 (O): Two lymph node fragments, no malignancy identified. 6. Lymph node(s), level 7 (P): One lymph node, no malignancy identified. CHEST (PA & LAT) [**2151-3-10**] IMPRESSION: 1. Similar appearance of left pneumonectomy space compared to recent postoperative radiograph but gradual increase in fluid since earlier radiographs. 2. Mild interstitial edema within the right lung. Brief Hospital Course: Pt was admitted and taken to the OR for left pneumonectomy for lung cancer. An epidural was placed for pain control w/ good effect. Pt was transferred to the ICU for post op management including brief IV vasopressor support. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain was placed in the left chest at the time of the operation and was d/c'd on POD#1. POD#1 an NGT was placed for decompression of a large gastric bubble and was removed w/in 24 hrs. Pt was started on sips and diet was progressed and [**Last Name (un) 1815**] well. POD#3 epidural was d/c'd and pt was transferred out of the ICU. He progressed well and steadily w/his post op recovery. On POD#4 pt had brief non-sustained episodes of Afib. Cardiology was consulted and pt was treated w/ lopressor and amiodarone w/ good response and conversion to NSR. Anticoag w/ IV heparin was initiated for known PE. Pt had been on lovenox prior to surgery. At the time of discharge pt was on coumadin w/ lovenox bridge. He was ambulatory w/ sats 97% on room air. Medications on Admission: Albuterol - (Prescribed by Other Provider) - 90 mcg Aerosol - 1 Aerosol(s) inhaled four times a day as needed for shortness of breath or wheezing Enoxaparin - 60 mg/0.6 mL Syringe - 1 Syringe(s) every twelve (12) hours Fludrocortisone - (Prescribed by Other Provider) - 0.1 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily) Fluticasone-Salmeterol - (Prescribed by Other Provider) - 250 mcg-50 mcg/Dose Disk with Device - 1 Disk(s) inhaled twice a day Isoniazid - (Prescribed by Other Provider) - 300 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) Medications - OTC Pyridoxine - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) Discharge Medications: 1. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days: then 200 mg once daily. Disp:*60 Tablet(s)* Refills:*0* 7. Oxycodone 5 mg Capsule Sig: [**12-16**] Capsules PO every 4-6 hours. Disp:*80 Capsule(s)* Refills:*0* 8. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO As Directed. Disp:*30 Tablet(s)* Refills:*2* 11. Outpatient [**Name (NI) **] Work PT/INR twice weekly/PRN Please call Dr.[**Name (NI) 23247**] office with results [**Telephone/Fax (1) 17753**] 12. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: VNA Network Discharge Diagnosis: T3N2 squamous cell carcinoma of the left main stem bronchus diagnosed [**11-21**]. Pulmonary embolism [**11-21**] now on lovenox. Post-obstructive pneumonia [**11-21**]. Chronic obstructive pulmonary disease. Latent tuberculosis. Pneumonia [**11-21**]. Discharge Condition: Good Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if experience: -Fever > 101 or chills -Increased cough, sputum production or shortness of breath -Chest pain -Incision develops drainage or increased redness Continue Lovenox 60 mg twice daily until INR 2.0 or greater Coumadin for atrial fibrillation and pulmonary embolism. INR Goal 2.0-3.0 Blood draw Friday at [**Hospital1 **] [**Location (un) 620**] call Dr.[**Name (NI) 23247**] office for further coumadin doses Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] Date/Time:[**2151-3-25**] 3:00 o the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**] Report to the [**Location (un) 861**] Radiology Department for a Chest-X-Ray 45 minutes before your appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**] appointment [**2151-4-1**] at 2:40pm Holter Monitor upon discharge from the hospital, Follow-up with Dr. [**Last Name (STitle) 911**] Coumadin follow-up with Dr. [**Last Name (STitle) 75965**] [**Telephone/Fax (1) 17753**] on Friday [**2151-3-12**] Completed by:[**2151-3-11**]

[ "196.1", "V15.82", "458.29", "496", "E938.7", "V12.01", "V12.51", "162.2", "427.31" ]

icd9cm

[ [ [] ] ]

[ "33.22", "32.59", "00.17", "40.3", "96.07" ]

icd9pcs

[ [ [] ] ]

7729, 7771

4842, 5883

339, 459

8069, 8076

2306, 4819

8606, 9288

1985, 2019

6597, 7706

7792, 8048

5909, 6574

8100, 8583

2034, 2287

281, 301

487, 952

974, 1587

1603, 1969

27,879

107,921

4241

Discharge summary

report

Admission Date: [**2149-4-1**] Discharge Date: [**2149-4-8**] Date of Birth: [**2100-1-23**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline / Wellbutrin Attending:[**First Name3 (LF) 1267**] Chief Complaint: DOE/fatigue Major Surgical or Invasive Procedure: AVR(#21 [**Company 1543**] Mosaic)[**4-1**] History of Present Illness: 49 yo F with a history of a bicsupid aortic valve followed by serial echocardiograms. Recent echo revealed RV dysfunction with increased MR, Ai and AS. She was referred for surgery. Past Medical History: PMH: - Crohn's disease since age 19, no surgeries, treated with prednisone off and on - prednisone induced hyperglycemia - COPD - PFTs in [**6-20**] showed FEV1/FEV 87% predicted - Aortic Stenosis (moderate,per echo [**1-20**]) - hypertension - high cholesterol - gastritis/GERD, h/o GI bleed - one seizures in the setting of emesis in [**12-20**], no AEDs - skin cancer on nose - inflammatory [**Last Name **] problem periodically - pyoderma gangrenosum-on L calf and R ankle, tx with Prednisone - osteopenia - all teeth extracted secondary to prednisone - right arm arterial bypass when she presented with right arm pain and pulselessness Social History: completed 12th grade, currently on disability but formerly worked in an airplane factory, divorced, lives with son, active [**Name2 (NI) 1818**] - 1-1.5 ppd x 32 years. No drinking or drug use (IVDA). Family History: mother deceased age 62 of stroke, HTN, high chol, father deceased age 56 of MI and also had low back pain, sisters x 4 one with diabetes and neuropathy, one brother deceased (in army), and another alive with HTN, high chol, and prostate cancer, one son healthy. Physical Exam: Admission: HR 80 NSR RR 20 BP 140/80 NAD Lungs Mild Rhonchi Heart RRR 3/6 SEM Abdomen obese, benign Extrem warm, 1+ edema No Varicosities Discharge: VS T 97 BP 105/56 HR 65 SR RR 18 O2sat 94%/3LNP Gen NAD Neuro Alert, non focal exam Pulm CTA bilat CV RRR, no murmur. Sternum stable, incision CDI Abdm Soft, NT/+BS Ext warm, [**1-15**]+edema bilat Pertinent Results: [**2149-4-1**] 12:23PM GLUCOSE-127* NA+-136 K+-3.0* [**2149-4-1**] 12:12PM UREA N-9 CREAT-0.7 CHLORIDE-114* TOTAL CO2-24 [**2149-4-1**] 12:12PM WBC-18.4* RBC-3.49*# HGB-9.7*# HCT-29.2*# MCV-84 MCH-27.8 MCHC-33.1 RDW-15.1 [**2149-4-1**] 12:12PM PLT COUNT-187 [**2149-4-1**] 12:12PM PT-13.8* PTT-38.8* INR(PT)-1.2* [**2149-4-8**] 05:20AM BLOOD WBC-9.6 RBC-3.33* Hgb-9.4* Hct-28.8* MCV-87 MCH-28.3 MCHC-32.7 RDW-15.4 Plt Ct-233 [**2149-4-8**] 05:20AM BLOOD Plt Ct-233 [**2149-4-8**] 05:20AM BLOOD PT-11.8 PTT-20.9* INR(PT)-1.0 [**2149-4-7**] 06:20AM BLOOD Glucose-76 UreaN-11 Creat-1.0 Na-141 K-3.7 Cl-99 HCO3-40* AnGap-6* RADIOLOGY Final Report CHEST (PA & LAT) [**2149-4-6**] 10:47 AM CHEST (PA & LAT) Reason: pna /plueral [**Hospital 18440**] [**Hospital 93**] MEDICAL CONDITION: 49 year old woman with cosistanlt requiring O2, low BP post cabg REASON FOR THIS EXAMINATION: pna /plueral effussion CHEST RADIOGRAPH INDICATION: Oxygen requirement, rule out of pneumonia and pleural effusion. COMPARISON: [**2149-4-4**]. As compared to the previous radiograph, the lung volumes have increased. Due to the increased lung volumes, band-like opacities in both lung bases are better seen than on the previous radiograph. These opacities could correspond to plate-like atelectasis, old post- infectious scars or cryptogenic organizing pneumonia. The remaining differential diagnosis could be further worked up by CT. There is unchanged subtle blunting of the right costophrenic angle, suggestive of either a small pleural scar or a small pleural effusion. No newly occurred opacities. No evidence of hyperhydration or cardiac failure. The size of the cardiac silhouette is slightly above the normal range. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 18441**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 18442**] (Complete) Done [**2149-4-1**] at 8:34:23 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-1-23**] Age (years): 49 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Left ventricular function. Preoperative assessment. ICD-9 Codes: 440.0, 424.1 Test Information Date/Time: [**2149-4-1**] at 08:34 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW4-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aortic Valve - Peak Gradient: *40 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 16 mm Hg Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Bicuspid aortic valve. Moderately thickened aortic valve leaflets. Systolic doming of aortic valve leaflets. Moderate AS (AoVA 1.0-1.2cm2) Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is systolic doming of the aortic valve leaflets. There is moderate aortic valve stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Biventricular systolic function is preserved. There is a well seated, well functioning bioprosthesis in the aortic position. There is trace perivalvular AI. MR remains mild. The study is otherwise unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2149-4-1**] 15:54 Brief Hospital Course: She was a direct admission to the operating room on [**2149-4-1**] where she underwent an AVR, please see OR report for details. In summary she had AVR with 21mm [**Company 1543**] Mosaic valve, her bypass time was 102 min with cross clamp of 75 minutes. She tolerated the operation well and was transferred to the ICU in critical but stable condition. She was extubated on the morning of POD #1 and later in the day was transferred to the floor. Once on the floors she had an uneventful post-operative course. Her chest tubes were removed late on POD1 and epicardial wires were removed on POD3. Her activity was advanced by nursing and PT. On POD4 she was transfused with PRBC's for a HCT of 22. her HCT stayed stable over the next 2 days and on POD6 she was transferred to rehabilitation at Lifecare of [**Location (un) 5165**]. Medications on Admission: Prednisone 10', Albuterol, Lipitor 20', Budesonide 6', Pletal 100", Duloxetine 30", Chantix, Lasix 40", Folate 1', Boniva 150'Qmo, Lisinopril 20', Ativan 0.5", Methadone 5 Q6/prn, Percocet 5/325-prn, Donnatal 16.2'/prn, Lyrica 150", Protonix 40", Carafate 1", Sulfasalazine 1000", Spiriva 18', Trazadone 300/hs, ASA 81', Calcium 500", Vit B12 100', MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Methadone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO bid (). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Sulfasalazine 500 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 16. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 20. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): 14mg/day x 1 week then 7mg/day patch. 21. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 22. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. 23. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month. 24. Donnatal 16.2 mg Tablet Sig: One (1) Tablet PO once a day as needed for diarrhea. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: AS/AI now s/p AVR PMH: HTN,^chol,COPD,PHTN,PVD,Crohn's, s/p GIB,Gastritis,GERD, Depression,CHF,Skin CA s/p excision(nose),L ear chrondrodermatitis,osteopenia,restless leg,C-sectionx2,R arm bypass/embolectomy,L caf debridement Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Already scheduled appointments: Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 18443**] [**Name12 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2149-4-14**] 1:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2149-4-14**] 3:20 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2149-6-30**] 10:20 Completed by:[**2149-4-8**]

[ "530.81", "272.0", "401.9", "790.01", "428.41", "496", "311", "416.8", "428.0", "396.2", "443.9", "V10.83", "746.4", "733.90" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "99.04", "88.72", "39.63" ]

icd9pcs

[ [ [] ] ]

10900, 10971

7576, 8408

344, 390

11241, 11249

2151, 2907

11562, 12122

1500, 1763

8812, 10877

2944, 3010

10992, 11220

8434, 8789

11273, 11539

6414, 7553

1778, 2132

293, 306

3039, 6370

418, 601

623, 1265

1281, 1484

12,306

101,207

52637

Discharge summary

report

Admission Date: [**2171-9-14**] Discharge Date: [**2171-9-21**] Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 4071**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization with a stent placed in the left anterior descending artery. History of Present Illness: Ms. [**Known lastname 6164**] is an 87 yo woman with h/o 3 vessel CAD s/p multiple PCIs, complete heart block s/p pacer, who presents after an episode of chest pain. She has trouble sleeping usually, and when she awoke at 4am, she noted substernal pressure in the lower chest at about [**7-24**]. She took 1 nitroglycerin sublingual tablet which did not help. She denied shortness of breath and nausea, but she did have 1 episode of vomiting. She states that she was experiencing diaphoresis prior to the pain, but she has had night sweats for over a year regularly. The pain lasted until about 10am, after which her son called EMS to bring her to the ED. In the ED, initial Vital Signs were T 98.1 BP 123/74 HR 62 RR 16 O2Sat 100%. Troponin was positive at 1.05 with CK of 391 and MB of 42. She was given plavix 300mg and started on a heparin gtt and was guaiac Neg. Upon arrival to the floor, patient denies chest pain, shortness of breath, nausea, vomiting, diarrhea. She admits to decreased appetite for many months and 25 lb loss (200lbs --> 175lbs) in the last seven months, though stable weight for the last [**2-15**] months. She endorses nightsweats for over a year off and on. She has a little cough for the last couple of years which has been stable, but she reports no recent coughing; she has been using cough syrup for the last couple of years. The cough sometimes has phlegm. She has difficulty swallowing and has difficulty chewing because of no teeth. She endorses ankle edema, joint pain and body pain "all over" chronicly. She denies dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea. She denies recent fevers, chills or rigors. She denies urinary symptoms and diarrhea but states that she doesn't urinate much in general; she doesn't drink much fluid. Past Medical History: - hx complete heart block status post pacemaker in 03/[**2166**]. [**Company 1543**] Sigma Dual - coronary artery disease - s/p NSTEMI on [**2169**] with BMS placement ** MI [**6-16**] w stent to prox RCA but TIMI II flow in distal RCA ** PCI/BMS to ramus branch [**7-21**] - HTN - Hyperlipidemia - asthma - s/p thyroidectomy [**11/2163**] - OA and chronic pain - GERD - Chronic Sweats: TSH and PPD normal - Glaucoma - shoulder bursitis Social History: Denies tobacco or ETOH current or in past. Worked as a [**Year (4 digits) **]. Lives alone w/ family nearby. Lives in [**Location (un) 538**]. Uses walker at home. From [**State 9512**] originally. Pt unable to [**State **] for herself now. Lives on [**Location (un) **]. Elevators in building. Her son, [**Name (NI) **], is taking care of her and visits her frequently, nearly every day. Her daughter, [**Name (NI) 402**], who lives in [**Name (NI) 669**] takes care of her medications. Her daughter, [**Name (NI) 108632**], in [**Name (NI) 8**] brings her to all her medical appointments. [**Last Name (LF) **], [**First Name3 (LF) 402**], and [**First Name4 (NamePattern1) 108632**] [**Last Name (NamePattern1) **] meals for her. She has another daughter in [**Name (NI) 5110**], a son in [**Name (NI) 4565**], and a son in [**State 9512**]. She all together has 9 children. Three have died. Has a sister in [**Name (NI) 4565**]. Husband died after they were separated many years ago. Family History: Mother with MI at age 70. No other cardiac hx, DM, or cancer. Physical Exam: VS: T= 98.0 BP= 132/78 HR= 62 RR= 16 O2 sat= 100%/ 2L GENERAL: well developed woman lying down in NAD. Oriented x3. Mood, affect appropriate. HEENT: EOMI. moist mucus membranes. CARDIAC: Reg Rhythm, Normal Rate LUNGS: CTAB, mild expiratory wheezing. Respirations unlabored. ABDOMEN: Soft, diffusely tender to mild palpation. No guarding or rebound tenderness. EXTREMITIES: tender to palpation over bones and muscles; bilateral lower extremity edema, nonpitting ; No right or left sided femoral bruit PULSES: Right: DP 2+ ; Left: DP 2+ Pertinent Results: [**2171-9-14**] 12:52PM BLOOD WBC-4.9 RBC-4.42 Hgb-12.9 Hct-39.5 MCV-89 MCH-29.2 MCHC-32.7 RDW-14.0 Plt Ct-229 [**2171-9-20**] 07:03AM BLOOD WBC-4.6 RBC-3.02* Hgb-9.1* Hct-27.9* MCV-92 MCH-30.0 MCHC-32.5 RDW-14.5 Plt Ct-187 [**2171-9-21**] 07:35AM BLOOD WBC-4.8 RBC-2.99* Hgb-8.8* Hct-27.5* MCV-92 MCH-29.4 MCHC-32.0 RDW-14.7 Plt Ct-221 [**2171-9-19**] 09:50AM BLOOD PT-12.1 PTT-26.3 INR(PT)-1.0 [**2171-9-14**] 12:52PM BLOOD Glucose-117* UreaN-13 Creat-0.9 Na-137 K-4.1 Cl-99 HCO3-25 AnGap-17 [**2171-9-21**] 07:35AM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-138 K-4.0 Cl-105 HCO3-23 AnGap-14 [**2171-9-14**] 12:52PM BLOOD CK(CPK)-391* [**2171-9-14**] 07:35PM BLOOD CK(CPK)-549* [**2171-9-15**] 02:08AM BLOOD CK(CPK)-473* [**2171-9-16**] 06:31AM BLOOD CK(CPK)-334* [**2171-9-14**] 12:52PM BLOOD CK-MB-42* MB Indx-10.7* proBNP-937* [**2171-9-14**] 12:52PM BLOOD cTropnT-1.05* [**2171-9-14**] 07:35PM BLOOD CK-MB-49* MB Indx-8.9* cTropnT-1.93* [**2171-9-15**] 02:08AM BLOOD CK-MB-37* MB Indx-7.8* cTropnT-1.07* [**2171-9-16**] 06:31AM BLOOD CK-MB-29* MB Indx-8.7* EKG: In the ED: Atrial pacing. Twave inversions in V2-V4, Twave flattening in V5, V6, I, aVL. Prolonged QTc (471). Compared to prior EKG from [**2170-5-11**]: A-V paced rhythm w left axis, wide QRS. Prior EKG from [**11-17**]: Ectopic atrial rhythm w normal axis; the precordial Twave inversions and lateral flattening are not present. CXR [**2171-9-14**]: No acute cardiopulmonary abnormality. TTE [**2171-9-16**]: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypo/akinesis of the distal half of the anterior septum and anterior wall. The apex is mildly dyskinetic. The remaining segments contract normally (LVEF = 30-35 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2166-7-23**], new regional left ventricular systolic function is now present c/w interim infarction/ischemia. Cardiac cath [**2171-9-16**]: 1. Selective coronary angiography of this right dominant system revealed 3 vessel CAD. The LMCA was large, ectatic, with mild disease. The proximal LAD was large, ectatic with mild disease. The mid LAD was heavily calcified and subtotally occluded, with serial 80-90% stenosis more distally. The distal LAD had a 50% stenosis and apical LAD had an 80% stenosis. The D1 had a 50% origin stenosis. D2 had a 50% origin stenosis. THe LCX was a small caliber (2mm) diffusely diseased vessel with an 80% origin stenosis but supplied very little LV. The RCA had an upward takeoff with a mid-vessel 20% ISR and more diffuse disease distally. The RPDA had serial 50% stenoses. 2. Successful PTCA and stenting of the mid LAD with a 3.0 x 24mm Driver bare metal stent and POBA of the distal LAD with a 2.5 x 20 NC [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 108633**]. Final angiography revealed no residual stenosis in the stent, no angiographically apparent dissection, and TIMI 3 flow. (see PTCA comments for details.) 3. Resting hemodynamics demonstrated systemic arterial hypertension (153/65 mmHg), mild pulmonary arterial hypertension (38/19/26 mmHg), and mildly elevated right and left sided filling pressures (mean RAP 11mmHg, RVEDP 13 mmHg, mean PCWP 13 mmHg). Cardiac index was severely depressed (1.6 L/min/m2). 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate to severe left ventricular systolic dysfunction. 3. Successful PTCA and stenting of the mid LAD and POBA of the distal LAD. 4. Mild left ventricular diastolic dysfunction. 5. Mild pulmonary arterial hypertension. Non-contrast CT pelvis [**2171-9-20**]: Small hematoma in the right proximal thigh anteriorly but no evidence of lower abdominal or pelvic retroperitoneal hematoma. Brief Hospital Course: Ms. [**Known lastname 6164**] is an 86yo woman with known CAD who was admitted for NSTEMI. # NSTEMI->STEMI: Ms. [**Known lastname 6164**] presented to the hospital after having six hours of substernal chest pressure which had resolved on its own. Her cardiac enzymes were elevated and peaked with a troponin-T of 1.9. She presented with T-wave inversions in V2-V4 and Twave flattening in V5-V6 on EKG; serial EKGs showed impressive T-wave changes, deepening T-waves in V1-V6 with no ST depressions or elevations. She was being treated with IV heparin while awaiting cardiac catheterization when she was noted to have marked ST elevations on telemetry. When prompted, she endorsed recurrence of her chest pain and she was sent for emergent cardiac catheterization and transferred to the cardiology ICU. Catheterization revealed 3 vessel disease with subtotal 80-90% occlusion of her mid LAD. She received a bare metal stent to mid LAD and angioplasty of distal LAD. Echocardiogram showed EF 30-35%. She was discharged on ASA, plavix, beta blocker, statin, and [**Last Name (un) **]. # Anemia: Patient's hematocrit dropped from 40->28 in the course of her hospitalization. This occurred in the setting of catheterization and volume resuscitation. Over the last 3 days of her hospitalization, her hematocrit remained stable. Nevertheless, a CT pelvis was obtained and did not show evidence of retroperitoneal bleed or significant hematoma. # Acute on chronic systolic heart failure: Shortly after her cardiac cath, Ms. [**Known lastname 6164**] had low blood pressures and low urine output. This was felt to be due to volume loss/blood loss with decreased systolic function. She improved with IV fluids. However, several days later she became somewhat volume overloaded on exam and required some gentle IV diuresis. She is not being discharged on lasix, but her volume status should be monitored as an outpatient. # Abdominal tenderness: Significant reflux disease with very tender abdomen. Patient reported that this was a chronic issue. She was given ranitidine to treat GERD as PPIs should be avoided while she is on plavix. # HTN: Nifedipine was stopped and olmesartan was changed to losartan. Her metoprolol dose was decreased. Please refer to discharge med list. # Hyperlipidemia: Increased simvastatin. # S/p thyroid thyroidectomy, Glaucoma, Asthma, h/o PPM for complete heart block, Depression: Not active during her stay. Her home meds were continued. Medications on Admission: Albuterol 90 mcg HFA Aerosol Inhaler one to two puffs inhaled every six (6) hours as needed for wheezing Brimonidine [Alphagan P] 0.1 % Drops 1 drop left eye twice a day Clopidogrel [Plavix] 75 mg Tablet one Tablet(s) by mouth once a day Clotrimazole 1 % Cream apply to affected areas twice a day 30 gram tube Dorzolamide [Trusopt] 2 % Drops 1 drop left eye twice a day Fluoxetine 40 mg Capsule one Capsule(s) by mouth once a day Fluticasone [Flonase] 50 mcg Spray, Suspension one spray nasally once a day Fluticasone [Flovent HFA] 110 mcg/Actuation Aerosol two puffs inhaled once a day Hydrocortisone 2.5 % Cream apply tid sparingly to itchy areas Latanoprost [Xalatan] 0.005 % Drops 1 drop left eye at bedtime Levothyroxine [Levoxyl] 112 mcg Tablet one Tablet(s) by mouth once a day Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr one Tablet(s) by mouth once a day Nifedipine [Nifedical XL] 60 mg Tablet Extended Rel 24 hr (2) one Tab(s) by mouth once a day Nitroglycerin 0.3 mg Tablet, Sublingual 1 Tablet(s) sublingually q 5 mins prn; if 3 needed [**Name8 (MD) 138**] md Olmesartan [[**Name8 (MD) 108631**]] 20 mg Tablet one Tablet(s) by mouth once a day Simvastatin 40 mg Tablet one Tablet(s) by mouth once a day Triamterene-Hydrochlorothiazid [Dyazide] 37.5 mg-25 mg Capsule one Capsule(s) by mouth once a day Ammonium,Pot.& Sodium Lactates [AmLactin XL] Lotion Apply to affected areas Aspirin 325 mg Tablet one Tablet(s) by mouth once a day Carbamide Peroxide Famotidine [Pepcid AC] 20 mg Tablet one Tablet(s) by mouth twice a day Food Supplement, Lactose-Free [Ensure] Liquid 1 Liquid(s) by mouth twice a day Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): In left eye. 7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): Place drops in left eye. 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): Place in left eye. 9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3 times a day) as needed for itching. 12. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a day. 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 17. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 18. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 19. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Primary Diagnosis: STEMI (heart attack) Secondary Diagnosis: NSTEMI (heart attack) Acute on Chronic systolic heart failure Arthritis Blood loss Anemia Hypertension Discharge Condition: All vital signs were stable. Patient has no nausea or vomiting. Discharge Instructions: You were admitted to the hospital because of a myocardial infarction (heart attack). We treated you by giving medications to help your heart and performing a cardiac catheterization. This procedure helped to visualize the blood vessels that supply your heart. During this procedure a stent was placed in one of your arteries. Because the stent was placed, it is very important for you to continue taking clopidogrel (Plavix). The following medications were were started or changed during your stay: Losartan 25 mg Metoprolol Succinate 50 mg Ranitidine 150 mg Simvastatin 80 mg The following medications were stopped: Nifedipine XL 60 mg Olmesartan 20 mg Sucralfate 1 g every 6 hours Simvastatin 40 mg Metoprolol succinate 100 mg You should continue taking the following medications: albuterol inhaler 1-2 puffs every 6 hours as needed aspirin 325 mg daily brimonidine eyedrops clopidogrel (plavix) 75 mg- Continue taking for life unless you develop a bleeding complication. clotrimazole cream dorzolamide eyedrops fluoxetine 40 mg fluticasone inhaler fluticasone nasal spray hydrocortisone cream latanoprost eyedrops lactic acid lotion levothyroxine 112 mcg Dyazide 37.5/25 Please go to the emergency room, call your doctor, or call 911 if you have recurrent chest pain, shortness of breath, nausea, fever, dizziness, or any other concerning symptom. Followup Instructions: 1. Please keep your appointments with the Device Clinic and Dr. [**Last Name (STitle) 73**], your cardiologist, for [**9-23**]: The DEVICE CLINIC appointment is scheduled at 10:30 and Dr. [**Last Name (STitle) 73**] will see you at 11:00am. [**Hospital1 18**] [**Hospital Ward Name **], [**Hospital Ward Name 23**] building, [**Location (un) 436**]. Phone:[**Telephone/Fax (1) 62**] 2. We scheduled an appointment for you with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your primary doctor: [**10-14**] at 10:20am. Phone: [**Telephone/Fax (1) 250**]. 3. Please keep your previously scheduled appointment with rheumatology: Provider: [**Name10 (NameIs) 3712**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2171-10-14**] 9:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**] Completed by:[**2171-9-21**]

[ "E879.0", "789.07", "338.29", "410.71", "726.10", "715.90", "263.9", "530.81", "428.23", "365.9", "414.01", "493.90", "401.9", "E878.1", "410.11", "285.9", "997.1", "780.8", "272.4", "V45.82", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "36.06", "00.66", "88.72", "00.45", "00.40" ]

icd9pcs

[ [ [] ] ]

14693, 14764

8662, 11146

226, 312

14972, 15038

4273, 8189

16441, 17352

3634, 3697

12842, 14670

14785, 14785

11172, 12819

8206, 8639

15062, 16418

3712, 4254

176, 188

340, 2143

14847, 14951

14804, 14826

2165, 2603

2619, 3618

67,377

177,878

46882

Discharge summary

report

Admission Date: [**2193-5-10**] Discharge Date: [**2193-5-16**] Date of Birth: [**2126-5-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 45**] Chief Complaint: palpitations Major Surgical or Invasive Procedure: none History of Present Illness: 66 YOF with h/o alcohol use, afib on coumadin, systolic CHF with EF 30%, HTN, presented with palpatation x3 days, worsening dyspnea with exertion, increased peripheral edema with abdminal ascites over past week. Reports difficulty sleeping due to dyspnea and palpatations, sleeping recumbant on 1 pillow. Speaks full sentences in ED in no obvious respiratory distress. Recently decreased her verapamil to 120 daily, questionable if PCP is [**Name Initial (PRE) **]. Has not had a drink since late [**Month (only) **]. . In the ED, patient's HR in 130s in Afib with good BPs. Given 10mg IV dilt x2. Admitted to [**Hospital Unit Name 196**] for diuresis and rate control. . On floor, patient was found resting in bed. Became tearful with discussing regarding her medical condition. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. . Past Medical History: Cardiac Risk Factors: Diabetes, + Dyslipidemia, + Hypertension . Cardiac History: CABG: none Percutaneous coronary intervention: none Pacemaker/ICD: none Social History: She is divorced, lives with her son. She works with historical manuscripts. She does smoke two packs of cigarettes a day. Was drinking 10 glasses of wine per day but quit four month ago. No recreational drugs, does not do any regular exercise, or follow a particular diet. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - 97.7 112/83 84 18 99% 3L NC Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**1-12**] murmur no r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. poor air movement, decreased breath sound b/l, wet crackles on right base, no wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2193-5-10**] 03:05PM BLOOD WBC-5.8 RBC-4.15* Hgb-12.9 Hct-39.0 MCV-94 MCH-31.1 MCHC-33.1 RDW-13.8 Plt Ct-202 [**2193-5-16**] 05:40AM BLOOD WBC-6.4 RBC-4.06* Hgb-12.7 Hct-38.6 MCV-95 MCH-31.4 MCHC-33.0 RDW-14.7 Plt Ct-195 [**2193-5-10**] 03:05PM BLOOD PT-42.1* PTT-39.6* INR(PT)-4.5* [**2193-5-16**] 05:40AM BLOOD PT-18.4* PTT-42.8* INR(PT)-1.7* [**2193-5-10**] 03:05PM BLOOD Glucose-105* UreaN-16 Creat-0.9 Na-134 K-3.1* Cl-98 HCO3-23 AnGap-16 [**2193-5-16**] 05:40AM BLOOD Glucose-95 UreaN-18 Creat-1.0 Na-138 K-3.7 Cl-97 HCO3-29 AnGap-16 [**2193-5-10**] 03:05PM BLOOD ALT-10 AST-25 AlkPhos-59 TotBili-1.5 [**2193-5-12**] 03:30AM BLOOD ALT-11 AST-19 LD(LDH)-174 AlkPhos-47 TotBili-1.3 [**2193-5-10**] 03:05PM BLOOD cTropnT-0.02* proBNP-[**Numeric Identifier 47330**]* [**2193-5-11**] 12:06AM BLOOD CK-MB-4 cTropnT-0.02* [**2193-5-11**] 08:15AM BLOOD CK-MB-3 cTropnT-0.01 [**2193-5-11**] 12:06AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2 [**2193-5-16**] 05:40AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.5* [**2193-5-12**] 03:30AM BLOOD TSH-2.0 [**2193-5-10**] 03:05PM BLOOD GreenHd-HOLD [**2193-5-12**] 12:19PM URINE Hours-RANDOM UreaN-502 Creat-202 Na-25 K-74 Cl-47 [**2193-5-12**] 12:19PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-[**10-26**] [**2193-5-12**] 12:19PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-5.0 Leuks-NEG [**2193-5-12**] 12:19PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.018 2D-ECHOCARDIOGRAM performed on [**2193-5-11**] demonstrated: L atrium dilation. Moderate global left ventricular hypokinesis (LVEF = 30-35%). RV moderately dilated with moderate global free wall hypokinesis. No AS or AR. Moderate to severe (3+) MR, Moderate to severe [3+] TR. The estimated pulmonary artery systolic pressure is normal. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] Small pericardial effusion with no signs of tamponade. [**2193-5-16**] Cardiology ECHO No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). Right ventricular chamber size is normal. with moderate global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta and aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion, most prominent near the inferior wall. There are no echocardiographic signs of tamponade. IMPRESSION: Mild left atrial appendage spontaneous echo contrast with depressed ejection velocities. No left atrial/appendage thrombus seen. Hypokinetic LV with moderate mitral regurgitation. Brief Hospital Course: 66 YOF with Afib on coumadin, systolic CHF with EF 30%, HTN, who presented with palpatations and found to be in Afib with RVR, and heart failure, treated in the CCU with dopamine drip for hypotension/bradycardia likely associated to IV diltiazem + other nodal agents. TEE and DCCV planned for [**5-16**]. . Mrs [**Known lastname 99458**] had episode of hypotension secondary to low cardiac output in the setting of bradycardia as the result of multiple nodal agents for RVR control (received 40 IV dilt + 20 PO dilt + home metoprolol + 240 verapamil CR). She had a repeat ECHO showed small pericardial effusion, EF stable (EF 30-35%) with 3+ MR, 3+ TR. She was transiently maintained on dopamine, amiodarone, atropine, calcium gluconate. Antihypertensives were held. She was continued on amiodarone and started on metoprolol for her atrial fibrillation. She was diuresised aggressively and was placed on standing lasix for her heart failure. She underwent DCCV after TEE, after which she was in sinus rhythm. After the cardioversion, she was discharged in stable condition with significant modification in her medications. She will follow up with her PCP and cardiologist. . # Code status: presumed full Medications on Admission: hydrochlorothiazide 12.5 mg a day Cozaar 50 mg a day metoprolol succinate 50 mg a day verapamil 240 mg a day warfarin Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Please start after you have completed the 10 day course of twice a day dosing. Disp:*30 Tablet(s)* Refills:*2* 3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Outpatient Lab Work [**5-18**] CHEM10 (Na/K/Co2/Cl/BUN/Cr/Ca/Mg/Phos/glucose), Coagulation (PT/INR) and send to PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Fax: [**Telephone/Fax (1) 97841**] Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Congestive Heart Failure Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came with heart failure and were in atrial fibrillation. You were treated with diuresis and given medication to control your heart rate. We were able to help you get rid of fluids to make you feel much better. You were discharged in stable condition. Please follow up with the following doctors. Please note we have made the following changes to your medications. STOPPED: Hydrochlorothiazide 12.5 mg a day Cozaar 50 mg a day Metoprolol succinate 50 mg a day Verapamil 240 mg a day Warfarin 5mg a day STARTED: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Please start after you have completed the 10 day course of twice a day dosing. 3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. It was a pleasure taking care of you. We wish you a speedy recovery. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:Friday [**2193-5-24**] 2:30PM. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**] Date/Time:[**2193-5-21**] 10:15; [**Location (un) **]. PCP [**Name Initial (PRE) 2169**]: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 41966**] [**Street Address(2) **], 4W, [**Location (un) **], [**Numeric Identifier 822**]. Date/Time: [**2193-5-21**] 3:30PM. New PCP if you prefer: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2193-5-22**] 2:35 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]

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icd9cm

[ [ [] ] ]

[ "88.72" ]

icd9pcs

[ [ [] ] ]

8801, 8850

6435, 7648

326, 333

8939, 8939

3030, 6412

10282, 11184

2108, 2190

7816, 8778

8871, 8918

7674, 7793

9090, 10259

2205, 3011

274, 288

361, 1619

8954, 9066

1641, 1799

1815, 2092

57,066

146,450

43057

Discharge summary

report

Admission Date: [**2180-6-22**] Discharge Date: [**2180-7-3**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Pedestrian struck by car Major Surgical or Invasive Procedure: [**6-30**]: ACDF C6-7 History of Present Illness: 85M s/p ped vs. auto, dragged about 20 feet, sustaining multiple injuries on [**6-22**]. The patient does not recall the event but he does know where he is now. complains of pain in his head and neck. feels subjectively weaker in L leg. Past Medical History: Coronary artery disease, s/p CABG in [**2157**]. Mild aortic regurgitation. Hypertension. Hyperlipidemia. Bifascicular block with an AV delay chronic renal insufficiency BPH Hypothyroidism. Social History: patient is russian speaking Family History: non-contributory Physical Exam: On Discharge: Patient is alert, oriented to person, place and time. His motor is full strength without obvious deficit. Wound is clean, dry and intact without hematoma Pertinent Results: Labs on Admission: [**2180-6-22**] 05:45PM BLOOD WBC-5.9 RBC-3.18* Hgb-10.2* Hct-29.9* MCV-94 MCH-32.1* MCHC-34.2 RDW-15.1 Plt Ct-168 [**2180-6-22**] 05:45PM BLOOD PT-13.3 PTT-23.7 INR(PT)-1.1 [**2180-6-22**] 05:45PM BLOOD Fibrino-258 [**2180-6-22**] 10:02PM BLOOD Glucose-171* UreaN-25* Creat-1.3* Na-140 K-4.2 Cl-109* HCO3-22 AnGap-13 [**2180-6-22**] 05:45PM BLOOD CK(CPK)-439* [**2180-6-30**] 01:54PM BLOOD CK(CPK)-66 [**2180-6-22**] 05:45PM BLOOD Lipase-138* [**2180-6-22**] 05:45PM BLOOD CK-MB-10 MB Indx-2.3 [**2180-6-22**] 05:45PM BLOOD cTropnT-<0.01 [**2180-6-22**] 10:02PM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9 [**2180-6-22**] 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs on Discharge: [**2180-7-1**] 06:55AM BLOOD WBC-9.4 RBC-3.30* Hgb-9.9* Hct-30.1* MCV-91 MCH-30.0 MCHC-32.9 RDW-17.8* Plt Ct-187 [**2180-7-1**] 06:55AM BLOOD PT-12.6 PTT-24.1 INR(PT)-1.1 [**2180-7-1**] 06:55AM BLOOD Glucose-179* UreaN-14 Creat-0.9 Na-134 K-4.2 Cl-103 HCO3-23 AnGap-12 [**2180-7-1**] 06:55AM BLOOD CK-MB-4 cTropnT-0.01 [**2180-7-1**] 06:55AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.8 IMAGING CT Head [**6-22**]: IMPRESSION: 1. Subarachnoid hemorrhage in the right sylvian fissure, and over posterior frontal sulcus near convexity on the right. Small subdural hemorrhage at the anterior falx. 2. Comminuted fracture of the nasal bones, and nasal septum. 3. Soft tissue laceration of the right frontal region. 4. Mucosal thickening and secretions in the left maxillary sinus. CT Torso [**6-22**]: IMPRESSION: 1. No definite evidence of injury on CT torso. 2. Incidental finding of a right adrenal mass. CT adrenal protocol, or MRI can be done to evaluate further. CT Sinus [**6-22**]: IMPRESSION: Committed fractures at the nasal bones, and nasal septum. Mucosal thickening in the left maxillary sinus with secretions. MRI Knee [**6-27**]: IMPRESSION: 1. Findings of posterolateral corner injury as described with concomitant tears of the ACL and PCL and avulsion fracture of the fibular head. 2. Nondisplaced fracture of the medial aspect of the medial femoral condyle. 3. Extensive tear of medial meniscus. Suspected tear of lateral meniscus. CTA of Head [**6-26**]: IMPRESSION: 1. Subarachnoid and subdural hemorrhage which demonstrates expected evolution, without evidence of a new focus of hemorrhage. 2. Isodense subdural collections overlying the frontal convexities which are slightly larger than on the prior study, and may represent mixing of subdural hemorrhage with CSF versus a more subacute hemorrhage. 3. Comminuted fracture of the nasal bone and nasal septum, not significantly changed since the prior study. There is also soft tissue laceration overlying the right frontal bone, without evidence of a displaced calvarial fracture. 4. No evidence of an aneurysm or hemodynamically significant stenosis, with an essentially unremarkable CTA of the head. CT C-spine [**7-1**]: IMPRESSION: 1. Status post anterior fusion at C6-C7 with intervertebral body device. Alignment appears near anatomic. There is widening of the right lateral facet joints at C6-C7 with air between the facets. This may be due to recent surgical intervention and would recommend correlation with operative details. 2. Persistent prevertebral swelling, unchanged from prior examination. No evidence for acute hemorrhage. 3. Air in the pretracheal subcutaneous tissue, again likely postoperative in nature. 4. Degenerative changes of the cervical spine are better described on prior examination with unchanged narrowing of the cervical canal at C6-C7. Brief Hospital Course: He was admitted to the Trauma Service. His facial lacerations were irrigated and sutured by Plastic Surgery. Orthopedics and Neurosurgery were consulted for his other injuries. His fibula fracture was managed non operatively; he was fitted with a knee immobilizer and is to remain non weight bearing on that extremity. An MRI of his left knee was done which shows a lateral cruciate ligament tear for which he will follow up as an outpatient if further intervention warranted. His spine injury was initially managed with a hard cervical collar. After several days while films were being reviewed by Neurosurgery and discussions with family took place the decision was made to surgically repair his spine. A request from Neurosurgery for medical clearance by Cardiology was made and patient was deemed medically cleared for the surgery. Geriatric Medicine was consulted for delirium; several recommendations pertaining to his medications were made. He was placed on Haldol standing dose at HS and prn dose if needed for increased agitation. For pain control he was placed on around the clock Tylenol and prn Oxycodone low dose. On [**6-30**], he went to the operating room with Dr. [**First Name (STitle) **] for ACDF of C6-7. Surgery was uneventful. Post-operatively he was maintained in a cervial collar for additional stability and remained in the pacu for observation prior to transfer to the floor. On [**7-1**], CT of the C-spine was performed to evaluate hardware placement. He was futher seen by PT and OT who determined he would be an appropriate candadate for rehabilitation. He was discharged to an appropriate facility on [**7-3**]. Medications on Admission: Lipitor 10 mg daily, fish oil, Flovent, hydrochlorothiazide 12.5 mg daily, Levoxyl 75 mcg daily, lisinopril 20 mg daily, terazosin 5 mg daily, aspirin 325 mg daily, eyedrops. (per outpt note) Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One (1) Drop Ophthalmic TID (3 times a day). 7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for agitation, confusion. 10. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Levoxyl 50 mcg Tablet Sig: One (1) Tablet PO once a day. 16. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: s/p Pedestrian struck Facial lacerations Nasal bone and septum fractures C6 on C7 posterior subluxation Avulsion fracture proximal fibula Left lateral cruciate ligament tear Delirium Discharge Condition: Neurologically Stable Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? You have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? You are required to wear your cervical collar at all times until seen in follow up. ?????? You may shower briefly without the collar; unless you have been instructed otherwise. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow up with Dr. [**First Name (STitle) **], Orthopedics in 2 weeks for your knee. Call [**Telephone/Fax (1) 1228**] for an appointment. NEUROSURGERY Follow Up Instructions/Appointments ??????Please return to the office in [**6-23**] days (from date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **] to be seen in 4 weeks. ??????You will not need imaging prior to your appointment as this was done prior to your discharge. Completed by:[**2180-7-3**]

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icd9cm

[ [ [] ] ]

[ "80.51", "81.02", "81.62", "86.59" ]

icd9pcs

[ [ [] ] ]

7965, 8031

4674, 6324

290, 314

8258, 8282

1079, 1084

10161, 10938

858, 876

6567, 7942

8052, 8237

6350, 6544

8306, 10138

891, 891

905, 1060

226, 252

1814, 4651

342, 582

1098, 1795

604, 796

812, 842

55,005

163,614

28355

Discharge summary

report

Admission Date: [**2126-10-30**] Discharge Date: [**2126-11-10**] Date of Birth: [**2066-2-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2126-10-31**] 1. Bentall procedure with a 29-mm [**Company 1543**] Freestyle aortic root xenograft with coronary button reimplantation (serial #[**Serial Number 68823**]). 2. Replacement of ascending aorta and hemi-arch using a Vascutek Dacron tube graft (catalog #[**Numeric Identifier 68824**], lot #[**Serial Number 68825**], serial #[**Serial Number 68826**]) and deep hypothermic circulatory arrest. History of Present Illness: Mr. [**Known lastname **] is a 60 year old male who has had a cardiac murmur which was detected 4 years ago. He was found to have a dilated aorta as well. He has been followed for aortic insufficiency and his dilated aorta with serial echocardiograms and chest MRI since his diagnosis. His most recent echo revealed moderate aortic insufficiency with dilations of 5.4 cm at the ascending aorta and 4.9 cm at the aortic root. He underwent a cardiac catheterization which revealed clean coronaries. He was referred for cardiac surgery evaluation. Past Medical History: Aortic Insufficiency Aortic aneurysm Hypertension Dyslipidemia Alcohol abuse since age 16, continues drinking several drinks per night. Last drink 10:30 PM [**2126-10-29**]. Excision of melanoma left shoulder Appendectomy Right knee surgery Social History: Mr. [**Known lastname **] lives with his wife and daughter. [**Name (NI) **] is a polo instructor. he denies smoking, but generally has 4-5 drinks each evening. Family History: Mr. [**Known lastname **] sister died of diabetes and myocardial infarction. Physical Exam: Pulse: 50 Resp:18 O2 sat: 98% RA B/P Right: 133/70 Left: Height: 72" Weight: 220 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: II/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: cath site no hematoma Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: Admission [**2126-10-30**] 02:31PM PT-13.1 PTT-25.0 INR(PT)-1.1 [**2126-10-30**] 02:31PM PLT COUNT-141* [**2126-10-30**] 02:31PM WBC-4.7 RBC-3.28* HGB-11.6* HCT-33.3* MCV-102* MCH-35.5* MCHC-34.9 RDW-13.2 [**2126-10-30**] 02:31PM %HbA1c-5.7 eAG-117 [**2126-10-30**] 02:31PM ALBUMIN-3.9 CALCIUM-8.8 CHOLEST-159 [**2126-10-30**] 02:31PM ALT(SGPT)-34 AST(SGOT)-37 CK(CPK)-56 ALK PHOS-35* AMYLASE-29 TOT BILI-0.7 DIR BILI-0.2 INDIR BIL-0.5 [**2126-10-30**] 02:31PM GLUCOSE-113* UREA N-16 CREAT-0.7 SODIUM-134 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-12 [**2126-10-30**] 06:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2126-10-30**] 06:39PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050* Discharge [**2126-11-8**] 04:25AM BLOOD WBC-7.8 RBC-3.02* Hgb-10.1* Hct-29.5* MCV-98 MCH-33.6* MCHC-34.4 RDW-14.9 Plt Ct-244 [**2126-11-8**] 04:25AM BLOOD Plt Ct-244 [**2126-11-8**] 04:25AM BLOOD PT-15.0* INR(PT)-1.3* [**2126-11-8**] 04:25AM BLOOD Glucose-110* UreaN-23* Creat-0.8 Na-140 K-4.1 Cl-106 HCO3-25 AnGap-13 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.6 cm Left Ventricle - Fractional Shortening: 0.35 >= 0.29 Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Stroke Volume: 83 ml/beat Aorta - Annulus: 2.7 cm <= 3.0 cm Aorta - Sinus Level: *5.3 cm <= 3.6 cm Aorta - Ascending: *4.0 cm <= 3.4 cm Aorta - Arch: 2.8 cm <= 3.0 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 9 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 5 mm Hg Aortic Valve - LVOT VTI: 24 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *2.2 cm2 >= 3.0 cm2 Mitral Valve - Pressure Half Time: 37 ms Mitral Valve - MVA (P [**2-2**] T): 6.0 cm2 Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A ratio: 1.50 Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Markedly dilated aortic sinus. Moderately dilated ascending aorta. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. No AS. Moderate (2+) AR. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**Name13 (STitle) 15110**] to co-existing AR, the pressure half-time estimate of mitral valve area may be an OVERestimation of true area. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is markedly dilated at the sinus level. The ascending aorta is moderately dilated. There are three aortic valve leaflets. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve appears structurally normal with trivial mitral regurgitation. Due to co-existing aortic regurgitation, the pressure half-time estimate of mitral valve area may be an OVERestimation of true mitral valve area. Post CPB: The cardiac output is 4.5L/min. The patient is being AV paced. There is a well seated bioprosthetic valve in the aortic position as well as an ascending aorta tube graft. The aortic valve has a peak gradient of 9mmHg and a mean gradient of 5mmHg. There is trace MR. The visible contours of the thoracic aorta are intact. There is preserved biventricular systolic function, allowing for ventricular pacing dyssynchony. Radiology Report CHEST (PA & LAT) Study Date of [**2126-11-7**] 4:04 PM [**Hospital 93**] MEDICAL CONDITION: 60 year old man s/p Ao replacement Final Report PA AND LATERAL VIEWS OF THE CHEST: Since the prior exam, the endotracheal tube and enteric tubes have been removed. Sternal closure wires are intact. A moderate left and small right pleural effusion are slightly decreased, with associated retrocardiac atelectasis. There is no new consolidation. There is no pneumothorax. The cardiac silhouette remains enlarged. There is no new hilar or mediastinal enlargement. Pulmonary vascular structures are normal in caliber. IMPRESSION: Slight decrease in moderate left and small right pleural effusions, without new abnormalities. Brief Hospital Course: This patient was admitted to [**Hospital1 18**] for cardiac catheterization prior to Bentall/AVR/Ascending aorta replacement. The cardiac catheterization revealed no significant coronary disease. On [**2126-10-31**] he was brought to the operating room for Bental procedure, please see the operative note for full details. In summary he had: 1. Bentall procedure with a 29-mm [**Company 1543**] Freestyle aortic root xenograft with coronary button reimplantation. 2. Replacement of ascending aorta and hemi-arch using a Vascutek Dacron tube graft and deep hypothermic circulatory arrest. His CARDIOPULMONARY BYPASS TIME was 161 minutes with a CROSS-CLAMP TIME of 140 minutes, and CIRCULATORY ARREST TIME of 19 minutes. He was transferred to the CVICU in stable condition on titrated propofol and phenylehprine drips. He was treated for atrial fibrillation with amiodarone/coumadin after failed electrical cardioversion. He was reintubated for alcohol withdrawal symptoms, sternal protection, and agitation. He was re-extubated on POD #5. Mr. [**Known lastname **] transferred to the floor on POD #6 to begin increasing his activity level. He was gently diuresed toward his pre-operative weight. He continued to make good progress and was cleared for from a physical therapy standpoint. On post-operative day nine he had rapid atrial fibrillation for 5 hours, which converted with increased doses of lopressor. On the following day in discussion with Dr. [**Last Name (STitle) 914**] he insisted on leaving against medical orders despite warnings of the risk of uncontrolled atrial fibrillation. He stated that he had no further questions regarding this risk, after the risk was explained at length. His chest radiograph revealed a small effusion, so he was asked to return to see Dr. [**Last Name (STitle) 914**] on [**11-12**] in his office after obtaining a CXR. Since he left early his coumadin follow-up had not been arranged. Therefore, an INR will need to be drawn during his visit on the 12th with dosing by the office of Dr. [**Last Name (STitle) 914**] until other arrangements can be made. The target INR 2.0-2.5 for atrial fibrillation. All follow-up appts were advised. Medications on Admission: Atenolol 50mg q.a.m. and 25mg q.p.m. HCTZ 25mg daily lisinopril 30mg daily Gemfibrozil 600mg twice daily Trazodone 100 one to two tablets daily B complex vitamin Centrum Silver Discharge Medications: 1. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 3. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg daily for one week, then decrease to 200mg daily ongoing. Disp:*60 Tablet(s)* Refills:*2* 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 7. potassium chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day for 2 weeks. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**5-7**] hours as needed for pain/fever. 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: Take 2.5mg on [**11-11**]. Target INR 2-2.5. . Disp:*30 Tablet(s)* Refills:*2* 16. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 17. Outpatient Lab Work INR to be drawn on [**11-12**] with results sent to the office of Dr. [**Last Name (STitle) 914**] at ([**Telephone/Fax (1) 11763**] until further notice. INR goal 2-2.5 for afib. Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Aortic Insufficiency s/p Bental/AVR Aortic aneurysm Hypertension Dyslipidemia postop atrial fibrillation Alcohol abuse since age 16, continues drinking several drinks per night. Last drink 10:30 PM [**2126-10-29**]. PSH: Excision of melanoma left shoulder Appendectomy Right knee surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Edema: none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] You will need to obtain a CXR on [**11-12**] at [**Hospital1 18**] on the [**Hospital Ward Name 517**]. Further you will need to have your INR drawn on the [**Hospital Ward Name 517**] at [**Hospital1 18**]. You will be called and on that morning and given an appointment for that same afternoon. You also have an appointment with Dr. [**Last Name (STitle) 914**] on [**2126-12-24**] at 1:00 Cardiologist:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2127-1-2**] 1:40 Please call to schedule appointments with your Primary Care Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8448**] ([**Telephone/Fax (1) 68827**] in [**5-6**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication: Atrial fibrillation Goal INR 2-2.5 First draw day after discharge([**11-12**]) to be followed by the office of Dr. [**Last Name (STitle) 914**] until further notice. Completed by:[**2126-11-10**]

[ "E878.1", "424.1", "780.60", "V70.7", "518.81", "V10.82", "272.4", "511.9", "441.2", "401.9", "V49.87", "291.0", "427.31", "997.1", "E878.2", "285.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21", "38.45", "96.71", "96.04", "88.42", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

12528, 12562

8359, 10549

341, 771

12895, 13064

2574, 7171

13904, 15202

1811, 1889

10777, 12505

7710, 8336

12583, 12874

10575, 10754

13088, 13881

1904, 2555

282, 303

799, 1350

1372, 1615

1631, 1795

7181, 7673

6,512

164,799

2115

Discharge summary

report

Admission Date: [**2186-3-27**] Discharge Date: [**2186-4-7**] Service: SURGERY Allergies: Morphine Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: [**2186-4-5**]: Tracheostomy, open gastrostomy-jejunotomy tube History of Present Illness: 82 yo F s/p fall from standing and hit back of head and neck on furniture, developed neck pain and then taken to [**Hospital **] Hospital. CT revealed C1 anterior and posterior arch fx and base of odontoid fx. Pt was given Morphine at OSH, developed stridors/resp distress and was intubated and then transferred to [**Hospital1 18**]. Past Medical History: HTN Parkinson's Disease Social History: unavailable Family History: N/A Physical Exam: On admission: 98.8 127/71 90 12 100% FiO2 60% PEEP 5 VT500 Gen: intubated, sedated HEENT: c-collar, atraumatic, PERRL Pulm: CTA b/l, no w/r/r Cardio: RRR, no m/r/g Abd: Soft, ND, BS+ Ortho: pulses palp, pelvis stable, R shin hematoma Pertinent Results: [**2186-3-27**] 05:43PM TYPE-ART TEMP-38.2 PO2-128* PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--2 [**2186-3-27**] 05:43PM freeCa-1.17 [**2186-3-27**] 08:04AM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF [**2186-3-27**] 06:10AM TYPE-ART PO2-62* PCO2-38 PH-7.37 TOTAL CO2-23 BASE XS--2 [**2186-3-27**] 06:10AM LACTATE-1.4 [**2186-3-27**] 05:57AM GLUCOSE-128* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-6.2* CHLORIDE-106 TOTAL CO2-22 ANION GAP-17 [**2186-3-27**] 05:57AM ALT(SGPT)-6 AST(SGOT)-29 CK(CPK)-133 ALK PHOS-143* AMYLASE-51 TOT BILI-0.6 [**2186-3-27**] 05:57AM LIPASE-43 [**2186-3-27**] 05:57AM cTropnT-<0.01 [**2186-3-27**] 05:57AM CK-MB-3 [**2186-3-27**] 05:57AM ALBUMIN-4.1 CALCIUM-9.8 PHOSPHATE-3.5 MAGNESIUM-2.0 [**2186-3-27**] 05:57AM URINE HOURS-RANDOM [**2186-3-27**] 05:57AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2186-3-27**] 05:57AM WBC-9.0 RBC-4.47 HGB-13.8 HCT-41.7 MCV-93 MCH-30.8 MCHC-33.0 RDW-13.0 [**2186-3-27**] 05:57AM NEUTS-86.6* BANDS-0 LYMPHS-9.1* MONOS-2.6 EOS-1.2 BASOS-0.5 [**2186-3-27**] 05:57AM PLT COUNT-261 [**2186-3-27**] 05:57AM PT-12.3 PTT-25.1 INR(PT)-1.0 [**2186-3-27**] 05:57AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.019 [**2186-3-27**] 05:57AM URINE BLOOD-MOD NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2186-3-27**] 05:57AM URINE RBC-1 WBC->50 BACTERIA-MANY YEAST-NONE EPI-1 TRANS EPI-1 Brief Hospital Course: 1. s/p [**2186**]2 yo F s/p fall from standing and hit back of head and neck on furniture, developed neck pain and then taken to [**Hospital **] Hospital. CT revealed C1 anterior and posterior arch fx and base of odontoid fx. Neurosurgery was following. Her CT c-spine confirmed the type 2 odontoid fracture. After extensive evaluation neurosurgery felt that her best treatment choice would be non-surgical in which whe will wear her hard c-collar at all times for 6 mos. 2. Pulmonary Pt was given Morphine at OSH, developed stridors/resp distress and was intubated and then transferred to [**Hospital1 18**]. Her vitals continued to improve to the point she was weaned and then extubated 2d later. However, 12 hours after extubation, she went into respiratory distress/stridors and was re-intubated. Pt then slowly stabilized. A tracheostomy was performed on [**2186-4-5**] for failed extubation. She remained stable following her surgery and throughout the rest of her hospital stay. 3. ID Her CXR showed a LLL atelectasis and she continued to have low grade temperatures and leukocytosis. Bl Cx have been NTD. Urine was +MRSA & Sputum Cx +MRSA and was therefore placed on vancomycin. A PICC line was placed and she was d/c'ed with 2 weeks of vancomycin. 4. FEN A nutrition consult was placed. Pt was being given tube feeds c fiber at 60cc for goal. She was then taken to the OR for an open gastrotomy-jejunostomy tube placement on [**2186-4-5**]. There were no complications with the procedure and the patient remained stable throughout the rest of her hospital stay. Medications on Admission: Zestril Discharge Medications: 1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Entacapone 200 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-2 MLs Miscell. Q4-6H (every 4 to 6 hours) as needed. 13. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Odontoid base, C1 arch, C2 fracture Discharge Condition: Stable Discharge Instructions: Please make and keep all follow up appointments. Take all medication as prescribed. Complete your 2 week course of vancomycin of 1 gm q12 hours starting on [**2186-4-7**]. Wear your cervical collar at all times. Followup Instructions: Make an appointment and follow up with neurosurgery in 1 month. Call [**Telephone/Fax (1) 1669**] Make an appointment and follow up with trauma clinic in 1 month. Call [**Telephone/Fax (1) 2359**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2186-4-7**]

[ "401.9", "428.0", "518.0", "518.81", "V09.0", "599.0", "V10.3", "332.0", "805.01", "E884.5", "041.11", "805.02", "496", "E849.0", "041.4" ]

icd9cm

[ [ [] ] ]

[ "38.91", "46.39", "96.04", "99.15", "96.72", "38.93", "31.1", "99.60" ]

icd9pcs

[ [ [] ] ]

5368, 5438

2524, 4110

223, 287

5518, 5526

1026, 2501

5786, 6140

745, 750

4168, 5345

5459, 5497

4136, 4145

5550, 5763

765, 765

175, 185

315, 653

779, 1007

675, 700

716, 729

18,570

115,912

1462+55287

Discharge summary

report+addendum

Admission Date: [**2128-6-22**] Discharge Date: [**2128-6-25**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8684**] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: none History of Present Illness: The patient is an 81 yo Mandarin-speaking female, who was recently discharged from [**Hospital1 18**] on [**6-20**] after a 4 day admission for evaluation of hematemesis. On her last admission, the patient had a HCT of 28 on admission. She received 2 U PRBCs in the ED. She underwent EGD on [**6-16**]. EGD disclosed "a few superficial non-bleeding 3 mm ulcers in the pylorus and incisura of the stomach. Red blood was seen in the fundus and stomach body. The blood was unable to be suctioned or lavaged due to clotting. A single cratered 9 mm ulcer was found in the incisura of the stomach. A visible vessel suggested recent bleeding. Five Epi injections were applied for hemostatis with success. Electrocautery was applied for hemostasis." The patient was started on an IV PPI [**Hospital1 **]. Her ulcers are secondary to NSAID use. In addition, she was using a Chinese herbal medicine which may cause increased gastric acid secretion. Following her brief MICU stay, the patient was transferred to the floor. She received an additional unit of PRBCs. Her HCT remained stable, and she was discharged on [**6-20**] with a HCT=33.6. Last evening, the patient felt dizzy, and she was taken to [**Hospital1 8685**]. There she was found to have a SBP ~80. She was found to have a HCT=24. She was transferred back to [**Hospital1 18**] for further management. Per her daughter, the patient denies any episodes of hematemesis or melena since her discharge. In the ED, the patient was hemodynamically stable (BP 100/58, HR 71). She was administered 1 L NS and 2 U PRBCs. The patient declined NG lavage. Past Medical History: Remote (10 years ago) history of maroon stools Glaucoma Social History: She is originally from [**Country 651**]. She lives with husband. Notes former tobacco use. Family History: The patient has a sister with diabetes. Physical Exam: General: Pale appearing elderly Chinese female in NAD. VS: Tm 99.4 Tc 98.6 BP 110/50-70 P 70-80 O2 97% RA HEENT: NC/AT. Sclerae anicteric. MMM. OP clear. Neck: Supple. No cervical LAD. Lungs: CTAB. CVS: RRR. S1, S2. No m/r/g. Abd: Soft, NT, ND, +BS. Extr: No c/c/e. Warm. Skin: No rashes or lesions. Pertinent Results: **FINAL REPORT [**2128-6-18**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2128-6-18**]): POSITIVE BY EIA. Reference Range: Negative. [**2128-6-24**] 08:44PM BLOOD Hct-33.7* [**2128-6-24**] 09:20AM BLOOD Hct-30.9* [**2128-6-24**] 05:30AM BLOOD Hct-31.8* [**2128-6-23**] 08:20PM BLOOD Hct-30.7* [**2128-6-23**] 03:46AM BLOOD WBC-7.6 RBC-3.59* Hgb-11.2* Hct-32.6* MCV-91 MCH-31.2 MCHC-34.4 RDW-14.4 Plt Ct-206 [**2128-6-21**] 11:15PM BLOOD PT-11.9 PTT-22.6 INR(PT)-0.9 [**2128-6-23**] 03:46AM BLOOD Glucose-84 UreaN-20 Creat-0.6 Na-144 K-3.4 Cl-112* HCO3-23 AnGap-12 [**2128-6-22**] 05:49AM BLOOD Glucose-99 UreaN-27* Creat-0.6 Na-141 K-3.9 Cl-110* HCO3-23 AnGap-12 [**2128-6-23**] 03:46AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0 [**2128-6-23**] 03:46AM BLOOD TSH-0.18* [**2128-6-23**] 03:46AM BLOOD T4-11.0 T3-95 Free T4-2.1* Brief Hospital Course: Pt was readmitted for Hct 24. She was transfused 2 u and given IVF. EGD was performed to show small ulcer on lesser curvature and was subsequently cuterized with epi. Her hematocrit has been stable at 31-32 since transfusion. She was transferred to floor on [**6-23**]. Her stool color has returned to [**Location 213**]. During the hospitalization, her TSH was found to be 0.18 and the rest of thyroid indicies are pending at the time of discharge. SHe has been recovering steadily and to be followed up at the Dr. [**Name (NI) 8686**] clinic on monday [**6-30**] for Hct check and further thyroid evaluation Medications on Admission: Brimonidine Tartrate 0.15% Ophth 1 drop OU [**Hospital1 **] Dorzolamide 2%/Timolol 0.5% Ophth 1 drop OU [**Hospital1 **] Latanoprost 0.005% Ophth soln 1 drop OU hs Pantopraxole 40 mg PO q12h Discharge Medications: Por 1. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 12 days. Disp:*48 Capsule(s)* Refills:*0* 5. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO q12 Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: GI ulcer/bleed Low TSH Discharge Condition: stable and recovering Discharge Instructions: You should call 911 or return to emergency room if you experience dizziness, chest pain, shortness of breath, black/bloody stool Followup Instructions: You will follow up with Dr.[**Name (NI) 8687**] nurse practioner on Monday at 10:10am to have hematocrit check and follow up of thyroid studies. Name: [**Known lastname 1156**],[**Known firstname **] [**Doctor First Name 1157**] Unit No: [**Numeric Identifier 1158**] Admission Date: [**2128-6-22**] Discharge Date: [**2128-6-25**] Date of Birth: [**2046-8-19**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1159**] Chief Complaint: see original note Major Surgical or Invasive Procedure: see original note History of Present Illness: see original note Past Medical History: see original note Social History: see original note Family History: see original note Physical Exam: see original note Pertinent Results: see original note Brief Hospital Course: The patient was discharged with 12 more days of amoxcillin/clarithromycin/protonix for total course of 14 days for treatment of positive H. pylori. Medications on Admission: see original note Discharge Medications: see original note Discharge Disposition: Home With Service Facility: [**Hospital6 313**], [**Location (un) 42**] Discharge Diagnosis: GI ulcer/bleed glaucoma Discharge Condition: stable and recovering Discharge Instructions: Please be sure to take your full course of medications as directed. You should call 911 or return to emergency room if you experience dizziness, chest pain, shortness of breath, black/bloody stool [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1160**] MD [**MD Number(1) 1161**] Completed by:[**2128-6-25**]

[ "E935.9", "285.1", "365.9", "041.86", "531.00" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

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6273, 6422

6001, 6020

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6721, 7078

6193, 6212

5944, 5963

6048, 6067

6089, 6108

6124, 6143

21,462

181,454

6900+6901

Discharge summary

report+report

Admission Date: [**2199-4-30**] Discharge Date: [**2199-5-3**] Service: [**Last Name (un) **] The patient is a very pleasant 85-year-old who had right upper quadrant pain and an increase in LFTs. She underwent a laparoscopic cholecystectomy with a cholangiogram on [**4-30**], performed by Dr. [**Last Name (STitle) 957**]; please see operative dictation. The patient's past medical history was significant for a CVA, coronary artery disease, status post myocardial infarction, hypertension, depression, hypothyroidism. She had a history of a right femur fracture and a right wrist fracture and has a diagnosis of myofascial pain syndrome, also peripheral vascular disease. Surgical history includes a history of open reduction and internal fixation of her right femur, total abdominal hysterectomy, bilateral salpingo-oophorectomy and bleeding, and an appendectomy was performed at the time of her total abdominal hysterectomy. The patient takes medications at home, which happens to be-- her home is [**Hospital6 459**]--Tylenol, calcium carbonate, captopril 50 mg t.i.d., Premarin 0.625 mg, Synthroid 100 mcg daily, Lopressor 50 b.i.d., Zocor 40 mg daily, multivitamin, vitamin D and Lactaid. The [**Hospital 228**] hospital course was eventful for the fact that the patient had a little bit of confusion as if she had some baseline dementia; however, this was not unexpected, therefore, in light of removal of the patient from her normal surroundings. The patient did well from an operative perspective. She had minimal pain and on postoperative day #2 was able to have clears judiciously and was not requiring any pain medication other than Tylenol. The patient continued to improve, was ambulating, worked extensively with the nursing staff and rehabilitation service. She did quite well and, in standard fashion, it was deemed that the patient was tolerating a diet, was voiding on her own, having bowel movements, her pain was well controlled and she was at her baseline mental status state. Therefore, she met criteria for discharge. The patient was discharged in stable condition on [**2199-5-4**], was discharged back to [**Hospital 100**] rehab facility. DISCHARGE DIAGNOSIS: Status post laparoscopic cholecystectomy with cholangiogram. SECONDARY DIAGNOSES: History of cerebrovascular accident, coronary artery disease, hypertension, depression, hypothyroidism, myofascial pain syndrome, and peripheral vascular disease [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**] Dictated By:[**Last Name (NamePattern1) 7823**] MEDQUIST36 D: [**2199-5-3**] 22:38:21 T: [**2199-5-6**] 13:55:56 Job#: [**Job Number 26006**] Admission Date: [**2199-4-30**] Discharge Date: [**2199-5-4**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4111**] Chief Complaint: Presents for elective cholecystectomy Major Surgical or Invasive Procedure: s/p lap chole [**2199-4-30**] History of Present Illness: 85 year old female with history of colon cancer status post [**Month (only) **] with history of RUQ pain, transiently elevated LFTS that have now normalized. Patient denies any pain or nausea. Past Medical History: prior cerebrovascular accident hypertension coronary artery disease peripheral vascular disease elevated cholesterol degenerative joint disease depression colon cancer mild dementia Social History: Resides at [**Hospital 100**] Rehab; son is health care proxy. Family History: noncontributory Physical Exam: VS: 95.9 56 186/42 18 96% RA GENERAL: ALERT, NAD HEENT: NCAT, EOMI, CV: RRR CHEST: CTA BILAT, NO WHEEZES ABD: SOFT/NTND; NO RUQ PAIN . WELL HEALED LOW MIDLINE SCAR EXT: NO EDEMA Pertinent Results: [**2199-5-1**] 08:00PM BLOOD WBC-9.1 RBC-3.92* Hgb-11.5* Hct-33.6* MCV-86 MCH-29.4 MCHC-34.3 RDW-14.6 Plt Ct-181 [**2199-5-1**] 03:58AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-140 K-3.8 Cl-107 HCO3-27 AnGap-10 [**2199-4-30**] 12:10PM BLOOD K-4.1 [**2199-4-30**] 11:00AM BLOOD Glucose-161* UreaN-22* Creat-0.8 Na-136 K-5.3* Cl-104 HCO3-22 AnGap-15 [**2199-5-1**] 03:58AM BLOOD CK(CPK)-168* [**2199-4-30**] 07:14PM BLOOD CK(CPK)-123 [**2199-4-30**] 12:10PM BLOOD CK(CPK)-54 [**2199-5-1**] 03:58AM BLOOD CK-MB-4 cTropnT-<0.01 [**2199-4-30**] 07:14PM BLOOD CK-MB-4 cTropnT-<0.01 [**2199-4-30**] 12:10PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2199-5-1**] 03:58AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1 [**2199-4-30**] 11:00AM BLOOD Calcium-8.7 Phos-4.6*# Mg-1.5* [**2199-5-2**] 08:00AM BLOOD Type-ART pO2-99 pCO2-44 pH-7.47* calHCO3-33* Base XS-7 [**2199-4-30**] 09:01AM BLOOD Type-ART pO2-87 pCO2-42 pH-7.33* calHCO3-23 Base XS--3 Brief Hospital Course: This pleasant 85 year old female was admitted posteroperatively to the BLUE surgical service under the care of Dr. [**Last Name (STitle) 957**]. She underwent a laparascopic cholecysectomy with intraoperative cholangiogram and direct laryngoscopy (because of reports of voice changes after [**Month (only) **] according to her son) on [**2199-4-30**]. Please see operative report for futher details on the procedure and intra-op findings. A few hours after the surgery, she had two episodes of emesis, but was otherwise stable. She had her electrolytes repleted. She did however remain in the PACU overnight because of her labile blood pressure. She tolerated her clear liquid diet and was advanced to a low fat diet on the morning of postoperative day two. She did have some confusion after being transferred to the floor and required a sitter overnight. Her narcotic pain medication was discontinued and the patient did not require any further pain medication. She was discharged to [**Hospital3 **] Facility on [**2199-5-4**], postoperative day 4 with a Foley catheter in place due to her ongoing diuresis. Medications on Admission: tylenol prn asa 325 mg po qd calcium carbonate 650 mg PO TID captopril 50 mg po bid estrogen 0.625 mg po qd levothyroxine Sodium 100 mcg PO DAILY simvastatin 40 mg PO DAILY metoprolol 75 mg PO BID Discharge Medications: 1. Sorbitol 70 % Solution Sig: One (1) ML Miscell. QOD (). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: Thirty (30) ML PO TID (3 times a day) as needed. 5. Guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 6. Hydrocortisone Acetate 25 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day). 7. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: status post laparoscopic cholecystectomy, intraoperative cholangiogram Discharge Condition: Good Discharge Instructions: Keep the incisions clean and dry. Please call Dr.[**Name (NI) 6275**] office if you have nausea, vomiting, redness/drainage about the wounds or fever >101. Please call if you have any other questions or concerns. Foley catheter is to be left in place upon discharge to [**Hospital 100**] Rehab as the patient is continuing to diurese fairly large amounts of fluids. This can be discharged at the facility in the next few days. Followup Instructions: Patient to follow up with Dr. [**Last Name (STitle) 957**] in [**3-14**] weeks.

[ "574.10", "413.9", "496", "401.9", "244.9", "428.0", "412", "V10.05", "443.9", "729.1", "294.8" ]

icd9cm

[ [ [] ] ]

[ "51.23", "87.53" ]

icd9pcs

[ [ [] ] ]

7088, 7153

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2992, 3024

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3779, 4699

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3547, 3564

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3579, 3760

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2915, 2954

3052, 3246

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3467, 3531

56,069

195,834

41609

Discharge summary

report

Admission Date: [**2146-8-6**] Discharge Date: [**2146-8-14**] Date of Birth: [**2085-6-17**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 8388**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Transjugular intrahepatic portosystemic shunt Esophagogastroduodenoscopy with dermabond placement Intubation (at outside hospital) Central venous catheter (internal jugular and femoral at outside hospital) History of Present Illness: 61 year old with cryptogenic cirrhosis, CAD s/p CABG, and DMII who has had a general sense of being unwell over the past few days. He had some mild epigastric pain and dark stool, though not like his previous episodes of melena. He saw his PCP today for the dark stools. While at the office he vomited blood. He was sent to the ED and a hematocrit was 29. He was taken to EGD where a large amount of blood was seen in the stomach (fresh and clots). A steady stream of blood was seen and he vomited a large amount of blood. The scope was removed, he was intubated and he was rescoped. An injection of epinephrine was made at the site of bleeding and apparent stoppage in active bleeding. He received 5 units of blood and HCT returned at 24. He received an additional 2 units of blood and his HCT at transfer was 31. During intubation he became hypotensive, a cordis was placed in his RIJ and right femoral. Levophed was started. He has continued to put out blood from his NG tube. At time of transfer to [**Hospital1 18**] he was on octreotide, pantoprazole ([**Hospital1 **]), levophed and propofol. Past Medical History: Cryptogenic Cirrhosis, c/b grade 2 esophageal varices, banded in [**4-/2145**] CAD s/p CABG DMII Depression Social History: Salesman at [**Last Name (LF) 90456**], [**First Name3 (LF) **] OSH record. Denies tobacco, occassional alcohol use. Family History: Noncontributory Physical Exam: Admission physical exam General: Intubated and sedated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Normal rate and regular rhythm, soft SEM at upper sternal border, distant heart sounds Abdomen: soft, non-tender, non-distended, decreased bowel sounds, though present, Liver tip at 2 FB BCM. No rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Not responding, sedated. PERRL. Transfer physical exam Vitals: T:98.1 BP:132/55 P:79 R:18 O2:98%RA General: obese comfortable appearing man in NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: no wheezes, rales, ronchi CV: Normal rate and regular rhythm, soft SEM at upper sternal border, distant heart sounds Abdomen: soft, non-tender, non-distended, decreased bowel sounds, though present, Liver tip at 2 FB BCM. No rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3. Nonfocal. Moving all extremities. Pertinent Results: Admission labs: [**2146-8-6**] 01:34AM BLOOD WBC-9.1 RBC-3.78* Hgb-11.8* Hct-33.7* MCV-89 MCH-31.1 MCHC-34.9 RDW-15.6* Plt Ct-119* [**2146-8-6**] 01:34AM BLOOD Neuts-75.3* Lymphs-18.8 Monos-3.8 Eos-1.9 Baso-0.2 [**2146-8-6**] 01:34AM BLOOD PT-14.9* PTT-29.7 INR(PT)-1.3* [**2146-8-9**] 11:08AM BLOOD Fibrino-471* [**2146-8-9**] 11:08AM BLOOD FDP-0-10 [**2146-8-6**] 01:34AM BLOOD Glucose-323* UreaN-49* Creat-0.9 Na-140 K-5.0 Cl-113* HCO3-20* AnGap-12 [**2146-8-6**] 01:34AM BLOOD ALT-15 AST-19 AlkPhos-56 TotBili-1.7* [**2146-8-6**] 01:34AM BLOOD Calcium-6.9* Phos-3.8 Mg-1.8 [**2146-8-9**] 11:08AM BLOOD Hapto-56 [**2146-8-8**] 12:51PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [**2146-8-8**] 12:51PM BLOOD HCV Ab-NEGATIVE [**2146-8-6**] 04:57PM BLOOD Type-ART Temp-37.6 pO2-189* pCO2-32* pH-7.39 calTCO2-20* Base XS--4 [**2146-8-6**] 04:57PM BLOOD Lactate-1.8 Transfer Labs: [**2146-8-9**] 03:14AM BLOOD WBC-5.9 RBC-3.00* Hgb-9.7* Hct-26.1* MCV-87 MCH-32.5* MCHC-37.4* RDW-17.3* Plt Ct-52* [**2146-8-10**] 04:15AM BLOOD WBC-6.5 RBC-3.16* Hgb-9.8* Hct-28.2* MCV-89 MCH-31.1 MCHC-34.8 RDW-16.7* Plt Ct-63* [**2146-8-11**] 04:43AM BLOOD WBC-5.3 RBC-2.88* Hgb-9.0* Hct-26.0* MCV-90 MCH-31.2 MCHC-34.5 RDW-16.5* Plt Ct-58* [**2146-8-12**] 05:00AM BLOOD WBC-5.3 RBC-2.86* Hgb-9.1* Hct-25.9* MCV-91 MCH-31.7 MCHC-35.0 RDW-17.3* Plt Ct-68* [**2146-8-13**] 05:20AM BLOOD WBC-4.9 RBC-2.62* Hgb-8.4* Hct-23.4* MCV-89 MCH-32.2* MCHC-36.1* RDW-17.6* Plt Ct-61* [**2146-8-14**] 04:45AM BLOOD WBC-5.9 RBC-2.44* Hgb-7.8* Hct-21.9* MCV-90 MCH-31.9 MCHC-35.6* RDW-18.0* Plt Ct-68* [**2146-8-14**] 04:45AM BLOOD PT-16.0* PTT-31.1 INR(PT)-1.4* [**2146-8-14**] 04:45AM BLOOD Glucose-235* UreaN-18 Creat-0.8 Na-134 K-3.7 Cl-105 HCO3-24 AnGap-9 [**2146-8-9**] 03:14AM BLOOD ALT-1232* AST-1485* AlkPhos-218* TotBili-1.7* [**2146-8-10**] 04:15AM BLOOD ALT-849* AST-481* AlkPhos-250* TotBili-2.4* [**2146-8-11**] 04:43AM BLOOD ALT-551* AST-186* AlkPhos-258* TotBili-1.7* [**2146-8-12**] 05:00AM BLOOD ALT-355* AST-101* AlkPhos-285* TotBili-1.4 [**2146-8-13**] 05:20AM BLOOD ALT-236* AST-56* AlkPhos-259* TotBili-1.5 [**2146-8-14**] 04:45AM BLOOD ALT-164* AST-48* AlkPhos-244* TotBili-1.3 [**2146-8-14**] 04:45AM BLOOD PT-16.0* PTT-31.1 INR(PT)-1.4* Microbiology: blood 8/30 pending negative urine [**8-9**] final negative blood 8/30 pending negative Imaging: [**8-6**] TTE The left atrium is mildly dilated. There is probably symmetric left ventricular hypertrophy (views are suboptimal). The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is probably normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is a trivial pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. UE U/S [**8-7**] FINDINGS: Grayscale and color Doppler ultrasonography of the right upper extremity demonstrates normal flow and compressibility of the right IJ, axillary, and both brachial veins. There is wall-to-wall flow demonstrated within the right subclavian vein. An occlusive thrombus is present within the right mid to distal cephalic vein, without extension into the deep veins. No fluid collections are seen. IMPRESSION: Occlusive thrombus within the right cephalic vein. No deep venous thrombosis. TIPS [**8-7**] FINDINGS: 1. Patent right hepatic vein. 2. Initial portal venography demonstrated a patent portal venous system, SMV, and splenic vein. Two prominent gastric variceal collaterals were seen. Initial portosystemic gradient of 20-25 mmHg. 3. Successful placement of a right hepatic vein to right posterior portal vein TIPS, using a 10 mm x 6 cm x 2 cm Viatorr stent, extended into the right hepatic vein with a 12 mm x 6 cm Luminexx stent. The TIPS shunt was dilated to 10 mm. The post-TIPS portosystemic gradient was 7-8 mmHg. 4. Post-TIPS venography demonstrated preferential flow through the portal vein and TIPS with reduced filling of the gastric varices (no targeted embolization was required). IMPRESSION: Successful TIPS placement, as described above. CXR [**8-7**] REASON FOR EXAM: Assess NG tube. NG tube tip is difficult to visualize. In the prior study performed a day earlier was in the stomach. ET tube is in standard position. Cardiomediastinal contours are unchanged. There are persistent low lung volumes. There is no evidence of pneumothorax or pleural effusion. Vascular congestion has resolved. Left lower lobe atelectasis is unchanged. There are no new lung abnormalities. TIPS project in the right upper quadrant. [**8-9**] ultrasound abd INDICATION: Post-TIPS, now with drop in hematocrit. Evaluate for hemorrhage, clot or stent thrombosis. COMPARISON: No prior ultrasound. TECHNIQUE: Right upper quadrant ultrasound with duplex son[**Name (NI) 493**] evaluation of the liver. FINDINGS: The liver shows a nodular contour consistent with cirrhosis. A TIPS stent is in place. The main portal vein is patent with antegrade flow of 52.6 cm/sec. Visualization of the most distal portion of the TIPS is limited by acoustic window. Wall-to-wall flow is demonstrated within the TIPS, although note is made of slow flow within the proximal TIPS at 53.2 cm/sec, and higher velocity flow within the mid and distal portions of the TIPS measuring 161 and 187 cm/sec, respectively. The left portal vein shows reversed flow towards the direction of the TIPS. The hepatic arteries are patent with normal waveforms. Hepatic veins show normal color flow. The gallbladder is moderately distended with mural thickening consistent with underlying liver disease. There is trace ascites in the right upper quadrant and no free fluid throughout the remainder of the abdomen. No evidence of hematoma as questioned. Spleen is enlarged measuring 18.1 cm. No hydronephrosis in either kidney. IMPRESSION: 1. Grossly patent TIPS, though with low velocities in its proximal portion and elevated velocities in its distal portion. Short-interval followup is suggested with repeat ultrasound. 2. Reversed flow in left portal vein consistent with presence of TIPS. Patent main portal vein with antegrade flow. 3. No evidence of right upper quadrant hematoma as questioned. 4. Findings consistent with cirrhosis; splenomegaly and trace right upper quadrant ascites. [**8-12**] Ultrasound of Abdomen FINDINGS: Liver again shows a nodular contour consistent with known cirrhosis. A TIPS is in place. Wall-to-wall flow is again visualized throughout the TIPS; Velocities in the proximal, mid, and distal TIPS are approximately 94, 154, and 183 cm/sec respectively. Since the previous examination, this represents an increase in the velocity in the proximal TIPS and a decreased gradient overall across the TIPS. Main portal vein remains patent with antegrade flow of 73 cm/sec. There is persistent reversal of flow in the left and anterior right portal veins towards the TIPS. The hepatic veins and IVC remain patent. There is antegrade flow within the splenic vein. Gallbladder remains distended with intraluminal sludge. There is no intra- or extra-hepatic biliary ductal dilation. Common hepatic duct measures 3 mm. IMPRESSION: Patent TIPS, with increased velocity in the proximal TIPS compared to [**2146-8-9**] compatible with improved intra-TIPS flow. Patent and antegrade main portal vein and reversed flow in the left and anterior right portal veins towards the TIPS. Brief Hospital Course: 61 year old male with a pmh of cryptogenic cirrhosis complicated by grade 2 esophageal varices, banded in [**4-19**], CAD s/p CABG, DM2 and depression who presented with an UGIB at the GE junction. . # UGIB: The patient arrived to the MICU intubated for airway protection. He underwent upper endoscopy by the liver service and was found to have varices at the gastroesophageal junction, large blood clots in the gastric fundus, but no active bleeding. It was thought most likely the patient had bled from gastric fundic varices. He went back for repeat EGD later in the day and was found to have fresh blood clots in the fundus, secondary to gastric variceal bleed. These were injected with dermabond. TIPS was recommended. His Hct was monitored and slowly trended down from 35 to 28 and he was transfused one unit of RBCs prior to going for TIPS on [**8-7**] given his history of coronary artery disease. He subsequently has melena attributed to passage of old blood without drops in his Hct. His hct remained stable on serial checks and melena stopped after 2 days. He was continued on protonix IV BID, octreotide drip, and ceftriaxone 1 gm daily for SBP prophylaxis. He required the use of pressors (levophed) for blood pressure initially. The TIPS procedure was uncomplicated and afterwards ultrasound showed patent stent though with poor flow. LFTs increased and peaked to 1200/1400 on [**8-9**] and then subsequently decreased. LFT abnormality was attributed to poor perfusion during TIPS and shock hepatitis. Viral hepatitis serologies were negative. He was transfered to the hepatology service on [**8-11**]. Ultrasound was repeated and again revealed patent TIPS with improved intra-TIPS flow. LFTs were noted to downtrend consistent with stabilization of TIPS. His hematocrit post TIPS initially stabilized around 26% from [**8-9**] to [**8-12**]. On the two days prior transfer, his his hematocrit had trended down to 23.4% on [**8-13**] and 21.9% on [**8-14**] prompting transfusion of 1 unit of PRBC. He remained hemodynamically stable since transfer to hepatology service on [**8-11**] and was hemodyncamically stable prior to transfer. # Hepatic Encephalopathy: Post extubation patient experienced agitation and delirium thought multifactorial due to hypernatremia, ICU delirium and hepatic encephalopathy. He was given free water in his tube feeds and was started on lactulose. His MS improved considerably and lactulose was continued with goal 500cc soft stool daily. He did not manifest with signs of infection. Following transfer to the hepatology service on [**8-11**] he was maintained on lactulose and rifaxamin and had no recurrence of hepatic encephalopathy. # Respiratory/intubation: The patient was intubated for airway protection. He was maintained on minimal vent settings and was extubated successfully on [**8-8**]. # DMII: The patient was noted to on oral diabetes management at home. He was covered with insulin sliding scale throughout admission. . # CAD: S/p CABG. The patient's aspirin and lisinopril were both held in the setting of bleed. These may be resumed once extended stability is ascertained. # RUE thrombus: RUE US was noted to be swollen so a LENI was obtained and revealed occlusive thrombus within the mid and distal right cephalic vein. No deep venous thrombus. He was not started on anticoagulation. This was managed with warm compresses and elevation of RUE. # HTN: Patient was changed from home ace-i to carvedilol for inpatient blood pressure management. He may be discharged on home lisinopril as appropriate. Medications on Admission: tylenol [**Telephone/Fax (1) 1999**] Q4prn ASA 81 mg daily citalopram 60mg daily iron 325mg PO TID glyburide 6mg PO daily lipoic acid 200mg PO daily Lisinopril 2.5mg PO daily Loratidine 10mg PO daily prn Mag gluconate 250mg PO daily Metformin 1000mg PO BID Multivitamin 1 tab daily Nadolol 20mg daily Pravachol 20mg daily Zantac 150mg PO BID Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Humalog 100 unit/mL Solution Sig: 0-10 units Subcutaneous four times a day: per attached sliding scale. 6. Pantoprazole 40 mg IV Q12H Discharge Disposition: Extended Care Discharge Diagnosis: Gastroesophageal Junction Variceal Bleed Hepatic Encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 62209**], You were transfered to [**Hospital1 69**] for emergent treatment of bleeding from blood vessels in your stomach. You arrived intubated and with a central venous catheter. You were evaluated and treated by the medicine service. You received an evaluation of this bleeding with endoscopy. You then needed an emergent procedure called a transjugular intrahepatic portosystemic shunt to allow some blood to bypass your your liver. This procedure allowed for better control of your bleeding. On the day of your hospital transfer, you received one unit of packed red blood cells for a blood level that had slowly decreased over two days. You were comfortable and had stable vital signs before transfering. Followup Instructions: As recommended at the time of discharge from [**Hospital 8641**] Hospital

[ "571.5", "V49.87", "287.5", "578.0", "456.20", "572.3", "453.81", "414.00", "572.2", "573.3", "250.00", "456.8", "311", "785.59", "280.0", "276.0", "V45.81", "286.9", "V42.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "45.13", "38.91", "44.43", "39.1" ]

icd9pcs

[ [ [] ] ]

15464, 15479

10991, 14575

279, 487

15587, 15587

3131, 3131

16495, 16572

1898, 1915

14967, 15441

15500, 15566

14601, 14944

15738, 16472

1930, 3112

228, 241

515, 1616

3148, 10968

15602, 15714

1638, 1747

1763, 1882

24,659

105,283

9637

Discharge summary

report

Admission Date: [**2168-6-4**] Discharge Date: [**2168-6-14**] Date of Birth: Sex: M Service:Tramsplant Surgery HISTORY OF PRESENT ILLNESS: The patient is a 40 year-old male with a history of insulin dependent diabetes status post pancreatic transplant in [**8-23**] who presented to an outside hospital on the a.m. of [**2168-6-4**] complaining of nausea, vomiting and abdominal pain. The patient reported that he was reported to be in both lower quadrants of his abdomen with some radiation to the back. The pain was constant and severe. The patient denied any fevers or chills. The patient reported he had several episodes of emesis. While in the Emergency Department he was having dry heaves, but was no longer having productive emesis. The patient had several formed bowel movements. He continued to pass flatus. The urinary symptoms. He also denied any changes in his bowel movements. He had no diarrhea. He had no bright red blood per rectum. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes status post pancreatic transplant complicated by postop nausea and vomiting for several months. 2. Retinopathy and neuropathy secondary to his diabetes. MEDICATIONS: 1. Prograf 3 mg b.i.d. 2. Rapamycin 5 mg q.d. times three days and then 2 mg q.d. (Rapamycin was restarted four days prior to admission after several months on hold). 3. Prednisone 5 q.d. 4. Bactrim single strength one q.d. 5. Aspirin 325 mg po q.d. 6. Neurontin 300 mg po b.i.d. 7. Ultram 50 mg b.i.d. ALLERGIES: Codeine. SOCIAL HISTORY: No tobacco and rare alcohol. PHYSICAL EXAMINATION: Vital signs on admission were 100.3, 117, 98/62, 20 and 95% on room air. General, the patient was lying still on side in severe pain. HEENT within normal limits. Cardiac regular rate and rhythm, but tachycardic. Lungs clear to auscultation bilaterally. Abdomen distended with decreased bowel sounds, extremely tender with guarding of the right abdomen. The rest of the abdomen was tender, but with no guarding. Rectal examination guaiac negative with no mass and a normal prostate. Extremities warm with 2+ pulses. LABORATORY: CBC was 6.5, 34 and 192. Differential was 86.9 neutrophils with no bands. Chem 7 was 142/3.7/100/24/24/1.3/176. AST 48, ALT 52, alkaline phosphatase 89, total bilirubin 0.7, amylase 64 and lipase 16. PT 13.4, PTT 27.4, INR 1.3. HOSPITAL COURSE: The patient was taken emergently to the Operating Room for an exploratory laparotomy after intravenous resuscitation. In the Operating Room the patient was found to have a volvulus with about 70 cm of ischemic jejunum and mesenteric venous thrombosis. The patient's perfusion was noted to be improved after the lysis of adhesions with doppler signals throughout small bowel. The pancreatic transplant appeared normal. The patient tolerated the procedure well and was transferred to the CICU with a plan to return him for a second look in 24 hours. The patient was returned to the Operating Room on the morning of [**2168-6-6**] during which the patient's ischemic jejunum was found to be nonviable and resected. The patient was left with 210 cm of small bowel. Please refer to the operative note for details on the surgery. The patient was thereafter returned to the CICU for continued monitoring. The patient was transferred out of the CICU on postoperative day number [**3-25**]. On postop day number [**5-27**] the patient was CAT scanned following some fever. CAT scan revealed some bilateral pleural effusions and some slight small bowel wall thickening adjacent to the patient's anastimotic site, but no explanation for the fever. The patient's stool was sent for C-diff testing, the results ultimately being negative. The patient's central line also being discontinued. The catheter tip was sent for cultures, but ultimately grew no organism. The patient ultimately successfully had his nasogastric tube discontinued and his diet advanced to regular and was deemed stable for discharge to home on [**2168-6-14**]. By the time of discharge the patient was afebrile. He was tolerating a regular diet and was having regular bowel movements. DISCHARGE CONDITION: Stable. FOLLOW UP: The patient was to follow up with Dr. [**Last Name (STitle) **] in clinic. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Doctor Last Name 14026**] MEDQUIST36 D: [**2168-9-20**] 22:26 T: [**2168-9-21**] 06:27 JOB#: [**Job Number 32626**]

[ "362.01", "250.51", "560.2", "357.2", "250.61", "V42.83", "536.3", "557.0" ]

icd9cm

[ [ [] ] ]

[ "54.59", "38.93", "45.62", "38.91" ]

icd9pcs

[ [ [] ] ]

4192, 4201

2409, 4170

4213, 4558

1622, 2391

167, 989

1012, 1552

1569, 1599

68,591

100,016

40814

Discharge summary

report

Admission Date: [**2188-5-24**] Discharge Date: [**2188-5-30**] Date of Birth: [**2132-11-19**] Sex: M Service: MEDICINE Allergies: Ampicillin / Thorazine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Trach change Mechanical ventilation History of Present Illness: Mr. [**Known lastname 89172**] is a 55 yo man with PMH significant for Downs Syndrome, MRSA pneumonia and respiratory failure in [**10/2187**] resulting in tracheostomy which was reversed [**2188-5-13**], who is transferred from s/p intubation at [**Hospital1 **] in [**Location (un) 1110**] today. Patient had been predominantly in rehab since developing MRSA pneumonia in [**10/2187**] (first [**Last Name (un) **] and then [**Hospital 5279**] Rehab Centers) and presented to [**Hospital1 **] from rehab for respiratory distress. He had been started on Rocephin [**5-22**] for presumed pneumonia at Rehab in setting of labored breathing. Patient was intubated at [**Hospital1 **] for labored breathing, accessory muscle use. Per report, there may have been some failed attempt in OSH ED to re-open his tracheostomy prior to intubation. . At OSH, patient received, levoquin 750mg @ 03:25, Vancomycin 1g @ 5:09 for pneumonia. He was ordered for 4L NS and received at least 2.5L. CXR and CT Chest appeared to show some fluid overload. Patient was difficult to maintain on sedation; blood pressure dropped on propofol, so patient was briefly on dopamine until sedation was switched to versed boluses prn, which he tolerated well. Trach site had some serosanguinous fluid leakage, so it was covered with guaze and tegaderm. Respiratory therapist in ED confirmed no air leakage while on the ventilator. Patient was transfered to [**Hospital1 18**] for further management. . In ED, initial VS were as follows: 99.9 (Rectal temp) 101 174/100 22 98% on ventilator with 100%FiO2. He was given 1amp D50 for a blood sugar of 69. He also received 250cc of IVF and 2.5mg bolus of IV versed for sedation while ventilated. EKG showed sinus tach with rate 103. CXR showed fluid overload with possible consolidation, so CTA of chest was done to further characterize ?consolidation and rule out PE. CTA showed no signs of PE and confirmed RUL and RML pneumonia, as well as fluid filled esophagus, suggesting aspiration. CT also showed moderate left and small right effusions, but no pulmonary edema. Vitals in ED prior to transfer to ICU were as follows: 99.8F HR 91 BP 92/53 RR 16 O2sat100% cpap FIO2 60%, PS 10, PEEP 5. . On arrival to the unit, patient is mechanically ventilated and appears comfortable. He is accompanied by his sister who was able to corroborate the above story. Of note, the patient is non-verbal at baseline but does make some signs, only eats icecream and [**Last Name (un) **] tea by mouth (for pleasure) and is otherwise fed through tube feeds. . Past Medical History: - Downs Syndrome - MRSA Pneumonia complicated by tracheostomy [**10/2187**] - reversed [**2188-5-13**] - C Diff Colitis - [**2188**] - Pseudomonas Colitis - [**2188**] - dx by colonoscopy, tx w cipro through G-tube - Adrenal Insufficiency - Seizure History, per sister this [**Name2 (NI) 89173**] with hospitalization in [**11-3**] - on keppra - Hx transaminitis - presumed to be secondary to antiepileptics - Hx of HBV - Membranoproliferative Glomerulonephritis Social History: Lives at Group Home, but has spent significant amount of time at Rehab since [**10/2187**] and presented from [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **]. [**Last Name (NamePattern1) 6961**] are his guardians, but his sister [**Name (NI) **] is also very involved in his care and finances. Family History: NC Physical Exam: ADMISSION EXAM: GEN: Comfortable appearing, opens eyes to command HEENT: ETT in place. NECK: Tegaderm placed over anterior neck; difficult to assess opening in skin. No drainage or erythema. CV: RRR, no murmur LUNGS: Rhonchi anteriorly R>L, CTAB laterally on both sides ABD: Soft, non-tender but distended. Central G-tube covered with gauze with tube feeds draining around opening. Ostomy erythematous, raw. No erythema on surrounding skin. EXT: LE cachectic, No LE edema. DISCHARGE EXAM: GEN: Comfortable appearing, opens eyes to command, not in distress HEENT/Neck: EOMI, trach in place with sputum surrounding, mild erythema around site CV: RRR, no murmur LUNGS: Rhonchi anteriorly, CTAB laterally on both sides ABD: Soft, non-tender but distended. Central G-tube covered with gauze. Mildly erythematous around opening. EXT: LE cachectic, No LE edema. Pertinent Results: ADMISSION LABS: . [**2188-5-24**] 11:50AM PT-18.8* PTT-31.4 INR(PT)-1.7* [**2188-5-24**] 11:50AM URINE RBC-28* WBC-7* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 [**2188-5-24**] 11:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2188-5-24**] 11:50AM WBC-11.7* RBC-2.84* HGB-10.5* HCT-31.6* MCV-111* MCH-37.1* MCHC-33.4 RDW-18.9* [**2188-5-24**] 11:50AM GLUCOSE-69* UREA N-54* CREAT-1.0 SODIUM-136 POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-10 [**2188-5-24**] 12:00PM LACTATE-2.0 . DISCHARGE LABS: . [**2188-5-30**] 03:56AM BLOOD WBC-8.1 RBC-2.32* Hgb-8.9* Hct-26.7* MCV-115* MCH-38.5* MCHC-33.5 RDW-17.4* Plt Ct-130* [**2188-5-30**] 03:56AM BLOOD Glucose-83 UreaN-29* Creat-1.1 Na-135 K-3.7 Cl-108 HCO3-24 AnGap-7* [**2188-5-30**] 03:56AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.5* [**2188-5-30**] 03:56AM BLOOD Vanco-25.0* . MICRO: C. diff negative Urine culture - no growth Blood culture x2 - no growth to date IMAGING: CXR [**2188-5-24**]: 1. Endotracheal tube terminating at the carina. 2. Mild pulmonary interstitial edema. 3. Right upper zone opacity may reflect aspiration pneumonitis or developing pneumonia. CT-A [**2188-5-24**]: IMPRESSION: 1. RUL and RML pneumonia, possible due to aspiration since the esophagus is fluid filled and dilated. 2. No PE. 3. Moderate left and small right effusions, but no pulmonary edema. 4. Mediastinal lymphadenopathy 5. Acute left 7th rib fracture. G/GJ/GI TUBE CHECK FINDINGS: Supine radiographs demonstrate jejunostomy tube with tip at the junction of the distal duodenum or proximal jejunum. Contrast is seen passing distally in the jejunum without evidence of leak. Bowel gas pattern is normal without evidence of leak. Imaged portion of the lungs are clear. Surgical clips are noted overlying the base of the heart. IMPRESSION: Jejunostomy tube in appropriate position with normal passage of contrast without evidence of leak. Brief Hospital Course: 55M with hx of Downs Syndrome, MRSA pneumonia c/b respiratory failure and tracheostomy, s/p tracheostomy reversal 10d prior to admission, transferred to [**Hospital1 18**] for hypoxic respiratory failure [**2-27**] RUL/RML aspiration PNA . # Aspiration PNA/respiratory distress: PE was ruled out as potential cause of respiratory distress. Imaging demonstrated RUL/RML pneumonia secondary to aspiration, as well as airway narrowing at site of prior tracheostomy. Likely secondary to aspiration, as patient was also noted to have fluid filled esophagus on CT scan. Patient was treated with hospital acquired and community acquired pneumonia with Vancomycin, Levoquin and Cefepime (8-day course). Cultures of urine and blood from OSH showed no growth. Aspiration may have been related to overflow at g-tube site. Tube feeds were initially held, and G tube study was ordered which showed jejunostomy tube in appropriate position with normal passage of contrast without evidence of leak. Patient on steroids at home for adrenal insufficiency, was not on PCP prophylaxis at home so bactrim daily was started. Patient was arranged to be transferred to [**Hospital Ward Name 517**] ICU service for extubation and potential IP intervention at site of airway narrowing. IP found an 0.8 cm focal area of stenosis with dynamic collapse at 2nd tracheal ring. The granulation tissue was debrided and IP replaced percutaneous trach through existing stoma. Patient will need evaluation for tracheal resection/reconstruction at IP o/p f/u in 2 weeks. Post-procedure CXR showed multifocal PNA, unchanged bilateral effusions, trach in appropriate position. Patient remained stable with new trach in place and did well prior to discharge. His last day of levaquin and cefepime will be on [**2188-5-31**]. . # Recent history of colitis: Reported recent history of both C.diff and Pseudomembranous colitis. Patient with with several episodes of lose stool. C. diff was checked and was negative. . # Down syndrome/Anxiety: At baseline, pt nonverbal. Pt was restarted on home dose of ativan given evidence of anxiety and aggitation w/groups of people while intubated. . # Adrenal Insufficiency: History unclear but patient currently on prednisone 20 daily - patient has not had outpatient endocrine evaluation. As per [**Hospital 228**] rehab facility steroids were started to treat low sodium. Patient currently with normal blood pressures. Steroid dose tapered to 10mg daily for 1 week with outpatient follow up of electrolytes. Patient started on PCP prophylaxis, which he should remain on if he is going to continue steroids long term. Patient will follow-up with endocrinology for further work-up of possible renal insufficiency. OSH records were faxed to endocrinology department when appointment was made. . # Hx of seizure disorder: Reportedly first seizure [**11-3**] at time of hospitalization with MRSA pneumonia. Continued home dose of Keppra. . #FEN: Concern for leaking at J tube site. Tube feeds were held as concern for leaking at feeding tube. Surgery was consulted and sutured the tube in place with clamp. Dressing in place over tube site. . # Prophylaxis: SubQ heparin, Famotidine . # Contact: [**Name (NI) 6961**] = guardians, [**Name (NI) 449**] and [**Name (NI) **] ([**0-0-**]), Sister [**Name (NI) **] [**Telephone/Fax (1) 89174**]. . # Code Status: FULL CODE (Confirmed with family) Medications on Admission: Prednisone 20mg daily Omeprazole 20mg [**Hospital1 **] Keppra 500mg [**Hospital1 **] (do not crush) Ativan 0.25-0.5mg via PEG Q8h PRN (for moderate to severe anxiety) Duonebs prn wheezing oxycodone Zinc Bacitracin ointment Bowel Regimen prn Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 1110**] Discharge Diagnosis: Primary diagnosis: Subglottic stenosis Hosptial acquired pneumonia . Secondary diagnoses: ? Adrenal insufficiency Down's syndrome Seizure disorder Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Mental Status: Confused - sometimes. (baseline) Discharge Instructions: It was a pleasure to participate in your care Mr. [**Known lastname 89172**]. You were admitted to [**Hospital1 18**] for evaluation of respiratory failure. You were found to have narrowing of your trachea. You were taken to the OR to have a procedure to replace tracheostomy. You were also treated for a pneumonia. . There was concern for your G tube not working appropriately. Surgery evaluated you and fixed your J tube. . You were started on steroids at your outpatient facility as you had low sodium. We decreased your dose of steroid and started you on Bactrim to prevent a type of lung infection called PCP. [**Name10 (NameIs) **] will have you follow-up with endocrinology here to further evaluate if you need to take steroids. . MEDICATION CHANGES: START Cefepime 2gm Q24 for one more day START Levofloxacin 750mg daily for one more day START Bactrim SS daily for prophylaxis for PCP DECREASE Prednisone to 10mg daily Followup Instructions: Department: Thoracic Multi [**Hospital 4094**] Clinic When: TUESDAY [**2188-6-10**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Thoracic Multi [**Hospital 4094**] Clinic When: TUESDAY [**2188-6-10**] at 3:00 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES - Endocrinology When: WEDNESDAY [**2188-6-11**] at 3:15 PM With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2188-6-10**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2188-6-10**] at 3:00 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2188-6-11**] at 3:15 PM With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2188-5-30**]

[ "536.8", "255.41", "251.2", "507.0", "300.00", "V44.1", "518.81", "345.90", "458.29", "478.74", "758.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.97", "33.23", "31.1", "96.6" ]

icd9pcs

[ [ [] ] ]

10364, 10451

6669, 10072

311, 349

10642, 10716

4689, 4689

11745, 13711

3793, 3797

10472, 10472

10098, 10341

10790, 11531

5267, 6646

3812, 4286

10562, 10621

4302, 4670

11551, 11722

252, 273

377, 2953

4705, 5251

10491, 10541

10731, 10766

2975, 3442

3458, 3777

3,133

116,031

15613

Discharge summary

report

Admission Date: [**2174-5-11**] Discharge Date: [**2174-6-7**] Date of Birth: Sex: M Service: [**Last Name (un) **] HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 174**] is a 43-year-old Caucasian gentleman who is status post liver re- transplantation for hepatitis C cirrhosis. This was complicated amongst other things by pancreatic pseudocyst development requiring surgical drainage. He was admitted with tachycardia and altered mental status with fever. PAST MEDICAL HISTORY: Remarkable for end-stage liver disease secondary to hepatitis C and alcohol-related cirrhosis. He had a failure of his first transplant with subsequent re- transplant. Liver failure was due to hepatic artery stenosis. MEDICATIONS ON ADMISSION: 1. Bactrim. 2. Epogen. 3. Ribavirin. 4. Protonix. 5. Ursodiol. 6. Interferon. 7. Olanzapine. 8. Insulin. 9. Imodium. 10. Lasix. 11. Reglan. 12. Atenolol. 13. Miconazole. 14. Tacrolimus. 15. Cortisone. He has recently been treated for hepatitis C recurrence. He also has a history of profound depression. PHYSICAL EXAMINATION: On exam, he was awake but somewhat disoriented. He had a temperature to 103 degrees, heart rate of 130, and blood pressure of 110/65. He had crackles on his chest, on the left side. Heart sounds were normal. His abdomen was soft and nondistended. His extremities were normal. LABORATORY DATA: His LFTs showed a bilirubin of 18, and he had a white cell count of 12.2. HOSPITAL COURSE: He was admitted to the intensive care unit, and an extensive workup was done, including CAT scan, ultrasound, and he was started on broad-spectrum antibiotics consisting of linezolid and Zosyn. He was kept n.p.o. on TPN, and supportive care was provided. Subsequent liver biopsy was consistent with fibrosing cholestatic hepatitis. Over the next 2 weeks, he had a progressively deteriorating course of worsening cholestasis and then proceeded to develop multiple organ failure requiring intubation and pressor support. In light of the poor prognosis of the underlying condition and after extensive discussion with the family, it was decided to withdraw support, subsequent to which the patient rapidly expired. DISCHARGE DIAGNOSES: Fibrosing cholestatic hepatitis, liver failure subsequent to liver transplant, and multiple organ failure. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Name8 (MD) 32797**] MEDQUIST36 D: [**2174-9-27**] 14:23:28 T: [**2174-9-28**] 07:07:20 Job#: [**Job Number 45122**]

[ "038.9", "577.0", "996.82", "250.01", "518.81", "276.5", "577.2", "995.91", "572.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.91", "54.59", "46.32", "50.11", "99.15", "46.39", "51.10", "96.04", "38.93", "54.91", "50.12", "00.14", "99.07" ]

icd9pcs

[ [ [] ] ]

2260, 2590

770, 1107

1523, 2238

1130, 1505

523, 744

53,714

156,019

40112

Discharge summary

report

Admission Date: [**2146-3-21**] Discharge Date: [**2146-3-25**] Date of Birth: [**2073-9-20**] Sex: M Service: MEDICINE Allergies: scallops Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 72 year old male with past medical history of COPD on 3L home oxygen, hypertension, AAA s/p endovascular repair of abdominal aortic aneurysm c/b STEMI requiring BMS LM, RCA as well limb ischemia requiring left femoral endarterectomy on [**2145-5-22**] now presenting with increasing SOB, sputum production x2days. . Patient was in USOH when noted gradual onset increased DOE with moderate increase in sputum production though no change in sputum character. Denies associated fever, HA, rhinorrhea, sore throat, chest pain, pleuritic pain, dysuria, calf tenderness/swelling, LE edema, PND, orthopenia. No recent sick contacts, recent travel. Reports complaince with lasix though notes self-d/c of flovent in recent months. This morning in setting of worsening SOB with associated wheeze checked O2 on home pulse oximeter and noted to be 87% on home 3L so called EMS. . On presentation to the ED, initial VS were: T 97.6, HR 102, BP 139/65, RR 17, O2 sat 90% 6L. 100% on NRB. Initial VBG showed 7.26/101/43/47 On exam poor aeration. CXR demonstrated ?pulmonary edema. Placed on noninvasive ventilation with improvement of symptoms and stabilization of O2 sats. Patient received levofloxacin 750mg, Lasix 20mg IV, Methylpred 125 IV, 2duonebs in treatment of likely COPD exacerbation as well as mild volume overload. . On arrival to the MICU, patient reports he is feeling better; though wheezy, shortness of breath had improved and is again without complaints of pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - COPD- baseline home O2 3LCN - Morbid Obesity - HTN - HL - AAA - Pulm. nodule - Edema - S/P abd. hernia repair Social History: Lives at home with wife, daughter, son-in-law and 3 grandchildren. Used to work as a office equipment repairman. Tobacco - quit [**2136**], was a lifetime smoker - 1-2ppd for 43 years EtOH - occasional ethanol drug use - denies. Family History: CAD/PVD - father and mother, died in their 70s CVA - brother in 60s. Brother diagnosed with alzheimers at age 60. Physical Exam: On admission: General: Alert, oriented, no acute distress, speaking in [**2-7**] sent3ences before becoming dyspneic HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP hard to assess in setting of habitus but not grossly up, no LAD CV: quiet HR, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: poor - mod aeration bilaterally; decreased bs with overlying crackles on the right, diffuse inspiratory and expiratory wheeze Abdomen: soft, obese non-tender, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, dopplerable pulses, no clubbing, cyanosis or minimal peripheral edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS [**2146-3-21**] 09:20AM BLOOD WBC-10.0 RBC-4.18* Hgb-12.4* Hct-39.9* MCV-95 MCH-29.7 MCHC-31.2 RDW-14.4 Plt Ct-202 [**2146-3-21**] 09:20AM BLOOD Neuts-75.0* Lymphs-17.3* Monos-6.3 Eos-0.9 Baso-0.4 [**2146-3-21**] 09:20AM BLOOD PT-11.0 PTT-31.1 INR(PT)-1.0 [**2146-3-21**] 09:20AM BLOOD Glucose-124* UreaN-22* Creat-0.9 Na-143 K-4.6 Cl-95* HCO3-39* AnGap-14 [**2146-3-21**] 09:20AM BLOOD CK(CPK)-122 [**2146-3-21**] 04:35PM BLOOD CK(CPK)-118 [**2146-3-21**] 09:20AM BLOOD CK-MB-5 proBNP-3326* [**2146-3-21**] 09:20AM BLOOD cTropnT-<0.01 [**2146-3-21**] 04:35PM BLOOD CK-MB-7 cTropnT-0.01 [**2146-3-21**] 09:20AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.4 [**2146-3-21**] 09:29AM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-101* pH-7.26* calTCO2-47* Base XS-13 Intubat-NOT INTUBA Comment-GREEN TOP [**2146-3-21**] 09:29AM BLOOD Lactate-1.6 DISCHARGE LABS [**2146-3-25**] 04:11AM BLOOD WBC-8.9 RBC-4.11* Hgb-12.0* Hct-38.0* MCV-92 MCH-29.3 MCHC-31.7 RDW-14.4 Plt Ct-217 [**2146-3-25**] 04:11AM BLOOD Glucose-106* UreaN-39* Creat-1.6* Na-141 K-3.4 Cl-86* HCO3-45* AnGap-13 [**2146-3-25**] 04:11AM BLOOD Calcium-8.3* Phos-4.6* Mg-2.5 [**2146-3-21**] 09:44PM BLOOD Type-ART pO2-34* pCO2-83* pH-7.35 calTCO2-48* Base XS-15 [**2146-3-25**] 04:16AM BLOOD Lactate-1.3 LENI NO DVT [**2146-3-20**] ECHO [**2146-3-21**] The left atrium is elongated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are not well seen. Physiologic mitral regurgitation is seen (within normal limits). There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size and global systolic function. CT CHEST WITH AND WITHOUT [**2146-3-21**] As compared to the previous examination, there is slightly improved contrast filling, currently no evidence of pulmonary embolism, but a filling inhomogeneity in the lingular artery. Bilateral mild-to-moderate pleural effusions, bilateral areas of dorsal and perifissural atelectasis. No evidence of right heart strain. No enlarged mediastinal lymph nodes. Saber-sheath trachea. CXR [**2146-3-20**] Mild congestive heart failure with bibasilar atelectasis and small bilateral pleural effusions.cardiomediastinal silhouette consistent with CXR [**2146-3-25**] Tip of right PICC terminates in the lower superior vena cava. Cardiac silhouette remains enlarged. Improving bilateral lower lobe opacities, possibly due to previously provided diagnosis of aspiration pneumonia. Vascular congestion has resolved. Pleural effusions are probably unchanged allowing for incomplete imaging of the costophrenic angle regions. Brief Hospital Course: 72 year old male with past medical history of COPD on 3L home oxygen, hypertension, AAA s/p endovascular repair of abdominal aortic aneurysm c/b STEMI requiring BMS LM, RCA as well limb ischemia requiring left femoral endarterectomy on [**2145-5-22**] now presenting with increasing SOB, sputum production x2days with e/o hypoxic, hybercarbic respiratory failure. . # Hypoxic Hypercarbic Respiratory Failure. Different diagnosis included acute COPD exacerabtion, heart failure, PE, pneumonia. History was most consistent with acute COPD flare with increased sputum production/change in character as well as increasing dyspnea. Exam with poor air movement, diffuse wheeze. No clear viral or bacterial URI as nidus to infection, however bilateral opacities R>L concerning for infection. However history not c/w PNA as patient lacks robust sputum production/change, fever, leukocytosis. CXR with increased interstial markings which raised the question of volume overload; TTE in [**1-17**] with preserved RV and LV function and patient without worsening edema, orthopnea, PND. Troponins were negative. Pulmonary embolus was thought unlikely. On arrival he required BiPAP, but was able to be weaned to a face mask the next morning. He was treated with azithromycin for possible infection and anti-inflammatory properties. He was diuresed with IV lasix in case of a component of acute on chronic CHF. He was treated for a COPD exacerbation with methylprednisone, then converted to PO prednisone. He is being written for a prednisone taper to be continued at rehab. He should continue with nebulizers and inhaled fluticasone. His Oxygen target saturation was 90 to 94% and PaO2 of 60-70 mmHg. . # Positive blood culture: patient had a positive blood culture and was started [**3-23**] on vancomycin. The speciation came back as coagulase-negative staph epidermis prior to discharge, so the vancomycin was stopped. . # Hypotension: [**3-24**] the patient had an asymptomatic, transient episode of hypotension that may have been due to over-diuresis. The IV furosemide was held, and his pressures improved. He continues to be total-body fluid overloaded and the furosemide can be restarted at rehab. . # Lower extremity edema. Appears to be a chronic problem as documents in several previous notes including DC summary from [**1-17**]. LENIs at that time negative. He was monitored clinically and give IV furosemide as above. . # CAD s/p STEMI. Biomarkers negative for ischemia. Patient without complaints of chest pain. EKG without signs of ischemia. Continued ASA 325mg; per patient Plavix was stopped as an outpatient. Continued on home enalapril and statin. . # FEN: regular diet # Prophylaxis: Was on subcutaneous heparin, but was stopped prior to transfer. # Access: PICC placed prior to transfer # Code: Full; confirmed, son is health-care proxy. Medications on Admission: Active Medication list: verified ALLOPURINOL - (Prescribed by Other Provider) - Dosage uncertain ENALAPRIL MALEATE - (Prescribed by Other Provider) - 5 mg Tablet- FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - 220 mcg Aerosol - FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - IPRATROPIUM-ALBUTEROL - (Prescribed by Other Provider) - 0.5 mg-3 mg (2.5 mg base)/3 mL Solution for Nebulization - prn SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by Other Provider) - 18 mcg Capsule, w/Inhalation Device - daily Discharge Medications: 1. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone 220 mcg/actuation Aerosol Sig: One (1) Inhalation once a day. 3. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: Complete 10 day course. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 2 tabs daily for 4 days ([**Date range (1) 58796**]); 1 tab daily for 4 days ([**Date range (1) 88139**]); half tab daily for 4 days (2/25-2/29). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution Sig: One Hundred (100) mg Intravenous once a day: Please titrate diuresis to goal euvolemia. Please monitor electrolytes while the patient is undergoing aggressive diuresis. 9. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Outpatient Lab Work Please monitor daily electrolytes to monitor creatinine, potassium and bicarbonate while the patient is on high dose lasix. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: primary diagnosis: chronic obstructive pulmonary disease acute on chronic diastolic heart failure secondary diagnosis: coronary artery disease hypertension hyperlipidemia morbid obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 88137**], You were admitted to the hospital for respiratory difficulties. You had difficulty breathing but you improved with removal of excess fluid and with breathing treatments. Please note the following changes to your medications: - Azithromycin for 10 days total ([**Date range (1) 88140**]) - START steroid taper: 40mg for 4 days; 20mg for 4 days and 10mg for 4 days - START aspirin 325mg daily - INCREASE lasix, and please call your physician if your weight increases by 3 lbs. Weigh yourself daily. Please be sure to monitor your electrolytes while you are on high dose lasix. - CONTINUE your other medications as prescribed. Followup Instructions: When you are discharged from the LTAC, please be sure to see your primary care physician and your other doctors. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "782.3", "518.84", "V45.89", "414.01", "V15.82", "412", "278.01", "428.0", "E944.4", "V45.82", "491.21", "272.4", "V46.2", "401.1", "428.33", "458.29" ]

icd9cm

[ [ [] ] ]

[ "38.97", "93.90" ]

icd9pcs

[ [ [] ] ]

11379, 11479

6582, 9431

296, 302

11709, 11709

3574, 6559

12546, 12798

2618, 2735

10100, 11356

11500, 11500

9457, 10077

11860, 12094

2750, 2750

12123, 12523

1818, 2218

237, 258

330, 1799

11619, 11688

11519, 11598

2764, 3555

11724, 11836

2240, 2354

2370, 2602

45,291

144,991

50176

Discharge summary

report

Admission Date: [**2199-7-9**] Discharge Date: [**2199-7-15**] Date of Birth: [**2128-4-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: 1. CTA 2. TTE History of Present Illness: Pt is a 71 yo female with hx of DM, HTN, Dyspnea of unclear origin on 2 liters home oxygen who presents with worsening shortness of breath over the last 4 months. . Patient states that her shortness of breath has been a chronic issue and no one has ever given her a diagnosis to explain the symptoms. She notes that she has been on oxygen at home for years. Over the past 4 months she has appreciated gradual worsening in her shortness of breath. She denies any event prior to this decline. Denies chest pain, palpitations. States that she chronically has shortness of breath with acitivity. Denies cough. Denies phlegm production. Denies recent increase in swelling in lower extremity or abdomen. Further patient denies recent travel, sick contacts. Denies recent fevers or chills. . Pt does note for the past 3-4 months she has had nausea on and off leading to occasional emesis. This typically occurs in the morning. Further she endorses loose stools twice daily for 4 months. . Today patient was fed up with her breathing so decided to call an ambulance to be evaluated in the emergency department. In the ED the patient triggered for hypoxia. Initially pt sat 92-93% on 6L NC. Pt desatted to 88% and was placed on non rebreather. CXR there was thought to be a left sided hazziness and pt got ceftriaxone and azithromycin. Labs revealed an elevated proBNP elevated and Troponin 0.05 with Flat CK. Lactate 4.4. Pt was also given lasix 40mg IV x one. EKG with ST 101 RAD NSST new TWI avf, V1-4. Vitals prior to transfer: 96.9 97 111/69 24 92 on nRB. . On the floor, pt is comfortable with non rebreather, satting in the high 90s. She feels that her breathing is much better than this morning. Past Medical History: PMH: 1. DM2 - diagnosed in [**2168**], does not check glc; last A1C 7.2 in [**2-14**] 2. HTN 3. obesity 4. GERD 5. h/o no-shows to clinic Social History: Mrs. [**Known lastname 1005**] was raised in [**Doctor Last Name **] care until the age of 16. She reports that during her childhood, she was abused by her [**Doctor Last Name **] parents, who burned her hands on the top of a hot stove, whipped her, and applied salt to the wounds. At age 14, she reports giving birth to two children after being raped. She tearfully expressed the desire to see these children someday before she dies, although at present she has had no contact with them and does not know where they live. Mrs. [**Known lastname 1005**] worked in a plastics factory and reports frequent exposure to espestos as part of her daily work routine. She did not wear a respirator. . SH: Lives with cat. Sister lives nearby. Pt lives independently, able to perform all ADLs and IADLs. Used to work in shoe factory, with electronics, with plastic. No current tobacco - quit cold [**Country 1073**] about 20y ago, 1ppd x20y prior. Denies EtOH or IVDU. Family History: FH: No lung disease. Father had pacemaker placed and died of unknown but heart-related issue. Mother was diabetic and died of unknown causes. One out of five siblings has history of hallucinations/psychiatric hospitalization. Physical Exam: Admission Physical Exam: Vitals: T: BP: 138/63 P: 106 R: 25-30 O2: 91% on 4L General: Alert, oriented, no acute distress, breathing labored HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, Difficult to estimate JVP given neck size Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley Ext: Edematous lower extremity, [**1-16**]+ equal bilaterally. . Discharge Physical Exam: VS: Temp 96.5, BP 116/77, HR 89, RR 22, 93% on 4L, I/O: 1,[**Telephone/Fax (1) 101669**] Gen: NAD, comfortable, breathing comfortable, sitting in chair Lungs: CTAB, no wheezes, no crackles, no rhonchi Cardiac: S3, S1 and S2, no murmurs Abd: soft, nt, nd, obese, pos bs Ext: bilateral pedal edema 2+ up to lower shins, hyperpigmented feet up to shin Pertinent Results: Admission Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2199-7-11**] 17:50 13.7* 4.79 11.6* 35.9* 75* 24.1* 32.2 16.1* 345 [**2199-7-11**] 05:20 11.6* 4.61 11.1* 34.5* 75* 24.0* 32.2 16.2* 363 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2199-7-11**] 05:20 71.0* 18.6 6.6 3.2 0.6 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2199-7-11**] 17:50 345 [**2199-7-11**] 17:50 14.2* 34.6 1.2* [**2199-7-11**] 05:20 363 [**2199-7-11**] 05:20 13.7* 25.3 1.2* LAB USE ONLY [**2199-7-11**] 17:50 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2199-7-11**] 17:50 203*1 25* 1.1 134 4.2 99 24 15 [**2199-7-11**] 05:20 163*1 26* 1.1 137 3.9 103 24 14 . Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2199-7-15**] 05:50 8.0 4.94 11.7* 37.2 75* 23.6* 31.4 15.5 342 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2199-7-15**] 05:50 342 [**2199-7-15**] 05:50 16.3* 39.3* 1.4* LAB USE ONLY [**2199-7-15**] 05:50 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2199-7-15**] 05:50 148*1 19 1.0 136 3.6 100 26 14 IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2199-7-15**] 05:50 8.8 3.4 1.8 . Studies: [**2199-7-11**] TTE: Marked right ventricular cavity enlargement with free wall hypokinesis and pulmonary artery systolic hypertension. Right-to-left intracardiac shunt at the atrial level. Compared with the prior study (images reviewed) of [**2194-10-23**], the findings are new and suggestive of an acute pulmonary process (e.g., pulmonary embolism). [**2199-7-11**] CTA Chest: Filling defect in the right middle and segmental branches of the right lower lobe pulmonary arteries compatible with acute pulmonary embolus. Additional filling defect in subsegmental branches of the left lower lobe. Flattening of the interventricular septum and reflux of contrast into hepatic veins could indicate a component of right ventricular strain. Small rounded opacity at the right lung base (3:70) may represent infarcted tissue. Dependent bibasilar atelectasis. Multiple sub-cm mediastinal lymph nodes. Fatty liver. Stable low density focus in the left adrenal gland could represent an adenoma. [**2199-7-11**] LENI's: Please note the exam is technically limited due to patient body habitus. Grayscale and Doppler son[**Name (NI) 1417**] of the right and left common femoral, superficial femoral, and popliteal veins were obtained demonstrating normal flow, compressibility, augmentation, and waveforms. No intraluminal thrombus is present. Calf veins could not be evaluated. IMPRESSION: No evidence of bilateral lower extremity DVT. Brief Hospital Course: Assessment and Plan: Pt is a 71 yo female with hx of DM, HTN, Dyspnea of unclear origin on 2 liters home oxygen who presents with worsening shortness of breath over the last 4 months, and found to have bilateral PE's with RV strain. She was initially admitted to the MICU. . #. Dyspnea/Hypoxia: On admission, it was found that she has had progressive shortness of breath over the past 3 months. She had an elevated white blood cell count however had not been febrile. A CXR was without infiltrate. CXR and PFTs in [**2197**] without evidence of COPD. Pt likely has component of OSA which is contributing to pulmonary disease. A CTA on [**2199-7-10**] demonstrated RLL and possible LLL PE's. A TTE on [**7-11**], demonstrated RV strain. She was started on heparin gtt; however, she was not therapeutic on heparin gtt for several hours and was started on therapeutic lovenox and coumadin. She was also diuresed with lasix which improved her shortness of breath. She left the unit on 6 liters nasal canula oxygen, and was stable. . On the medicine floor, she remained hemodynamically stable. She was saturating at low 90% on 5L NC which improved to 93% on 4L. She received further diuresis with IV lasix. Her SOB improved. . She was weaned down on the oxygen to 4L, and on discharge required 4L. Her home O2 requirement is 2L secondary to possible OSA. Patient has had dyspnea diagnosis in the past, requiring O2, but has not followed up with pulmonology. . Her INR was monitored, and was 1.4 on discharge. On the day of discharge, warfarin was increased from 5 to 7.5. INR should be rechecked daily until INR reaches goal of [**1-16**]. Lovenox should continue until INR is therapeutic for 48 hours. . On the day of discharge she was hemodynamically stable, and required 4L oxygen per nasal cannula. . # RV failure: Patient found to have RV strain (likely secondary to PE), with RV failure on physical exam including increased LE edema. She was diuresed with IV lasix [**Hospital1 **], with some improvement in oxygen requirement and LE discomfort. She continued on lasix for diuresis, and was discharged on 80mg PO BID. This should be down-titrated over the next week; Patient's ins/outs and daily weights should be monitored, and she should be diuresed approximately [**1-17**] Kg further before down-titration of her lasix. After [**1-17**] Kgs are diuresed, lasix should be decreased to keep her fluid status even. While patient continues on lasix [**Hospital1 **], her electrolytes should be monitored at least every other day and potassium and magnesium repleted as appropriate. . #. Elevated Lactate: lactate 4.0 on admission, was likely secondary to work of breathing, and improved without intervention. . #. Acute Kidney Injury: Likely secondary to elevated lactate on admission. Urine lytes were suggestive of prerenal, creatinine was followed and trended downward. Home enalapril was held and nephrotoxins were avoided. Enalapril was restarted on discharge. . # Left leg pain: The patient reported left leg pain, that was chronic in nature. Lower extremity U/S was done which showed no DVT; however the calf veins were not visualized due to body habitus. It was thought that she may have post-phlebitic syndrome vs. DVT. She was continued on Warfarin as above. Her pain was managed with standing tylenol. PT evaluated the patient and recommended continued physical therapy for an extended period of time. With diuresis, the patient's leg pain resolved and standing tylenol was made prn. . # Chronic lymphedema: Wound consult was placed, and they recommended cleansing legs daily with gentle foam cleanser then pat dry, Moisturize B/L LE's and feet daily with aloe vesta. Additionally, if pt is observed picking or re traumatizing ulcers, consider daily protective dressings with Adaptic, dry gauze then Kerlix. . #. UTI: Borderline UA, culture negative. Was treated with bactrim for two days, but discontinued [**1-15**] renal function and no growth on culture. . #. Nausea: [**Month (only) 116**] be related to bowel wall edema in setting of volume overload state, also considered atypical presentation of CAD but was ruled out with cardiac enzymes and EKG. Nausea improved without intervention and omeprazole was continued. . #. Diarrhea: Unclear etiology, improved without intervention. #. DM: Glyburide and metformin were initially held, and glyburide restarted on discharge. She was treated with a humalog sliding scale while in-house, to be continued on discharge. . #. HTN: Continue Clonidine. Held HCTZ and Enalapril in the setting of renal dysfunction. BP remained normotensive; enalapril restarted on discharge. Medications on Admission: Albuterol inhaler Amitryptiline 25mg Daily Clonidine 0.1mg [**Hospital1 **] Enalapril 20mg Daily Furosemide 20mg Daily Glyburide 10mg Daily HCTZ 25mg Daily Metformin 1000mg twice daily Aspirin 325mg Daily Discharge Medications: 1. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-15**] Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 7. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 10. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain or flatulence. 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 2 weeks. 17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 18. Insulin Lispro 100 unit/mL Solution Sig: ASDIR Subcutaneous four times a day: Per sliding scale. 19. Outpatient Lab Work Please draw INR daily until patient at goal INR of [**1-16**]. [**Month (only) 116**] discontinue lovenox when INR > 2 for 48 hours. 20. Outpatient Lab Work Please draw Chem 10 every other day while patient being diuresed, and replete K to goal of 4.0, Mg to goal of 2.0. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnoses: 1. Pulmonary emboli 2. Acute kidney failure Secondary Diagnoses: 1. Diabetes Mellitus, Type II 2. Hypertension 3. GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 1005**], It was a pleasure taking care of you during this hospitalization. You were admitted with shortness of breath and found to have blood clots in your lungs. You were started on medications to thin your blood. You were placed on oxygen to help with your breathing. You also had some decreased kidney function, which improved during this hospitalization. You also should follow-up in sleep clinic to evaluate whether you could have an underlying problem such as sleep apnea - this could be contributing to your chronic shortness of breath and need for oxygen. The following medications were changed during this admission: -STOP Hydrochlorothiazide -STOP Metformin -START Insulin sliding scale, to be taken at meals and bedtime -CHANGE Aspirin from 325 mg to 81 mg daily -INCREASE Lasix to 80 mg twice daily for the next week; this will gradually be decreased. - START Warfarin 7.5 mg daily - START Lovenox twice daily, to be continued until INR at goal of [**1-16**] for 48 hours - START Omeprazole 40 mg daily - START albuterol and atrovent nebulizer treatments as needed for shortness of breath . Please continue all other home medications you were on prior to this admission. Followup Instructions: Please make an appointment to see your PCP 1-2 weeks after discharge from [**Hospital1 **] facility. Department: SLEEP UNIT NEUROLOGY When: THURSDAY [**2199-7-25**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 6856**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

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18481

Discharge summary

report

Admission Date: [**2115-6-4**] Discharge Date: [**2115-6-20**] Date of Birth: [**2036-11-11**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Fever to 101.7, increased mental confusion, weakness Major Surgical or Invasive Procedure: (1) Cholangiogram with exchange of right PTC drain [**2115-6-4**] (2) Removal of biliateral PTC drains under fluoroscopy [**2115-6-10**] (3) Central Venous Line History of Present Illness: Patient is a 78 year old male with an extensive past medical history significant for cholangiocarcinoma with common bile duct obstruction and biliary stents, s/p recent admission for decreased mental status now presents with fever to 101.7 (oral) this morning with decreased mentation (daughter states that the patient was unable to follow commands) and weakness. Patient also states that he felt nauseated this morning, though denies vomiting. Prior to this event, patient had been doing well since his discharge from the hospital on [**2115-5-16**], and had afebrile, mentating well, eating well, ambulating and moving bowels without difficulty. The patient's daughters also report noticing blood clots draining from his right transhepatic drain site. Past Medical History: 1. cholangiocarcinoma, s/p Roux-en-Y hepaticojejunostomy, CBD excision, cholecystectomy [**10-12**] 2. hepatic encephalopathy 3. liver dysfunction 4. Coronary artery disease 5. s/p CABG '[**03**] 6. atrial fibrillation 7. colon ca, s/p resection '[**05**] 8. hyperlipidemia 9. gout 10. microcytic anemia 11. s/p hip replacement 12. cataracts 13. diabetes type II 14. hypothyroidism 15. s/p incisional hernia repair [**3-15**] 16. CHF 17. emphysema Social History: Ex-Smoker, 20-30 pack years, quit 10yrs ago. Physical Exam: On admission: v/s: T 98.2 HR 96 BP 90/50 RR 18 SP02 94% room air Gen: pleasant middle-aged male, sickly appearing, no acute distress Neuro: Patient awake and alert to person and place, though is disoriented to time. Patient is able to recall the President of the United States CV: atrial fibrillation, normal S1 and S2, no murmur Lungs: CTA bilaterally Abdomen: soft, distended, non-tender. Right transhepatic drain with bilious fluid leaking around skin incision. Skin macerated around drain site. Rectal: normal tone, prostate firm, flecks of occult blood positive stool Pertinent Results: SEROLOGIES: [**2115-6-4**] 08:30PM BLOOD WBC-10.1# RBC-2.45*# Hgb-8.1*# Hct-24.6*# MCV-100*# MCH-32.9* MCHC-32.8 RDW-20.1* Plt Ct-65* [**2115-6-5**] 08:00AM BLOOD WBC-6.7 RBC-2.42* Hgb-8.3* Hct-24.0* MCV-99* MCH-34.2* MCHC-34.4 RDW-19.9* Plt Ct-67* [**2115-6-6**] 05:50AM BLOOD WBC-5.6 RBC-3.02* Hgb-9.8* Hct-27.9* MCV-92# MCH-32.4* MCHC-35.0 RDW-20.3* Plt Ct-58* [**2115-6-7**] 06:30AM BLOOD WBC-4.2 RBC-3.46* Hgb-11.1* Hct-32.6* MCV-94 MCH-32.1* MCHC-34.1 RDW-20.1* Plt Ct-59* [**2115-6-9**] 05:32AM BLOOD WBC-6.4 RBC-3.09* Hgb-9.8* Hct-29.2* MCV-95 MCH-31.9 MCHC-33.7 RDW-19.1* Plt Ct-49* [**2115-6-10**] 05:24PM BLOOD WBC-5.3 RBC-3.23* Hgb-10.5* Hct-30.3* MCV-94 MCH-32.6* MCHC-34.7 RDW-19.7* Plt Ct-76* [**2115-6-11**] 03:03AM BLOOD WBC-4.9 RBC-2.66* Hgb-8.6* Hct-24.8* MCV-93 MCH-32.4* MCHC-34.8 RDW-19.2* Plt Ct-106* [**2115-6-11**] 10:15AM BLOOD WBC-5.3 RBC-3.16* Hgb-9.8* Hct-28.7* MCV-91 MCH-31.0 MCHC-34.2 RDW-19.7* Plt Ct-92* [**2115-6-11**] 10:00PM BLOOD WBC-5.7 RBC-3.27* Hgb-10.5* Hct-29.7* MCV-91 MCH-32.2* MCHC-35.4* RDW-19.7* Plt Ct-82* [**2115-6-12**] 09:45AM BLOOD WBC-6.2 RBC-3.66* Hgb-11.2* Hct-33.1* MCV-90 MCH-30.6 MCHC-33.9 RDW-19.2* Plt Ct-75* [**2115-6-12**] 03:20PM BLOOD WBC-6.3 RBC-3.52* Hgb-11.4* Hct-32.0* MCV-91 MCH-32.3* MCHC-35.5* RDW-19.5* Plt Ct-70* [**2115-6-12**] 09:04PM BLOOD WBC-6.5 RBC-3.62* Hgb-11.1* Hct-32.7* MCV-91 MCH-30.7 MCHC-33.9 RDW-19.0* Plt Ct-63* [**2115-6-16**] 08:09AM BLOOD WBC-5.3 RBC-3.34* Hgb-10.6* Hct-30.6* MCV-92 MCH-31.8 MCHC-34.8 RDW-18.3* Plt Ct-33* [**2115-6-19**] 06:30AM BLOOD WBC-4.6 RBC-3.51* Hgb-11.3*# Hct-31.4* MCV-89 MCH-32.0 MCHC-35.9* RDW-18.0* Plt Ct-28* [**2115-6-20**] 07:18AM BLOOD WBC-4.4 RBC-3.52* Hgb-10.9* Hct-31.1* MCV-88 MCH-31.0 MCHC-35.1* RDW-17.5* Plt Ct-29* [**2115-6-4**] 08:30PM BLOOD PT-15.2* PTT-35.3* INR(PT)-1.5 [**2115-6-9**] 05:32AM BLOOD PT-14.6* PTT-34.3 INR(PT)-1.4 [**2115-6-10**] 05:24PM BLOOD PT-14.0* PTT-30.6 INR(PT)-1.3 [**2115-6-11**] 03:03AM BLOOD PT-15.0* PTT-35.4* INR(PT)-1.5 [**2115-6-11**] 10:15AM BLOOD PT-15.0* PTT-31.0 INR(PT)-1.5 [**2115-6-11**] 02:05PM BLOOD PT-14.6* PTT-30.9 INR(PT)-1.4 [**2115-6-11**] 10:00PM BLOOD PT-14.5* PTT-30.6 INR(PT)-1.4 [**2115-6-12**] 03:19AM BLOOD PT-14.8* PTT-30.4 INR(PT)-1.5 [**2115-6-12**] 09:45AM BLOOD PT-14.4* PTT-29.6 INR(PT)-1.4 [**2115-6-13**] 03:44AM BLOOD PT-14.2* PTT-29.5 INR(PT)-1.3 [**2115-6-4**] 08:30PM BLOOD Glucose-102 UreaN-30* Creat-1.8* Na-128* K-4.3 Cl-96 HCO3-20* AnGap-16 [**2115-6-6**] 12:14AM BLOOD Glucose-101 UreaN-31* Creat-1.4* Na-125* K-4.2 Cl-96 HCO3-22 AnGap-11 [**2115-6-6**] 10:40AM BLOOD Glucose-146* UreaN-29* Creat-1.2 Na-125* K-4.5 Cl-94* HCO3-22 AnGap-14 [**2115-6-8**] 06:50AM BLOOD Glucose-104 UreaN-24* Creat-1.3* Na-125* K-4.7 Cl-90* HCO3-24 AnGap-16 [**2115-6-9**] 05:32AM BLOOD Glucose-126* UreaN-22* Creat-1.2 Na-120* K-4.5 Cl-94* HCO3-24 AnGap-7* [**2115-6-9**] 05:00PM BLOOD Glucose-163* UreaN-23* Creat-1.2 Na-123* K-5.0 Cl-93* HCO3-22 AnGap-13 [**2115-6-10**] 01:51AM BLOOD Glucose-135* UreaN-24* Creat-1.1 Na-123* K-4.8 Cl-96 HCO3-21* AnGap-11 [**2115-6-10**] 10:15AM BLOOD Glucose-221* UreaN-25* Creat-1.1 Na-125* K-4.7 Cl-96 HCO3-20* AnGap-14 [**2115-6-10**] 05:24PM BLOOD Glucose-91 UreaN-25* Creat-1.1 Na-129* K-4.7 Cl-95* HCO3-26 AnGap-13 [**2115-6-11**] 03:03AM BLOOD Glucose-132* UreaN-31* Creat-1.1 Na-130* K-5.0 Cl-100 HCO3-24 AnGap-11 [**2115-6-12**] 03:19AM BLOOD Glucose-147* UreaN-34* Creat-1.0 Na-130* K-4.2 Cl-98 HCO3-25 AnGap-11 [**2115-6-14**] 06:51AM BLOOD Glucose-149* UreaN-35* Creat-0.9 Na-128* K-4.7 Cl-97 HCO3-25 AnGap-11 [**2115-6-15**] 11:20AM BLOOD Glucose-170* UreaN-40* Creat-1.0 Na-127* K-5.2* Cl-96 HCO3-24 AnGap-12 [**2115-6-16**] 08:09AM BLOOD Glucose-160* UreaN-39* Creat-1.0 Na-129* K-5.4* Cl-96 HCO3-24 AnGap-14 [**2115-6-16**] 06:59PM BLOOD Glucose-100 UreaN-42* Creat-1.1 Na-130* K-5.1 Cl-97 HCO3-25 AnGap-13 [**2115-6-17**] 06:25AM BLOOD Glucose-110* UreaN-41* Creat-0.9 Na-129* K-5.2* Cl-98 HCO3-22 AnGap-14 [**2115-6-19**] 06:30AM BLOOD Glucose-127* UreaN-35* Creat-0.9 Na-128* K-4.6 Cl-95* HCO3-28 AnGap-10 [**2115-6-20**] 07:18AM BLOOD Glucose-124* UreaN-35* Creat-0.9 Na-130* K-4.6 Cl-96 HCO3-31* AnGap-8 [**2115-6-4**] 08:30PM BLOOD ALT-21 AST-32 AlkPhos-145* Amylase-25 TotBili-1.7* [**2115-6-5**] 08:00AM BLOOD ALT-21 AST-36 AlkPhos-136* Amylase-22 TotBili-1.3 [**2115-6-6**] 05:50AM BLOOD ALT-21 AST-33 AlkPhos-116 TotBili-3.5* [**2115-6-6**] 10:40AM BLOOD ALT-21 AST-32 AlkPhos-116 TotBili-3.1* [**2115-6-7**] 06:30AM BLOOD ALT-21 AST-28 AlkPhos-126* Amylase-25 TotBili-2.4* [**2115-6-9**] 05:32AM BLOOD ALT-17 AST-21 AlkPhos-114 Amylase-38 TotBili-1.7* [**2115-6-10**] 10:15AM BLOOD ALT-18 AST-20 AlkPhos-131* TotBili-2.1* [**2115-6-10**] 05:24PM BLOOD ALT-19 AST-22 AlkPhos-121* Amylase-43 TotBili-2.7* [**2115-6-11**] 03:03AM BLOOD ALT-21 AST-23 AlkPhos-110 Amylase-37 TotBili-4.0* DirBili-2.3* IndBili-1.7 [**2115-6-11**] 10:15AM BLOOD ALT-23 AST-28 AlkPhos-121* TotBili-5.5* DirBili-2.8* IndBili-2.7 [**2115-6-12**] 03:19AM BLOOD ALT-20 AST-26 AlkPhos-119* TotBili-6.1* DirBili-2.5* IndBili-3.6 [**2115-6-13**] 03:44AM BLOOD ALT-20 AST-24 AlkPhos-134* TotBili-3.1* [**2115-6-14**] 06:51AM BLOOD ALT-18 AST-22 AlkPhos-139* TotBili-2.6* [**2115-6-15**] 11:20AM BLOOD ALT-19 AST-25 AlkPhos-168* TotBili-2.6* [**2115-6-16**] 08:09AM BLOOD ALT-17 AST-23 Amylase-46 TotBili-3.3* [**2115-6-17**] 06:25AM BLOOD ALT-17 AlkPhos-162* Amylase-46 TotBili-3.1* [**2115-6-18**] 05:24AM BLOOD ALT-16 AST-29 AlkPhos-160* TotBili-2.3* [**2115-6-20**] 07:18AM BLOOD ALT-18 AST-30 AlkPhos-182* TotBili-2.3* [**2115-6-4**] 08:30PM BLOOD Lipase-17 [**2115-6-5**] 08:00AM BLOOD Lipase-20 [**2115-6-7**] 06:30AM BLOOD Lipase-37 [**2115-6-8**] 06:50AM BLOOD Lipase-36 [**2115-6-9**] 05:32AM BLOOD Lipase-64* [**2115-6-10**] 05:24PM BLOOD Lipase-61* [**2115-6-11**] 03:03AM BLOOD Lipase-42 [**2115-6-16**] 08:09AM BLOOD Lipase-59 [**2115-6-17**] 06:25AM BLOOD Lipase-55 [**2115-6-4**] 08:30PM BLOOD Calcium-7.6* Phos-4.4# Mg-2.0 [**2115-6-5**] 08:00AM BLOOD Albumin-2.1* Calcium-7.7* Mg-2.0 [**2115-6-8**] 06:50AM BLOOD Albumin-2.5* Calcium-7.6* Phos-3.2 Mg-2.0 [**2115-6-10**] 10:15AM BLOOD Albumin-2.5* [**2115-6-12**] 03:19AM BLOOD Albumin-2.6* Calcium-8.0* [**2115-6-16**] 08:09AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.4 Mg-1.8 [**2115-6-17**] 06:25AM BLOOD Albumin-2.3* [**2115-6-20**] 07:18AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.7 [**2115-6-7**] 06:30AM BLOOD %HbA1c-5.0 [Hgb]-DONE [A1c]-DONE [**2115-6-7**] 06:30AM BLOOD TSH-7.4* [**2115-6-4**] 08:30PM BLOOD Ammonia-53* [**2115-6-12**] 09:04PM BLOOD HCG-<5 RADIOLOGY: [**2115-6-4**]: Successful upsizing from a 10-French right percutaneous transhepatic biliary drainage tube to a 12-French drain. [**2115-6-6**] Cholangiogram: Unremarkable tube cholangiogram, with free flow of contrast into the jejunum. [**2115-6-6**] Abd CT: 1) Progression of right and left intrahepatic biliary ductal dilatation. Cholangitis cannot be excluded. 2) Interval increase in ascites. No evidence of an abscess. 3) Stable celiac axis lymphadenopathy. 4) Stable nonocclusive portal vein thrombosis. 5) No enhancing liver lesions. 6) Decreased size of low attenuation splenic lesion, suggestive of evolution of infarct. 7) Stable anterior abdominal wall hernia containing loops of small bowel, without evidence of obstruction. [**2115-6-10**] IR Procedure: 1. Pull back cholangiogram demonstrating obstructed left hepatic duct, with a patent right hepatic duct, and a patent anastomosis. 2. Bleeding from the right tube insertions site, possibly from the intercostal artery, controlled by manual compression. 3. Right hepatic duct stented with 8 mm x 18 mm SMART stent, with overlapping 8 mm x 16 mm Wallstent. Left hepatic duct stented with 8 mm x 18 mm Protege. self expanding stent. The right tract embolized with thrombin, and Gelfoam. [**2115-6-10**] Chest Xray: Interval appearance of a moderate sized right pleural effusion, the definite nature (simple or complex) of which cannot be determined on this study. [**2116-6-13**] Chest Xray: PICC with its tip in the right atrium. If this is withdrawn [**6-15**] centimeters, it will be in the SVC. This was communicated to the IV staff at the time of interpretation. Improved aeration at the left lung base, however, increased atelectatic changes at the right lung base. [**2115-6-18**] Chest Xray: Stable appearance of the chest. Partial bilateral lower lobes atelectasis unchanged. Status post thoracotomy. MICROBIOLOGY: [**2115-6-4**] Bile: VRE+, Gram negative rods, rare yeast; [**6-4**] blood: non-fermenter (sensitive to Meropenum), [**6-8**] blood: negative PATHOLOGY: HEparin dependent antibodies: Negative Brief Hospital Course: This is a 78 year old gentleman with a history of cholangiocarcinoma complicated by a common bile duct obstruction who presented on [**6-4**] with fevers and reported blood output from his right biliary catheter and bilious leaking around the drains. On admission he presented with fevers, mental status changes, and a low hematocrit. He had a prolonged hospital course as detailed: With regards to his underlying biliary disease the patient underwent cholangiogram with successful upsizing from a 10-French right percutaneous transhepatic biliary drainage tube to a 12-French drain on hospital day 2. On hospital day 7 the patient underwent internalization of his PTC drains via interventional radiology but had a post-procedure chest x-ray that revealed a right-sided pleural effusion and dropping hematocrit. It was thought that he had a hemothorax from injury to an intercostal blood vessel during the procedure and he received 2 prompt units of blood with stable subsequent hematocrit levels on serial checks. He had a slight rise in LFTs and total bilirubin after drain internalization but these trended downwards towards his baseline levels by day of discharge. From a neurologic standpoint the patient's mental status had improved after commencement of antibiotics and blood transfusion upon admission as well as IV fluids to correct pre-renal acute renal failure. He did require significant pain medications during his hospitalization. From a cardiovascular standpoint he remained in normal sinus rhythm and stable on his home amiodarone regimen with intermittant episodes of atrial fibrillation. From a pulmonary standpoint, as stated above, the [**Hospital 228**] hospital course was complicated by a pneumothorax requiring diuresis. He continued to have mild congestive heart failure throughout his hospital course requiring intermittant diuresis and he was discharged on home oxygen therapy, which he had been taking in the past, as well as a standing regimen of [**Hospital1 **] Lasix. There were no episodes of respiratory failure or distress during his hospitalization. From a hematology standpoint the patient was transfused 3 units of blood on hospital day 2 with appropriate rise in his hematocrit and improvement in mental status and weakness. He also had a low platelet count and hematocrit and required several transfusions of blood and platelets after hemothorax that occured during his PTC internalization on hospital day 7. He was found to be heparin-dependent antibody negative and the etiology was presumed to be secondary to Linezolid. Though in the low range his platelet counts remained stable over the last 2 weeks of his hospital course. Prior to discharge he was started on a standing regimen of qeekly Epogen and daily Iron tablets for his anemia. From an immunology standpoint he was started on empiric levofloxacin and linezolid while pan-cultures were pending; coverage was eventually taylored to include approximately 2 weeks Linezolid and Meropenum when admission culture data revealed meropenum-sensitive non-fermenting gram negative bacteria and vancomycin-resistant enterococcus from his blood and bile. Repeat pan-cultures several days after antibiotics started were negative and he remained afebrile for the remaining duration of his hospital course. His antibiotics regimen was completed prior to discharge, though he was discharged on levofloxacin for prophylaxis. From a GI standpoint nutrition services were consulted for starting the patient on nutritional supplements and [**Last Name (un) **] diabetes was consulted with recommendation for re-starting the patient on home insulin therapy, which he had been taking in the past. Otherwise he was on a regular diet throughout his hospital course. From a renal standpoint the patient had an elevated creatinine as well as hyponatremia on admission. He received several days of hypertonic saline IV fluids with improvement in his hyponatremia and bolused IV fluids with resolution in his acute renal failure. From a social services standpoint the patient was consulted by social work and case management and was set-up with a visiting nurse for home consultation. He also worked with physical therapy daily and was seen to be able to ambulate on his own during the last week of his hospitalization. Medications on Admission: 1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (un) **]:*30 Tablet(s)* Refills:*2* 2. Amiodarone HCl 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Last Name (un) **]:*30 Tablet(s)* Refills:*2* 3. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (un) **]:*30 Tablet(s)* Refills:*2* 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). [**Last Name (un) **]:*2700 ML(s)* Refills:*2* 5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (un) **]:*30 Tablet(s)* Refills:*2* 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Last Name (un) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Last Name (un) **]:*60 Capsule(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. [**Last Name (un) **]:*30 Tablet(s)* Refills:*2* 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) units Injection ASDIR (AS DIRECTED): 0-60, give 4oz [**Location (un) 2452**] juice, 61-100 no units, 100-120 2 units, 121-160 4 units, 161-200 6 units, 201-240 8 units, 241-280 10 units, 281-320 12 units, >320 notify physician. [**Name Initial (NameIs) **]:*30 ml* Refills:*2* Discharge Medications: 1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Name Initial (NameIs) **]:*60 Capsule(s)* Refills:*2* 3. Amiodarone HCl 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Name Initial (NameIs) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*2* 6. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day). [**Name Initial (NameIs) **]:*900 ML(s)* Refills:*2* 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2* 9. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) ml Injection QMOWEFR (Monday -Wednesday-Friday): Inject subcutaneously. [**Name Initial (NameIs) **]:*30 ml* Refills:*2* 10. Insulin NPH Human Recomb 300 unit/3 mL Syringe Sig: Per sliding scale ml Subcutaneous twice a day: 14 units (0.14 ml) in the morning and 4 units (0.04 ml) at bedtime. [**Name Initial (NameIs) **]:*1 month supply* Refills:*2* 11. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding scale Subcutaneous once a day: Check blood sugars at breakfast, lunch, dinner, and bedtime and inject subcutaneous insulin as indicated: For blood sugar 80-119 0.03 ml, for 120-159 0.05 ml, for 160-199 0.07 ml, for 200-239 0.09 ml, for 240-279 0.11 ml, for 280-319 0.13 ml, for 320-359 0.15 ml, for 360-400 0.17 ml. [**Name Initial (NameIs) **]:*1 month supply* Refills:*2* 12. Syringe & Needle Dispenser Misc Sig: Five (5) Miscell. as needed: Syringes for Insulin injection. [**Name Initial (NameIs) **]:*1 month supply* Refills:*2* 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. [**Name Initial (NameIs) **]:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Encephalopathy Secondary: Cholangiocarcinoma, Congestive heart failure, cholangitis, coronary artery disease, hypertension, diabetis, hyperlipidemia, hypothyroidism Discharge Condition: Stable Discharge Instructions: You should take all medications as prescribed. In particular, follow your insulin regimen as prescribed by [**Last Name (un) **]. You should continue taking oxygen at home as prescribed for you. You should continue your regular activity and diet. You should return to the ED or notify your physician with any worsening fevers, abdominal pain, worsening jaundice, worsening swelling of your legs, worsening nausea/vomitting. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-6-26**] 9:00 Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 18368**] Call to schedule appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2115-6-25**]

[ "427.31", "496", "428.0", "280.0", "276.1", "155.1", "578.1", "572.2", "576.2", "287.5", "998.11", "511.8", "790.7", "576.1", "244.9" ]

icd9cm

[ [ [] ] ]

[ "99.07", "00.14", "87.54", "99.05", "51.98", "97.05", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

19138, 19189

11139, 15447

366, 529

19407, 19415

2459, 11116

19887, 20420

16864, 19115

19210, 19386

15473, 16841

19439, 19864

1861, 1861

274, 328

557, 1312

1876, 2440

1334, 1784

1800, 1846

339

183,291

27346

Discharge summary

report

Admission Date: [**2187-8-7**] Discharge Date: [**2187-8-14**] Date of Birth: [**2120-7-17**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Gallstone Pancreatitis Abdominal Pain Major Surgical or Invasive Procedure: Exploratory laparotomy, Cholecystectomy, Gastrostomy History of Present Illness: This 67-year-old woman admitted for who has known gallstone pancreatitis. She had ARDS and had a significant necrotizing pancreatitis at her last admission. We were able to ride her through her pancreatic problem, without the need for an operation at that point in time, and we were able to ultimately get her out of the hospital after she recovered from her pulmonary failure problem. She was markedly debilitated and went to a rehab facility for many weeks. In the meantime, I have seen her, and I followed her course from the clinic. She has had generally strong progression, but has been unable to gain weight, and does not eat more than soft solids, with limited amounts. She claims of abdominal pain when she eats, as well as regurgitation. She, in general, has a failure to thrive and general unwellness. We also knew that we would have to address her gallbladder and its stone disease at some point in time. Past Medical History: 1. HTN 2. Diverticulitis 3. ETOH Abuse 4. GERD 5. Renal Insufficiency 6. Necrotizing Pancreatitis 7. Respiratory Failure s/p tracheosotomy [**2187-5-10**] Social History: Used to drink alcohol heavily until [**2174**]. Smoked [**1-12**] cigs/day, quit years ago. Lives in [**Location 2624**] with her daughter and son-in-law. Does not work. Came here from [**First Name8 (NamePattern2) 466**] [**Country 467**] 5 years ago. Family History: NC Physical Exam: Post-op PE VS: 98.4, 82, 146/76, RR 15, 100% O2-intubated. HEENT: intubated, L and R IJ lines inplace CV: RRR, normal S1, S2, no M/R/G Lungs: CTA bilat. ABD: soft, mildly distended, no tympany, diffuse tenderness Wound: dressing with serosanguinous drainage Ext: DP 2+ bilat., no edema Neuro: Awake, alert and oriented Pertinent Results: US INTR-OP 60 MINS [**2187-8-7**] 10:20 AM US INTR-OP 60 MINS Reason: PSEUDOCYST INDICATION: Patient with complicated pancreatitis and pseudocyst formation. For possible surgical cystgastrostomy. TECHNIQUE: The patient has already had a laparotomy and a gastrostomy performed. Using sterile technique, intraoperative son[**Name (NI) 867**] was performed using transgastric approach and also from an intragastric position. REPORT: FINDINGS. A small amount of anterior fluid measuring about 10 mL was seen. Corresponding to the pancreas' position, there is an ill-defined, enlarged isoechogenic material likely representing a phlegmon. No discrete fluid collection is seen elsewhere. Using son[**Name (NI) 493**] visualization, the small anterior cyst was aspirated. Further passes were obtained from the phlegmon also under ultrasound guidance. CONCLUSION: No evidence of large pseudocyst corresponding to recent CT images CHOLANGIOGRAM,IN OR W FILMS [**2187-8-7**] 9:54 AM CHOLANGIOGRAM,IN OR W FILMS Reason: CHOLANGIOGRAM INDICATION: Intraoperative cholangiogram. FINDINGS: Eight spot films were provided from intraoperative fluoroscopic guidance for cholangiogram. Images demonstrate filling of normal appearing biliary tree without filling defects or stricture and free passage of ontrast into the duodenum with some reflux into distal pancreatic duct. Sponge markers overly the right upper abdomen. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 67014**],[**Known firstname 67015**] [**2120-7-17**] 67 Female [**-5/3398**] [**Numeric Identifier 67016**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif SPECIMEN SUBMITTED: GALLBLADDER (1). Procedure date Tissue received Report Date Diagnosed by [**2187-8-7**] [**2187-8-7**] [**2187-8-11**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/tk?????? DIAGNOSIS: Gallbladder: Cholesterolosis. No inflammation. Cardiology Report ECG Study Date of [**2187-8-8**] 9:51:38 PM Sinus tachycardia with ventricular premature beats. Possible anterior myocardial infarction - age undetermined. Lateral ST-T changes are non-specific. Compared to the previous tracing of [**2187-8-3**] ventricular arrhythmia is seen and ST-T wave abnormalities are more marked. Read by: [**Last Name (LF) 474**],[**First Name3 (LF) 475**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 106 146 86 328/390 38 -14 99 [**2187-8-10**] 06:05AM BLOOD WBC-10.9 RBC-3.31* Hgb-8.8* Hct-26.8* MCV-81* MCH-26.7* MCHC-32.9 RDW-16.6* Plt Ct-194 [**2187-8-11**] 02:20PM BLOOD Glucose-121* UreaN-5* Creat-0.8 Na-138 K-3.8 Cl-102 HCO3-29 AnGap-11 [**2187-8-11**] 02:20PM BLOOD Calcium-8.1* Phos-1.8* Mg-1.5* Brief Hospital Course: She was admitted on [**2187-8-7**] for a planned pseudocyst gastrectomy, but there was no evidence of a cyst intraoperatively. She underwent a CCY and went to the SICU intubated. Pain: She had an epidural that was providing good pain relief. She was changed to PO Tylenol with Codeine once her diet was advanced. GI: She was NPO, with and NGT and IV fluids. The NGT remained for 3 days. She had return of bowel function and her diet was advanced. Resp: She was successfully extubated later the evening of her surgery. She did not have any respiratory issues. CV: Regular rate and rhythm. She was getting Metoporol IV and then switched to PO Atenolol and Lisinopril once tolerating PO meds. Renal: Her BUN and creatinine were monitored closely. She received a fluid bolus for low urine output the night of her surgery. Her BUN and creatinine were stable and WNL. Wound: She had an abdominal incision with staples. The incision was clean, dry, and intact and there was no drainage. The staples will be removed at her follow-up appointment. Medications on Admission: lisinopril, atenolol, protonix, FeSO4, pancrease Discharge Medications: 1. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 1 months. Disp:*35 Tablet(s)* Refills:*0* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*qs Tablet(s)* Refills:*2* 6. Pancrease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day: with meals. Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Gallstone Pancreatitis Pancreatic Pseudocyst Discharge Condition: Stable Discharge Instructions: RETURN TO ER IF: * fevers/chills * nausea/vomiting * inability to take medication * increased abdominal pain * decreased urine output * any bleeding * redness/swelling/drainage from wound You may shower and wash incision with soap and water. Pat dry. No heavy lifting >10 lbs for 4 weeks. Continue to walk several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**12-11**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment. Completed by:[**2187-8-14**]

[ "427.89", "228.09", "427.31", "577.1", "276.3", "403.91", "577.2", "998.11", "553.1", "276.51", "574.90", "783.7" ]

icd9cm

[ [ [] ] ]

[ "39.98", "87.53", "96.07", "51.22", "99.04", "52.01", "53.49", "43.0" ]

icd9pcs

[ [ [] ] ]

7040, 7097

5078, 6123

351, 406

7186, 7195

2187, 5055

7574, 7743

1828, 1832

6222, 7017

7118, 7165

6149, 6199

7219, 7551

1847, 2168

273, 313

434, 1359

1381, 1537

1553, 1812

9,973

180,540

6862

Discharge summary

report

Admission Date: [**2140-10-17**] Discharge Date: [**2140-10-22**] Date of Birth: [**2084-5-2**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: GIB Major Surgical or Invasive Procedure: colonoscopy History of Present Illness: . HPI: Mr.[**Known lastname 25925**] is a 56 M with h/o multiple sclerosis and an upper GIB who presented to an OSH after an epsiode of BRBPR this morning. The patient is cared for during the week by a PCA who noted approximately 1 cup of BRBPR after a BM and in the shower the AM of admission. The PCA also noted that his stool was normal color and that the patient appeared pale and somnolent. At home, the patient's blood pressure was 71/42, then 79/47 after drinking Gatorade. At the OSH, the patient was hypotensive in the 70s and had a Hct of 24 for which he received 2U of PRBCs and 3L IVF. He underwent NGL at the OSH, which was negative. He was started on omeprazole and transferred to [**Hospital1 18**]. Also of note, he was intermittently hypoglycemic at OSH but here his glucose is 133. In the ED, he was hemodynamically stable with a repeat Hct of 35, he was found to have UTI and was hypothermic with a rectal temperature of 92. He was started on levofloxacin. The patient has never had a colonoscopy, but had a sigmoidoscopy in [**7-27**] after an episode of BRBPR and found to have hemorrhoids. Of note, the patient was discharged on [**10-9**] after ICU hospitalization for PNA which was treated with a course of vancomycin, zosyn, and levofloxacin. . ROS: +chronic constipation, +difficulty breathing x 1 episode today, + difficulty swallowing, + decreased PO intake; denied CP, palpitations, syncope, headache, change in vision, dizziness, lightheadedness, change in bowel or bladder function . PMH: progressive multiple sclerosis (followed by Dr. [**Last Name (STitle) 25923**] [**Name (STitle) 25924**]) neurogenic bladder (s/p suprapubic tube placement) h/o multiple UTI's h/o upper GIB (ulcerative esophagitis and gastritis [**12-24**] NSAIDS) GERD HTN CHF (unknown EF) h/o "sepsis" L eye blindness intrathecal baclofen pump (10 years) ??sleep apnea - sleep study scheduled for [**10-26**] . Social History: Retired college professor. Disabled, has personal care assistant. Married with 3 children. No smoking. No EtOH. . Family History: Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother has diabetes. . Allergies: Percocet makes him sleepy . Medications: Lisinopril 20 mg PO BID Albuterol [**11-23**] PUFF IH Q4-6H:PRN Multivitamins 1 CAP PO DAILY Amlodipine 5 mg PO DAILY Oxybutynin 5 mg PO BID Brimonidine Tartrate 0.15% Ophth. 1 DROP OU Q8H Paroxetine HCl 40 mg PO DAILY Fentanyl Patch 25 mcg/hr TP Q72H Gabapentin 400 mg PO Q8H . Physical Exam: Vitals: T 95.0 BP 145/85 HR 88 RR 18 O2 96% on 2L NC Gen: NAD, lying on in bed on his side HEENT: sluggish pupils, dry MM. EOMI. Neck: Supple without LAD Cardio: RRR, nl s1/s2, no m/r/g Resp: mild rhonchi in L mid-lung field Abd: soft, nt, nd, +BS. No rebound/guarding. Suprapubic cath and baclofen pump in place. Ext: extreme spacicity LE > UE, 3+ symmetric pedal edema Neuro: A & O to person, place, month, year, day, but not date; able to recall recent holiday and president. CN II-XII grossly intact. Pt does not move LE. 3/5 strength UE BL (only with repeated prompting). . Asssesment: 56 M with lower GIB, likely hemorrhoids vs AVM vs polyp vs malignancy. . Plan: # GIB - continue carafate and PPI [**Hospital1 **] - Golytely prep - colonoscopy in AM or Wednesday - [**Hospital1 **] Hct - Transfuse for Hct < 26 . # UTI - Unclear whether this is a true infection or colonization [**12-24**] suprapubic catheter. - Will not continue levaquin at this time - F/u UCx, BCx - Restart abx if pt appears sick . # Elevated PTT: lab error vs drug effect vs lupus anticoagulant - repeat and if still high, check lupus anticoagulant . # Hyperglycemia: patient reported hypoglycemic at OSH but here he is mildly hyperglycemic. - follow fingersticks . # Prophylaxis: PPI, no heparin products given recent GI bleed, TEDs in place . # FEN: NPO after MN for procedure, maintenance IVF . # Access: R PICC, L PIV 22" x 2 - will replace 1 with larger bore . # Communication - Wife, [**Name (NI) 2048**] [**Name (NI) 25925**] - cell: [**Telephone/Fax (1) 25928**], work: [**Telephone/Fax (1) 25929**], home: [**Telephone/Fax (1) 25930**] . FULL CODE Past Medical History: progressive multiple sclerosis (followed by Dr. [**Last Name (STitle) 25923**] [**Name (STitle) 25924**]) neurogenic bladder (s/p suprapubic tube placement) h/o multiple UTI's h/o upper GIB (ulcerative esophagitis and gastritis [**12-24**] NSAIDS) GERD HTN CHF (unknown EF) h/o "sepsis" L eye blindness Social History: Retired college professor. Disabled, has personal care assistant. Married with 3 children. No smoking. No EtOH. Family History: Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother has diabetes. Pertinent Results: [**2140-10-17**] 06:10PM GLUCOSE-128* UREA N-27* CREAT-0.9 SODIUM-136 POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15 [**2140-10-17**] 06:10PM ALT(SGPT)-30 AST(SGOT)-26 ALK PHOS-105 TOT BILI-0.4 [**2140-10-17**] 06:10PM CALCIUM-8.7 PHOSPHATE-4.5 MAGNESIUM-2.1 [**2140-10-17**] 06:10PM WBC-4.4 RBC-4.23* HGB-12.0* HCT-35.8* MCV-85 MCH-28.4 MCHC-33.6 RDW-16.4* [**2140-10-17**] 06:10PM NEUTS-59.6 LYMPHS-33.2 MONOS-4.9 EOS-1.1 BASOS-1.3 Brief Hospital Course: [**Hospital Unit Name 13533**]: Mr. [**Known lastname 25925**] was transfered to the [**Hospital Unit Name 153**] with concern of rapid GI bleeding. He was given fluids, but his hematocrit remained stable. GI was consulted and they will scope him in the morning. His prep will be started on transfer. Wife to find out names of "steroid" for MS as well as ?antibiotic for UTI ppx? Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q8H (every 8 hours) as needed. 10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 16. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 17. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 18. Methylprednisolone Sodium Succ 1,000 mg/8 mL Recon Soln Sig: One (1) g Injection once a month: To be given by VNA, last given [**2140-10-21**]. Disp:*qs 3 months* Refills:*3* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Lower Gastrointestinal Bleeding Acute Blood Loss Anemia Multiple Sclerosis Discharge Condition: stable Discharge Instructions: Please take your medications as listed below. Please follow up with your PCP and your neurologist. Call your doctor if you experience recurrent bleeding or black stool, lightheadedness, shortness of breath, chest pain, or other concerning symptoms. Followup Instructions: 1. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2140-10-27**] 12:00 2. Please follow up with your PCP in the next week to have your blood counts checked, and to arrange for a surgical evaluation to have your hemorhoids treated 3. Please follow up with Dr. [**Last Name (STitle) **] to have your sleep study arranged at [**Location (un) 620**] (in a hospital setting). 4. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2140-11-16**] 1:00 5. Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2140-11-16**] 1:00

[ "211.3", "276.52", "401.9", "530.81", "340", "455.2", "428.0", "596.54", "428.32", "285.1" ]

icd9cm

[ [ [] ] ]

[ "45.16", "45.42" ]

icd9pcs

[ [ [] ] ]

7511, 7574

5508, 5891

274, 287

7692, 7700

5034, 5485

7997, 8758

4927, 5015

5914, 7488

7595, 7671

7724, 7974

2814, 4453

231, 236

315, 2232

4475, 4781

4797, 4911

27,577

198,353

1323

Discharge summary

report

Admission Date: [**2165-12-15**] Discharge Date: [**2165-12-23**] Date of Birth: [**2089-7-2**] Sex: M Service: CARDIOTHORACIC Allergies: Gluten Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2165-12-16**] -left heart Catheterization,coronary angiogram [**2165-12-17**] - CABGx4 (Left internal mammary artery->Left anterior descending artery, Saphenous vein graft (SVG)->Posterior descending artery, SVG->Diagonal artery, SVG->Obtuse marginal artery.) History of Present Illness: This 76 year old Russian speaking male presented to the ER after awakening from sleep with chest pain. He ruled out for an infarction. Catheterization showed severe left main and triple vessel disease and Cardiac Surgery was consulted for surgical revascularization. Past Medical History: Insulin dependent diabetes mellitus Hypercholesterolemia Hypertension chronic kidney disease coronary artery disease Celiac sprue s/p pericardial tamponade [**7-24**] s/p coronary angioplasty Social History: Born in [**Country 532**], moved to US in [**2150**]. Lives with his wife and son. Former organic chemistry professor. He has never smoked. He does not consume alcohol on a regular basis (1 drink every 2-3 months). Family History: [**Name (NI) 1094**] mother died in what was thought to be an MI in the holocaust. Physical Exam: Admission: Pulse:53 Resp:12 O2 sat:95%RA B/P Right:150/69 Left:149/64 Height: 5'2" Weight:130 LBS General: comfortable Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: No Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [-] Neuro: Grossly intact. mobes 4 ext. follows commands, R handed Pulses: Femoral Right:palp Left:palp DP Right:dop Left:palp [**Doctor Last Name **] Right: palp Left:palp Radial Right:palp Left:palp Carotid Bruit Right: - Left:- Pertinent Results: [**2165-12-17**] ECHO PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results before surgical incision. POST-BYPASS: Normal biventricular systolic function. LVEF 55%. [**2165-12-23**] 06:55AM BLOOD WBC-9.0 RBC-3.06* Hgb-9.5* Hct-29.1* MCV-95 MCH-31.1 MCHC-32.8 RDW-15.3 Plt Ct-192 [**2165-12-22**] 07:00AM BLOOD WBC-8.0 RBC-2.98* Hgb-9.3* Hct-27.6* MCV-92 MCH-31.2 MCHC-33.8 RDW-15.5 Plt Ct-146* [**2165-12-23**] 06:55AM BLOOD Glucose-215* UreaN-40* Creat-2.5* Na-132* K-4.5 Cl-95* HCO3-28 AnGap-14 [**2165-12-22**] 07:00AM BLOOD Glucose-284* UreaN-42* Creat-2.6* Na-132* K-4.9 Cl-95* HCO3-27 AnGap-15 Brief Hospital Course: Mr. [**Known lastname 8133**] was admitted to the [**Hospital1 18**] on [**2165-12-15**] for management of his chest pain. He ruled out for a myocardial infarction. He was started on Plavix, nitroglycerin and Heparin. A cardiac catheterization was performed which revealed severe left main and three vessel disease. Given the severity of his disease, the cardiac surgical service was consulted for surgical management. He was worked-up in the usual preoperative manner and was ready for surgery. On [**2165-12-17**] he was to the Operating Room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next 24 hours, he awoke neurologically intact and was extubated. He required low dose pressors for a couple of days and a baseline random Cortisol was 25. Midodrine and Florinef were begun. The pressor was weaned off and he transferred to the floor on POD 3. Beta blockade, aspirin and a statin were resumed. Later on postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The Physical Therapy service was consulted for assistance with his postoperative strength and mobility. Immediately after transfer he was found to have a glucose of 400. He transferred back to the ICU for an insulin infusion. This weaned off, steroids were stopped and he was stable. .He was begun on Lantus with sliding scale coverage and he transferred back to the floor. His glucose control was improving, however, he was still hyperglycemic to 260 and Lantus was increased to 15 U with SSI coverage. He has unsteady on his feet and unable to safely be sent home. Rehabilitation was discussed with him and his family and they agreed to a transfer to such a facility for further recovery prior to discharge. He did occasionally drop his BP to the 80s upon standing, although he was asymptomatic and it rose quickly to the 100s. Arrangements were made for follow up after discharge. Wounds were clean and healing well. Restrictions, precautions and medications were discussed with he and the family prior to discharge. Arrangements for follow up were made as well. Medications on Admission: Aspirin 325 po daily Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB, cough. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: 2sprays Nasal TID Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 1 puff [**Hospital1 **] Polysaccharide Iron Complex 150 mg po TID Metoprolol Tartrate 25 po daily Sevelamer HCl 400 mg po TID Montelukast 10 mg po daily Tamsulosin 0.8 po q HS Clopidogrel 75 mg po daily Simvastatin 40 mg po daily Amiodarone 200 po 3X/WEEK (MO,WE,FR). Amlodipine 5 mg po daily B Complex-Vitamin C-Folic Acid 1 mg po daily Lantus 8 units SC q AM Humalog 100 unit/mL Solution Sig: take [**First Name8 (NamePattern2) **] [**Last Name (un) **] sliding scale Subcutaneous qachs. Calcitriol 0.25 mcg po daily Loratadine 10 mg po daily Discharge Medications: 1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) inj Injection once a month. 2. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day. Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. Tablet(s) 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. Disp:*30 Tablet(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. Disp:*30 Tablet(s)* Refills:*0* 11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal TID (3 times a day). 12. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Capsule(s) 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 16. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. Disp:*1 * Refills:*2* 18. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO HS (at bedtime). 19. Lantus 100 unit/mL Cartridge Sig: 15 units Subcutaneous once a day. 20. Humalog 100 unit/mL Cartridge Sig: see sliding scale below Subcutaneous ac and HS: 120-160:4units SQ 161-200:6units SQ 201-240:8units SQ 241-280:10units SQ 281-320:12units SQ Begin HS coverage at 161. 21. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO three times a day. 22. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts Unstable angina s/p coronary angioplasty Type I diabetes mellitis Nasal polyps Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 170**]) [**2166-1-22**] at 1:00 PM Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. ([**Telephone/Fax (1) 250**]):[**2165-12-31**] 8:50am Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.([**Telephone/Fax (1) 62**]):[**2166-1-16**] 10:00am Completed by:[**2165-12-23**]

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icd9cm

[ [ [] ] ]

[ "88.55", "39.61", "37.22", "88.52", "36.13", "36.15" ]

icd9pcs

[ [ [] ] ]

9097, 9163

3589, 5862

285, 550

9344, 9344

2134, 3566

9946, 10358

1312, 1396

6741, 9074

9184, 9323

5888, 6718

9489, 9923

1411, 2115

235, 247

578, 847

9358, 9465

869, 1063

1079, 1296

10,635

160,068

50064

Discharge summary

report

Admission Date: [**2123-4-19**] Discharge Date: [**2123-4-20**] Date of Birth: [**2068-11-10**] Sex: F Service: [**Hospital Unit Name 153**] REASON FOR ADMISSION: Shortness of breath and wheezing. HISTORY OF PRESENT ILLNESS: This is a 54-year-old woman with a history of multiple medical problems and multiple admissions, most significant of which is asthma with three prior intubations and multiple hospital admissions, who now presents with three days of cough and shortness of breath. Until three days ago, the patient was doing fairly well and was in her usual state of health. Then, three days ago, she initially developed a tender neck lymphadenopathy, right greater than left, without a sore throat. This then progressed to a dry cough and then to a productive cough with yellow sputum over the last 24 hours prior to admission. This was accompanied by shortness of breath and increasing wheezing requiring more frequent nebulizer use at home. It got to the point where she was requiring continuous nebs at home. She did not check peak flows at home. She denies any recent travel. She does report [**Hospital Unit Name **] contacts regarding the children with whom she works. She does report positive chills, but did not check any temps at home. She has some question of a history of aspiration, but denies any recent aspiration events or aspiration precautions. When her wheezing and shortness of breath persisted, she came into the ED. PAST MEDICAL HISTORY: 1) Asthma with multiple admissions, last admission [**2122-11-15**], three prior intubations. Asthma is reportedly unresponsive to steroids in the past. Last PFTs were in [**2115**] and showed a more restrictive lung pattern. 2) Neurodegenerative demyelinating syndrome of unclear etiology. 3) History of severe leg muscle spasms. 4) Labile hypotension, on Florinef, has reported history of adrenal insufficiency. 5) Depression/anxiety. 6) History of right IJ thrombus in [**2112**], status post anticoagulation x 6 months. 7) Recent history of IGG deficiency, had been on high dose IGG until [**3-/2114**]. 8) Status post appendectomy. 9) Status post cholecystectomy. 10) Anemia consistent with anemia of chronic disease. She has a history of colonic hyperplastic polyp in [**2111**]. 11) Esophagitis. 12) Dysphagia/aspiration, status post G-tube placement in [**2115**] secondary to poor PO intake and aspiration. She reportedly had a swallowing eval in [**2122-10-16**] which showed a moderate to severe dysphagia, but no frank aspiration. 13) Hyperlipidemia. 14) Left breast papilloma in [**2118**], status post excision and reconstructive surgery. 15) Osteoporosis. 16) Hypothyroidism. 17) Atypical chest pain. OUTPATIENT MEDICATIONS: 1) singulair 10 mg q hs, 2) Serevent MDI 2 puffs [**Hospital1 **], 3) albuterol MDI 2 puffs prn, 4) Flovent MDI 2 puffs [**Hospital1 **], 5) Levoxyl 50 mcg qd, 6) baclofen 20 mg tid, 7) Florinef 0.1 mg qd, 8) Klonopin 2 mg tid, 9) beclomethasone nasal spray 2 sprays to each nostril [**Hospital1 **], 10) [**Doctor First Name **] 60 mg [**Hospital1 **], 11) albuterol nebs q 2-4 h prn, 12) BuSpar 10 mg tid, 13) Lipitor 10 mg qd, 14) ativan 2 mg prn, 15) Serax 30 mg q hs prn insomnia, 16) calcium carbonate 500 mg tid, 17) Vitamin D 400 qd, 18) [**Hospital1 102130**] 4 mg qid, 19) Atrovent 2-3 puffs qid. ALLERGIES: 1) Azmacort which causes facial rash and bronchospasm, 2) clindamycin, 3) fentanyl, 4) versed. ADMISSION PHYSICAL EXAM: Vitals - temp 97, heart rate 91, BP 106/51, respiratory rate 16, O2 sat 100% on 5 liters nasal cannula. General - appears pale, thin, frail, with baseline slow speech. HEENT shows EOMI, anicteric sclerae, dry mucous membranes, clear oropharynx. Neck supple, with shotty lymphadenopathy, right greater than left, in the anterior cervical chain. Heart is regular, no murmurs, rubs, or gallops. Lungs reveal diffuse wheezing bilaterally with prolonged expiratory phase. No accessory muscle use. Fair to restricted air movement. Extremities without edema. Dry skin. Pulses - 2+ distal bilaterally. ADMISSION LABS: WBC 17, hematocrit 39.5, platelets 446. Chem-7 - sodium 135, K 3.0, chloride 100, bicarb 26, BUN 16, creatinine 0.7, glucose 142. UA with negative nitrite, negative leukocyte esterase, 0 red blood cells, 0 white blood cells, 0 bacteria. Urine cultures and blood cultures were drawn and pending. EKG shows normal sinus, 78 beats per minute, normal axis and intervals, normal R wave progression. T wave inversion in III and AVL, but otherwise no acute ST changes compared with prior survey from [**11-16**]. Arterial blood gas 7.26/65/97. Chest x-ray - no acute cardiopulmonary process. HOSPITAL COURSE - 1) ACUTE RESPIRATORY DISTRESS: The patient was admitted to the [**Hospital Unit Name 153**] on [**Hospital Ward Name 516**] where she continued on continuous nebs initially. She received a single dose of prednisolone in the ED, but she received no further doses of such. She improved from a respiratory standpoint with nebulizer treatments, chest PT, and some mild to moderate suctioning. She was back at respiratory baseline by [**2123-4-20**]. She did have a chest CT performed to search for bronchiectasis given her history of aspiration in the past, her history of neuromuscular disorder, and her old PFTs that showed more of a restrictive rather than obstructive pattern. 2) RIGHT LOWER QUADRANT PAIN: It was infrequent, and was not accompanied by significant abdominal tenderness, fevers, chills, nausea, diarrhea, melena or bright red blood per rectum. Her white count continued to improve since admission. She had undergone appendectomy and cholecystectomy in the past. Her LFTs, amylase and lipase were all within normal limits. It was felt that her symptoms were most likely consistent with constipation, and she was watched without further episodes of abdominal pain. 3) NEURODEGENERATIVE DEMYELINATING SYNDROME: She was continued on her baclofen and [**Year/Month/Day 102130**]. 4) BLOOD PRESSURE: The patient's blood pressure was low at times with an episode of hypotension to the systolic blood pressure of 70s. This did come up with intravenous saline boluses x 2. She was continued on her Florinef during her course here. She does carry a diagnosis of adrenal insufficiency from the past. DISCHARGE STATUS: DC to home. DISCHARGE CONDITION: Fair. DISCHARGE DIAGNOSIS: Acute respiratory distress secondary to asthma. SECONDARY DIAGNOSES: 1) Degenerative demyelinating syndrome. 2) Right lower quadrant abdominal pain. 3) Hypotension related to adrenal insufficiency. 4) Anemia of chronic disease. DISCHARGE MEDS: Same as meds on admission with the addition of azithromycin 500 mg x 3-day course. FOLLOW-UP: Appointment with PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, on [**2123-4-22**]. Follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD in the pulmonary division on [**2123-5-6**], with full PFTs scheduled prior to that appointment. DR.[**First Name (STitle) **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 11-575 Dictated By:[**Last Name (NamePattern1) 19919**] MEDQUIST36 D: [**2123-4-20**] 11:53 T: [**2123-4-23**] 12:17 JOB#: [**Job Number 104536**]

[ "300.00", "272.0", "733.00", "244.9", "493.90", "311", "789.01", "341.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6411, 6418

6440, 6489

3502, 4107

6511, 7351

2760, 3486

249, 1479

4124, 6389

1502, 2735

81,122

159,267

25498

Discharge summary

report

Admission Date: [**2155-7-14**] Discharge Date: [**2155-7-26**] Date of Birth: [**2111-7-13**] Sex: M Service: MEDICINE Allergies: Tegaderm Attending:[**First Name3 (LF) 8104**] Chief Complaint: metestatic melanoma presenting for IL-2 infusion Major Surgical or Invasive Procedure: s/p central line placement IR guided right hepatic artery branch embolization Past Medical History: PPx: With the exception of seeing a marriage counselor twice several years ago, the pt has never seen a psychiatrist or counselor. His oncologist did start him on Celexa 10mg ~7 mos ago, increasing the dose to 20mg ~4 mos ago. Past Medical History: Treatment History (per OMR): Mr. [**Known lastname 8952**] initially noticed bleeding from a skin lesion on his left upper arm in late [**2153-8-31**]. He was subsequently evaluated and ultimately had a punch biopsy performed in early [**Month (only) **], which showed invasive malignant melanoma. He had wide local excision and sentinel lymph node sampling on [**2153-12-20**] and his pathology at that time revealed a superficial spreading [**Doctor Last Name 10834**] level IV melanoma with a depth of invasion of 2.24 mm, focal ulceration, and 8 mitoses/mm2. In the sentinel lymph node, a cluster of MART-1 positive cells were noted and thought to be consistent with micrometastases. On [**2154-1-17**] he underwent a left axillary dissection, and all 17 lymph nodes removed and evaluated were free of disease. He commenced adjuvant interferon on [**2154-2-13**]. Current Treatment: Week 10 adjuvant interferon alpha 2b on [**4-17**] Social History: Born in [**Location (un) **] to intact family, has 2 brothers. Family is still in [**Location (un) **]. Completed high school, then started working. Currently self-employed, working from home, as project manager for telecommunications company. He is a project manager for a telemarketing company and works from home. He has been married for over seven years and he and his wife have a 16 month old. He is a former smoker and quit 2-3 years ago, previously smoked a quarter-to-half a pack a day. He did this for approximately 20 years. He states that he drinks on average 10 beers per week. Family History: Pt denies any past psychiatric family history. There is no family history of melanoma. His maternal grandfather was a heavy smoker and died from lung cancer. His mother and father remain alive and reasonably well, aged 70 and 68 respectively. He has two younger brothers aged 39 and 37 who are healthy. Physical Exam: Vitals: T: 97.4 BP: 136/89 P: 99 R: 28 O2: 94% 3 L General: Alert, oriented, no acute distress, lying flat post cath HEENT: [**Last Name (LF) 3899**], [**First Name3 (LF) 13775**], Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally on atnerior exam (limited to post cath supine position), no wheezes, rales, rhonchi CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, hypoactive BS, tender in RUQ and LUQ to moderate palpation, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: Labs on admission [**2155-7-14**] 10:25AM BLOOD WBC-8.5 RBC-4.51* Hgb-12.1* Hct-37.7* MCV-84 MCH-26.9* MCHC-32.2 RDW-12.7 Plt Ct-333 [**2155-7-14**] 10:25AM BLOOD Neuts-76.2* Lymphs-15.3* Monos-7.0 Eos-1.3 Baso-0.3 [**2155-7-14**] 10:25AM BLOOD PT-12.3 PTT-22.6 INR(PT)-1.0 [**2155-7-14**] 10:25AM BLOOD Glucose-89 UreaN-15 Creat-0.7 Na-139 K-5.0 Cl-101 HCO3-26 AnGap-17 [**2155-7-14**] 10:25AM BLOOD ALT-77* AST-34 CK(CPK)-66 TotBili-0.5 [**2155-7-22**] [**2155-7-22**] Radiology CT ABDOMEN &PELVIS W/O CONTRAST 1. New predominantly perihepatic hemorrhage likely arising from a segment VII liver lesion. 2. New moderate bilateral pleural effusions. [**2155-7-23**] Cardiology ECHO IMPRESSION: Small circumferential pericardial effusion without evidence of hemodynamic compromise. Normal biventricular cavity size with normal regional and low normal left ventricular systolic function. No valvular pathology or pathologic flow identified [**2155-7-25**] Radiology CHEST (PORTABLE AP) IMPRESSION: 1. Low lung volumes. 2. Moderate right subpulmonic effusion. 3. Bibasilar atelectasis at the lung bases. 4. Questionable prominence of right hilum could be due to lymphadenopathy. Brief Hospital Course: Mr. [**Known lastname 8952**] is a 44 YOM with metastatic melanoma to liver and lungs who presented for IL-2 therapy . # Liver metasteses bleed: On treatment day #8 of IL-2 the patient was noted to have a Hct drop from 33.9 to 20. Repeat Hct was 18.5, plt 59, INR 1.3. LFTs were also elevated acutely. BP was 130-140, but tachycardic to 100-120. He was transfused 2 units with resulting Hct of 23.1 and then transfused another 2 units. CT torso revealed active hemorrhage from one of multiple liver lesions. He was taken to IR where a groin central line was placed. He underwent Angio of celiac and hepatic arteries. No active bleeding was seen and the tumors were actually hypovascular, but some superior vessels of the right hepatic artery were embolized with gelfoam as this was sight of most substantial bleeding on recent noncon CT. There were no complications. He was then transferred to the ICU for monitoring. Serial Hcts were checked and were stable and he was transferred out of the ICU. His pain continued to improve on the floor, though he still required pain medication at time of discharge. . # Metastatic melanoma: The patient finished IL-2 on [**2155-7-18**]. He was continued on oxycodone PRN for pain. Will follow-up with biologics team as outpatient early this week. . # Myocarditis: The patient was found to have elevated CK, troponin, and CKMB consistent with IL-2 induced myocarditis. He was monitored on telemetry and was found to have a few short runs of NSVT. His biomarkers trended back down over time. # Depression: The patient was continued on his home dose celexa. #Hypoxia: Combination of effusion/splinting/atelectasis. Has small oxygen requirement at time of discharge. Was encouraged to ambulate and use incentive spirometer. #Pleural effsion: Seen previously. Given recent IL-2/volume overload/recent embolization and minimal O2 requirement did not perform tap at this time. #Volume overload: TTE performed revealed Small circumferential pericardial effusion without evidence of hemodynamic compromise. Normal biventricular cavity size with normal regional and low normal left ventricular systolic function. No valvular pathology or pathologic flow identified. -Initiated lasix. -Will need to be closely monitored in outpatient setting. At follow-up appointment will need: -volume status assessment -laboratory testing including hematocrit/K/renal function -pain assessment -ambulatory oxygen measured Medications on Admission: celexa Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Dilaudid 4 mg Tablet Sig: .5 Tablet PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Home oxygen 1-3L continuous pulse dosed for portability Discharge Disposition: Home Discharge Diagnosis: Metastatic melanoma - s/p C1W1 HD IL-2 therapy Hemorrhagic hepatic metastases s/p embolization Myocarditis pleural effusion Discharge Condition: Alert, oriented and ambulatory 88% ambulatory room air Discharge Instructions: You were admitted for IL-2 therapy. Your hospitalization was complicated by a hemorrhage of a liver lesion, which required embolization. You also have fluid overload. You should use your oxygen as prescribed and weigh yourself daily. Medication changes: Started lasix Started dilaudid: This medication may make you drowsy. you should not drive while taking this medication. Please call [**Telephone/Fax (1) 63698**] ([**Doctor First Name **]) or [**Telephone/Fax (1) 63699**] ([**State 622**])with any questions or concerns. They will be calling you on Monday. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2155-7-30**] 2:30PM With: [**Name8 (MD) **], MD 617-667 Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: RADIOLOGY When: TUESDAY [**2155-8-26**] at 2:00 PM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "39.79", "38.93", "00.15", "88.47" ]

icd9pcs

[ [ [] ] ]

7333, 7339

4465, 6921

318, 398

7507, 7564

3252, 4442

8175, 8656

2238, 2545

6978, 7310

7360, 7486

6947, 6955

7588, 7823

2560, 3233

7843, 8152

230, 280

670, 1610

1626, 2222

78,173

183,952

47942

Discharge summary

report

Admission Date: [**2192-5-9**] Discharge Date: [**2192-5-12**] Date of Birth: [**2124-6-13**] Sex: M Service: MEDICINE Allergies: Verapamil Attending:[**First Name3 (LF) 10323**] Chief Complaint: shortness of breath, chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 67 year old man with a history of metastatic pancreatic cancer and hx of DVT diagnosed in [**Month (only) 958**] on Lovenox 1mg/kg [**Hospital1 **] who is admitted following CT Torso today to assess for progression pancreatic cancer that showed bilateral PEs with possible right heart strain. The patient was first diagnosed with bilateral DVTs on [**3-19**], and was started on lovenox. At time of diagnosis, he did have right lower extremity tenderness. Since initiation of lovenox, the patient has taken it meticulously at 8am and 8pm daily and lower extremity pain has long resolved. However, this Saturday morning (4 days PTA), he awoke with intermittent sharp stabbing right sided chest pain (non-pleuritic), associated with right-sided abdominal pain radiating around his side. Chest pain did not radiate. Pain was associated with dyspnea on exertion on climbing 1 flight of stairs and occasional palpitatons. No lightheadedness/dizziness or syncope. The patient was evaluated by his oncologist, who increased his fentaynl patch for radiating abdominal pain, and referred him for a CT torso with contrast to evaluate for progression of disease. CT showed multiple segmental pulmonary emboli, and thrombus surrounding the tip of his porto-cath extending into his low SVC. The patient was referred to the emergency department. . In the ED, initial VS were: 99.8 123 170/79 18 100% on RA. The patient was started on a weight-based heparin drip with bolus. He underwent lower extremity duplexes. He was admitted to the ICU for close monitoring given ongoing tachycardia. . On admission to the [**Hospital Unit Name 153**], VS 116 20 160/73 100%. The patient states that chest pain currently resolved. He denies shortness of breath at rest, calf tenderness, palpitations. Abdominal pain well controlled on fentanyl patch (due to be changed [**5-10**]). No recent fevers, chills. Appetite intact on megestrol. . Review of systems: (+) Per HPI; recent history of constipation, improved on increase in bowel regimen (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure, palpitations. Denies abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - IPMN - adenocarcinoma of the pancreas (see below) - Hypertension - Hyperlipidemia - Elevated PSA since approx [**2179**] with 4 negative Bx - Microscopic hematuria - Colon polyps (benign) (last colonoscopy [**2187**], planned 5-year follow-up) - Glaucoma (mild, low tension) - Nephrolithiasis - h/o tendonitis (R index) - Diverticulosis - Lumbar disc disease - Ventral hernia - h/o positive PPD - s/p fusion of lower spine ([**2179**]) . ONCOLOGIC HISTORY: - [**10-17**] diagnosed with IPMN - [**1-/2192**]: admitted to [**Hospital1 112**] with intense, crampy abdominal pain. MRI showed a lesion in the uncinate head of the pancreas. - [**2192-2-16**]: EUS done at [**Hospital1 18**] showed a 2.5 x 2.5 cm mass in the uncinate process of the pancreas as well as several cysts. Biopsy of the uncinate mass was suspicious for adenocarcinoma. Biopsy of the mass in the tail continued to show mucinous fluid, consistent with IPMN. - [**2192-3-9**]: planned Whipple procedure; during the procedure he was found to studding of the liver with at least 15 discrete nodules in both lobes. He also had 1 firm, hard, whitish nodule that was in close proximity to the pancreatic head. Liver and pancreatic biopsies were taken and he was proven to have adenocarcinoma in the liver. A port-a-cath was placed. - [**2192-4-9**]: Gemcitabine 1000mg/m2 day 1 - [**Date range (1) 101157**]: admitted for jaundice, hyperbilirubinemia, biliary obstruction. ERCP was done with sphincterotomy and CBD stent placed - [**2192-4-16**]: Gemcitabine 1000mg/m2 day 8 - [**2192-4-23**]: day 15 Gemcitabine HELD due to dehydration - [**2192-5-1**]: Gemcitabine given Social History: Originally from [**Location (un) 4708**]. Professor [**First Name (Titles) **] [**Last Name (Titles) 75591**] at [**Hospital1 498**]. He drinks occasional alcohol and does not smoke (smoked for 6 months in the [**2140**]'s), denies environmental exposures. Married with 2 sons. Family History: Older brother died of pancreatic cancer in his 60s. [**Name (NI) **] brother died of lung cancer at age 53. Father had DM and possible heart disease. No family history of hypercoagulability. Physical Exam: Physical Exam: Vitals: BP 154/81 P 101 O2 99%RA General: Pleasant, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, + S4 and loud P2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, + hepatomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; no calf tenderness Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . Pertinent Results: Admission Labs: [**2192-5-9**] 07:00PM BLOOD WBC-8.8 RBC-2.55* Hgb-7.5* Hct-25.3* MCV-99* MCH-29.2 MCHC-29.5* RDW-16.0* Plt Ct-190 [**2192-5-9**] 07:00PM BLOOD Neuts-94.6* Lymphs-4.3* Monos-0.4* Eos-0.5 Baso-0.2 [**2192-5-9**] 07:00PM BLOOD PT-12.9* PTT-27.2 INR(PT)-1.2* [**2192-5-9**] 07:00PM BLOOD Glucose-173* UreaN-15 Creat-0.8 Na-137 K-4.2 Cl-103 HCO3-24 AnGap-14 [**2192-5-10**] 02:57AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.7 . Imaging: CT chest/abd/pelvis with contrast: 1. Bilateral pulmonary emboli with occlusion of the right lower lobe pulmonary artery, new from [**2192-4-6**]. Eccentric thrombus in the left lower lobe pulmonary artery suggests that this portion may be subacute, but it is still new from [**2192-4-6**]. There is no definite evidence of right heart strain. This finding was communicated to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**] by phone at 1:50 p.m., [**2192-5-9**], upon discovery. 2. Heterogeneous opacity in the right lower lobe with extension into the right middle lobe may represent aspiration, infection or right lower lobe infarct. 3. Filling defect at the inferior tip of the Port-A-Cath within the SVC may be due to thrombus at the tip, less likely due to mixing of contrast. 4. Interval increase in size of numerous hepatic hypodensities, consistent with metastatic disease. The pancreatic head adenocarcinoma is similar to [**2192-4-6**]. Adjacent peripancreatic nodes are unchanged. A hypodense lesion in the pancreatic tail is likely a side branch IPMN, which is slightly larger, possibly due to progressive ductal obstruction. 5. Fat stranding in the right upper quadrant omentum may represent post-surgical or post-radiation change, but omental metastasis is not excluded. The finding is similar in appearance to [**2192-4-6**]. 6. Common bile duct stent with air in the gallbladder and pneumobilia, attesting the stent patency. . LENIS: 1. Partially occlusive thrombus in the mid superficial femoral vein on the left. 2. Apparent resolution of the remainder of the venous thromboembolisms from the [**3-19**] study. . ECHO: The left atrium is mildly dilated. There is a 1.6 x 1.7 round, mildly mobile echogenic mass in the right atrium, likely representing the extension of a known catheter-associated thrombus. An independent pathology, such as myxoma or other tumor cannot be entirely excluded. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate-sized right atrial mass, likely thrombus. No PFO or ASD seen. Normal global and regional biventricular systolic function. Discharge Labs: [**2192-5-12**] 06:00AM BLOOD WBC-4.8 RBC-3.28* Hgb-9.8* Hct-31.5* MCV-96 MCH-29.8 MCHC-31.1 RDW-15.7* Plt Ct-207 [**2192-5-12**] 06:00AM BLOOD PT-12.8* PTT-28.3 INR(PT)-1.2* [**2192-5-12**] 06:00AM BLOOD Glucose-173* UreaN-13 Creat-0.7 Na-132* K-4.5 Cl-96 HCO3-25 AnGap-16 [**2192-5-11**] 06:00AM BLOOD ALT-43* AST-23 AlkPhos-177* TotBili-1.0 [**2192-5-12**] 06:00AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1 Brief Hospital Course: 67 year old male with a history of metastatic pancreatic cancer and recent history of DVT ([**3-19**]) on Lovenox admitted with bilateral PEs and SVC clot surrounding porto-cath. . # Pulmonary embolism: Patient admitted to the [**Hospital Unit Name 153**] with bilateral segmental pulmonary emboli and thrombosis in low SVC surrounding porto-cath, despite use of lovenox. On admission he was started on a heparin drip. He was mildly tachycardic, but otherwise asymptomatic. No evidence of right heart strain on physical exam or EKG. He underwent LENIs that showed partially occlusive thrombus in the mid superficial femoral vein on the left. He then underwent echo, that showed extension of his catheter related thrombus into his right atrium and moderate pulmonary hypertension. Once confirmed to be hemodynamically stable, he was called out from the ICU to the oncology service. On the floor he was hemodynamically stable. Heparin gtt was stopped and the patient was started on fondaparinux 7.5mg sc daily and discharge a day later on the same. His port stopped drawing and TPA did not work to unclot the port. Arrangements were made for him to follow up for outpatient port follow-up and flow studies. . # Anemia: Patient admitted with HCT 25, trending down over the past several months. Prior to starting a heparin drip, he was found to be guaiac negative, but had bleeding hemorrhoid. Follow-up HCT 21, without localizing source of bleed. Stool guaiacs negative. Patient was transfused 1 unit PRBCs and hematocrit remained stable. He was transferred to the floor and Hct remained stable. . # Metastatic Pancreatic Cancer: On gemcitabine, s/p cycle 3 day 2 on admission. Course complicated by worsening anemia and recent admission for obstructive jaundice (resolved). Patient with chronic right sided abdominal pain related to disease, well controlled on fentanyl patch. He was followed by oncology throughout admission. He was continued on pain control with a fentanyl patch. . #HTN: stable. Continue home amlodipine and benazapril. Changing atenolol to metoprolol while in house. He was discharged on his home dose of atenolol. . #HL: Chronic. Holding statin given transaminitis. . #glaucoma: Continue home eye drops . #BPH: Chronic. Continue terazosin . # Code: DNR/DNI, confirmed with patient. Medications on Admission: Atenolol 50 mg daily Amlodipine-Benazepril 1 tablet daily Megestrol Acetate 400 mg PO BID Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES [**Hospital1 **] Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation Docusate Sodium 100 mg PO/NG [**Hospital1 **] Fentanyl Patch 100 mcg/hr TP Q72H Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Terazosin 2 mg PO HS Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Discharge Medications: 1. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) Subcutaneous once a day. Disp:*30 syringe* Refills:*2* 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 3. amlodipine-benazepril Oral 4. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO BID (2 times a day) as needed for constipation. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 7. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Pulmonary emboli Deep vein thrombosis Pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 4427**], It was pleasure taking care of you at [**Hospital1 827**]. You were admitted for persistent deep vein thrombosis, pulmonary emboli (blood clots in your lungs), and cardiac thrombus (blood clot in your heart). You have been treated with blood thinners. Please continue to take the blood thinner, Fondaparinux, daily after discharge. Medication Changes: Stop taking Megestrol Acetate Stop taking Lovenox Start taking Fondaparinux Sodium 7.5mg subcutaneously daily In addition, your port was clotted during this hospitalization, and you will need a study as an outpatient to evaluate if your port can be used in the future. Followup Instructions: You will need a flow study as an outpatient of your port. You should be contact[**Name (NI) **] to set this up. If you do not hear from them, please call the pheresis unit at ([**Telephone/Fax (1) 6795**]. Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2192-5-14**] at 12:00 PM With: [**Doctor Last Name 24141**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ENDO SUITES When: THURSDAY [**2192-5-17**] at 1:30 PM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2192-5-17**] at 1:30 PM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage

[ "415.19", "453.41", "401.9", "600.00", "285.9", "157.8", "272.4", "V58.61", "453.77", "365.9", "197.7" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12920, 12926

9245, 11575

302, 308

13026, 13026

5622, 5622

13859, 14792

4707, 4902

12037, 12897

12947, 13005

11601, 12014

13177, 13545

8819, 9222

4932, 5603

2283, 2729

13565, 13836

231, 264

336, 2264

5638, 8802

13041, 13153

2751, 4395

4411, 4691

27,869

194,131

466

Discharge summary

report

Admission Date: [**2104-10-28**] Discharge Date: [**2104-10-31**] Service: CARDIOTHORACIC Allergies: Xanax / Ativan Attending:[**First Name3 (LF) 3948**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Flexible bronchoscopy with therapeutic aspiration History of Present Illness: [**Age over 90 **] yo man with aortic stenosis, CRF, left renal artery stenosis, COPD, tobacco abuse who called EMS for acute dyspnea/hemoptysis last night. Had approx 5 tbl of BRB followed by a few episodes of coin sized blood. Per patient's wife, patient was lethargic and sleepy after d/c last week from hospital. [**Name (NI) **] wife awoke around 230am today when patient was coughing up blood and noted to be dyspneic. She also states that the VNA noted some "abnormal sounds" in her right lung on exam. Past Medical History: # Chronic renal failure - Followed by Dr. [**Last Name (STitle) **]. On Epogen. - Baseline creatinine is 2.0 - 2.4. # Claudication - Walks 1.5 miles daily but has to stop and rest. # Aortic stenosis - Mean gradient 60 on last ECHO [**9-6**] - Declined AVR or valvuloplasty # B12 deficiency # HTN # GERD # PVD # H/O stomach cancer - s/p total gastrectomy and Roux-en-Y in late [**2085**] # Left renal artery stenosis - s/p stenting [**2102-3-8**] # Type 2 DM # Hyperkalemia in the past attributed to dietary supplements # Paroxysmal atrial fib - reported after gastrectomy but no h/o recurrence # COPD # TIA # Abdominal aortic aneurysm repair # Right ICA 50% occluded, [**Doctor First Name 3098**] 90% occluded Social History: Lives at home with his wife. [**Name (NI) **] [**Name (NI) **] [**Known lastname 3937**] is a ED physician in [**Name9 (PRE) 1727**]. Phone numbers are [**Telephone/Fax (1) 3938**] and [**Telephone/Fax (1) 3939**]. Patient is a retired jazz musician--- played the clarinet and sax. No ETOH or drugs. Smoked [**3-4**] PPD for 30 years but quit approximately 20 years ago. Family History: No fam hx or early CAD. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS:98.6, 60, 140/76, 24, 95%NRB (prior to intubation) Gen: intubated and sedated, appears younger than stated age HEENT: ETT 8-[**Street Address(2) 3949**] NECK: trachea midline, no stridor, supple LYMPHATICS: no cervical or supraclavicular lymphadenopathy, no thyromegaly Chest: [**Month (only) **] BS LLL CV: reg rate, [**3-6**] SM throughotu ABD: soft, NT/ND, NABS, no HSM EXT: no CCE NEURO: intubated and sedated, responds to pain Pertinent Results: [**2104-10-28**] 05:30AM PT-36.1* PTT-38.3* INR(PT)-3.8* [**2104-10-28**] 05:30AM PLT COUNT-230 [**2104-10-28**] 05:30AM NEUTS-86.6* LYMPHS-8.5* MONOS-3.1 EOS-1.3 BASOS-0.5 [**2104-10-28**] 05:30AM WBC-3.4* RBC-4.30* HGB-11.9* HCT-38.4* MCV-89 MCH-27.8 MCHC-31.0 RDW-15.6* [**2104-10-28**] 05:30AM CALCIUM-7.8* PHOSPHATE-2.3*# MAGNESIUM-1.7 [**2104-10-28**] 05:30AM CK-MB-NotDone cTropnT-0.13* [**2104-10-28**] 09:33AM PT-21.2* PTT-35.6* INR(PT)-2.0* [**2104-10-28**] 04:19PM PT-15.4* PTT-35.6* INR(PT)-1.4* CXR [**2104-10-28**]: LLL infiltrate [**2104-10-28**] Chest CT: 1. New small-to-moderate bilateral non-hemorrhagic pleural effusions. New left lower and upper lobe hemorrhage or pneumonia. 2. Upper lobe predominant emphysema and signs of small airway disease. 3. Severe atherosclerotic calcifications of all imaged vessels, with old aortic dissection, not imaged entirely, but grossly unchanged since [**2101**]. 4. Cardiomegaly, left atrial enlargement and left ventricular hypertrophy. 5. Fluid-filled esophagus. Recent aspiration. 6. Anemia. 7. Severe aortic valve calcification. 8. Left adrenal adenoma. 9. Prior gastrectomy. 10. Pulmonary hypertension. [**2104-10-28**] CXR: Brief Hospital Course: After presenting to the ER 0n [**2104-10-28**], Mr. [**Known lastname 3950**] was intubated for airway protection. A CXR demonstrated infiltrate in LLL and his INR was found to be supratherapeutic at 3.9. Mr. [**Known lastname 3950**] was then evaluated in the ER by interventional pulmonology, who performed flexible bronchoscopy for his hemoptysis. The bronchoscopy revealed no active bleeding. He was found to have evidence of old bleeding in superior segment of the left lower lobe and friable airways throughout. No endobronchial lesions were noted. His coumadin was held and he received fresh frozen plasma to correct his coagulopathy. His repeat INR came back at 2.0. He was admitted to the CVICU and put on a ventilator. He remained stable overnight. On hospital day 2, he was extubated in the morning without complications. He remained stable throughout the day. That evening, he was transferred out of the CVICU to the floor, where he immediately developed shortness of breath and began coughing up a small volume of blood-tinged sputum. He maintained his saturations in the mid-90's on 4LNC and 40%FM. He was triggered for marked nursing concern and was then transferred to the CVICU, where after receiving IV Lasix and morphine, he became considerably more comfortable. He had an uneventful night. On hospital day 3, a palliative care consult was obtained and it was determined that the patient wished not to pursue aggressive care any longer and wanted to be discharged home with hospice services. A referral was made to hospice. He was provided with liquid morphine for comfort. That evening, his care was transferred to the Cardiac service. Mr. [**Known lastname **] was placed on a lasix drip and was diuresed as he has been volume overloaded. Additionally, He refused oral medications except for morphine. On hospital day 4, he was discharged home with hospice. Patient has chosen to not be rehospitalized. Regarding code status, according to the patient's wishes and in consultation with his son, [**Name (NI) **] [**Hospital 3951**] health care proxy, he was made DNR/DNI. The DNI order was temporarily rescinded while the patient was intubated for less than 24 hours, but was then put back into effect after extubation. At the time of discharge, his code status remained DNR/DNI. Medications on Admission: Sucralfate 100 mg/mL Suspension Sig: Two (2) Tspns PO QID (4 times a day). Tspns Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO Q AM (). Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q AM (). Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Amlodipine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) inj Injection once a week. Outpatient Lab Work Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) aerosol Inhalation every 6-8 hours as needed for shortness of breath or wheezing. Disp:*1 canister* Refills:*2* Discharge Medications: 1. Home Oxygen Home Oxygen 3-15 Liters continuous to maintain comfort 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*2* 4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). Disp:*qs * Refills:*2* 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 5 days. Disp:*3 Tablet(s)* Refills:*0* 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*qs * Refills:*2* 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Furosemide 10 mg/mL Solution Sig: 40-100mg miligrams prn Injection Twice to Three Times daily as needed for shortness of breath or wheezing. Disp:*1 bottle* Refills:*0* 12. Hyoscyamine Sulfate 0.125 mg Tablet, Rapid Dissolve Sig: [**1-2**] Tablet, Rapid Dissolves PO twice a day as needed for secretions. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2* 13. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch Transdermal every seventy-two (72) hours as needed for secretions. Disp:*10 patches* Refills:*2* 14. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for nausea. Disp:*60 Tablet(s)* Refills:*2* 15. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 16. Furosemide 10 mg/mL Solution Sig: Two (2) Mililiters (20mg) PO twice a day: Also: can give in addition 20-100mg orally prn dyspnea. Disp:*1 Bottle* Refills:*2* 17. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) patch Transdermal once a day. Disp:*30 patches* Refills:*2* 18. Oxycodone 20 mg/mL Concentrate Sig: 1-20 mg PO q1hr. Disp:*90 ml* Refills:*0* Discharge Disposition: Home With Service Facility: Good [**Hospital 3952**] Hospice Discharge Diagnosis: Chronic renal failure Followed by Dr. [**Last Name (STitle) **]. On Epogen. Baseline creatinine is 2.0 - 2.4. Claudication: Walks 1.5 miles daily but has to stop and rest. Aortic stenosis: Mean gradient 60 on last ECHO [**9-6**] Declined AVR or valvuloplasty B12 deficiency HTN GERD PVD H/O stomach cancer s/p total gastrectomy and Roux-en-Y in late [**2085**] Left renal artery stenosis s/p stenting [**2102-3-8**] Type 2 DM Hyperkalemia in the past attributed to dietary supplements Paroxysmal atrial fib COPD TIA Abdominal aortic aneurysm repair Right ICA 50% occluded, [**Doctor First Name 3098**] 90% occluded Discharge Condition: stable Discharge Instructions: You were hospitalized because you had were short of breath. You were found to be bleeding from your lungs. You also had heart failure, with fluid in your lungs as well. After discussions with you, your family, and your physicians, it was descided to discharge you home, with the assistance of hospice care. Please contact your hospice care takers or your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] if you require anything at all to make you more comfortable. Followup Instructions: Follow-up with with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as needed. Completed by:[**2104-10-31**]

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icd9cm

[ [ [] ] ]

[ "33.24", "96.04", "99.07", "96.71" ]

icd9pcs

[ [ [] ] ]

9946, 10009

3779, 6085

241, 330

10668, 10677

2539, 3756

11206, 11337

2011, 2036

7526, 9923

10030, 10647

6111, 7503

10701, 11183

2051, 2061

2083, 2520

191, 203

358, 872

894, 1606

1622, 1995

52,010

173,716

42164

Discharge summary

report

Admission Date: [**2160-10-8**] Discharge Date: [**2160-10-11**] Date of Birth: [**2094-1-20**] Sex: M Service: MEDICINE Allergies: Iodine / Shellfish Attending:[**First Name3 (LF) 3984**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Endotrachial intubation Triple Lumen Central Venous Line Placement Arterial Line Placement Bronchoscopy History of Present Illness: 66 year old gentelman, with DM, CAD, chronic Afib, hiatal hernia, [**Last Name (un) **] esophagus with mutliple esophageal dilatations who had robotic prostatectomy for T1C prostate adenocarcinoma on [**2160-9-18**] at OSH. During the surgery he lost about 150 cc blood however post-op he became anemic and had exp-lap on [**9-20**] for evacuation of clots and hemostatis. Post-op he developed prolonged ileus for which NG tube placement was difficult [**1-23**] large hiatal hernia. Ileus eventually resolved. PEG was considered (alb 1.6), however anesthesia at OSH considered him high risk and thought of Dobhoff. After dobhoff was placed unsuccessfully [**10-4**], he started to have upper airway bleeding requiring intubation. He was on lovenox for DVT prophylaxis, and after 1 dose of coumadin for chronic Afib, INR 2.36). CXR showed stable ARDS [**Date range (1) 79119**]. He required multiple transfusions during his stay. His last Hct was 24.3 and received 2 units at the time of transfer to [**Hospital1 18**]. His Last INR 1.44. . His plt dropped from 166 on [**9-27**] to 40 on [**10-7**]. Received plt transfusion morning of [**10-8**] and plt was up to 62. HIT antibodies and SRA test were sent. Heme consult at OSH thought it was most likely due to lovenox which was stopped [**10-5**]. Also, regarding his 4 blasts on his differentials of count, heme consult at OSH thought it is most likely a leukomoid reaction but could not exclude underlying hematological malignancy. they sent [**10-8**] flow cytometry that is still pending. . Due to repeat bleed from his upper airway he was rebronched and new ETT was placed. . Post-op he also developed pneumonia for which he was placed on vanc, ceftaz. On [**10-6**] ID thought there is no active pneumonia anymore, stopped tobra, and recommended completing ceftaz [**10-3**] days. His bronch cultures from [**10-4**] are negative so far. . Also post-op, he had Afib with RVR that required IV dilt and esmolol and digoxin. Lung nuclear scan did not show PE. Echo on [**9-24**] showed EF 55%, Aortic thickening but no stenosis, mikld MR, LAE, normal wall motion. Off dilt IV now. . Nutrition: on TPN for the last 4 days came on PSV, Fio2 60%, TV 650, RR 18, PEEP 8. on propofol for sedation. Past Medical History: HL Afib HTN CAD DM Hypothyroidism Acoustic Neuroma Bell's palsy Hiatal hernia GERD OA Depression Social History: Married with adult children. Lives in [**Location 686**] Family History: No family h/o hematological malignancy Physical Exam: Admission Phsyical Exam: Vitals: T: 99.8 BP: 134/84 P: 98 irregular R: [**12-4**] O2: 100% General: intubated, sedated, not responding to voice, sternal rub, resisted opening left eye, moved left eyebrow when name called. Did not follow commands. HEENT: Sclera anicteric, MM relatively dry, oropharynx seems clear, but intubated. Right eye open Neck: supple, JVP not elevated, no LAD, right IJ Lungs: good air entry bilaterally anteriorly and axillary, with faint insp rhonchi bilaterally, no crackles. reduced breath sounds on right side CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, no palpable masses or organomegaly. surgical clean wounds with steristrips, echymotic patch at left and right lower quadrant, non-distended, bowel sounds present Ext: 1+ pulses, slight pitting edema bilaterally up to knees, right UE PICC . Ventilator: PS 15 PEEP 8 FiO2 50% TV 800-1000 cc RR 12-15 Pertinent Results: [**2160-10-8**] 04:12PM BLOOD WBC-14.1* RBC-3.74* Hgb-11.2* Hct-32.3* MCV-86 MCH-29.9 MCHC-34.7 RDW-18.3* Plt Ct-70* [**2160-10-8**] 04:12PM BLOOD PT-14.7* PTT-36.5* INR(PT)-1.3* [**2160-10-9**] 02:26PM BLOOD FDP->1280* [**2160-10-9**] 02:26PM BLOOD Fibrino-345 [**2160-10-8**] 04:12PM BLOOD Glucose-161* UreaN-50* Creat-1.0 Na-140 K-3.9 Cl-105 HCO3-26 AnGap-13 [**2160-10-8**] 04:12PM BLOOD ALT-69* AST-88* LD(LDH)-2700* AlkPhos-110 TotBili-1.7* [**2160-10-8**] 04:12PM BLOOD Albumin-2.3* Calcium-7.1* Phos-3.0 Mg-2.0 [**2160-10-9**] 02:26PM BLOOD Hapto-170 [**2160-10-9**] 01:00AM BLOOD TSH-11* [**2160-10-9**] 01:00AM BLOOD Free T4-0.66* [**2160-10-8**] 04:32PM BLOOD Lactate-1.6 MICRO [**2160-10-11**] Blood Culture, Routine-PENDING-NGTD [**2160-10-10**] CATHETER TIP-IV WOUND CULTURE-PENDING-NGTD [**2160-10-10**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-PENDING; Respiratory Viral Antigen Screen-PENDING; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PENDING [**2160-10-10**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-FINAL; Immunoflourescent test for Pneumocystis jirovecii (carinii)-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-PRELIMINARY; ACID FAST CULTURE-PRELIMINARY [**2160-10-10**] URINE CULTURE-PENDING-NGTD [**2160-10-10**] Blood Culture, Routine-PENDING-NGTD [**2160-10-10**] Blood Culture, Routine-PENDING-NGTD [**2160-10-9**] URINE CULTURE-PENDING-NGTD [**2160-10-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY [**2160-10-8**] URINE CULTURE-FINAL-Negative [**2160-10-8**] Blood Culture, Routine-PENDING-NGTD [**2160-10-8**] Blood Culture, Routine-PENDING-NGTD IMAGING: CT CHEST, ABD & PELVIS W/O CONTRAST ([**2160-10-8**]) 1. Heterogeneous but widespread opacities in each lung, predominantly of ground glass attenuation. Major differential considerations include multifocal pneumonia, although other processes could be considered such as heterogeneous involvement with edema, respiratory distress syndrome or even hemorrhage in the appropriate clinical setting. 2. Extensive left lower lobe atelectasis with mucus plugging and hyperdense material, potentially due to aspiration of barium or other hyperdense substance. 3. Large hiatal hernia. 4. Cholelithiasis. 5. Minimal colonic wall thickening, which can probably be explained in the setting of widespread edema. 6. Fluid collections in the pelvis which would be compatible with resolving hematomas. 7. Small nodule in the anterior subcutaneous fat of the right lower quadrant, probably benign, but correlation with physical findings and attention in follow-up is suggested. CT HEAD W/O CONTRAST ([**2160-10-8**]) 1. No acute intracranial hemorrhage or mass effect . Large area of hypodensity in the right cerebellar hemisphere adjacent to the remote craniotomy, presumably prior insult; correlate with history. If there is continued concern for parenchymal changes and acute infarcs, MRI is more sensitive and can be considered if not contra-indicated. 2. Left mastoid air cells -opacification from fluid/mucosal thickening. TTE ([**2160-10-9**]) Suboptimal image quality due to body habitus. Overally left ventricular ejection fraction is normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen but is probably normal. No significant valvular abnormality. Mildly elevated pulmonary artery systolic pressure. Dilated thoracic aorta. Brief Hospital Course: Patient was transferred from OSH for further management of his respiratory failure and increasing leukocytosis and blast forms. Upon arrival, the patient was intubated and sedated. A bone marrow biopsy was obtained, the final results of which remain pending. The preliminary read reported dysplasia with approximately 30% blasts. A head CT was performed that showed a large area of hypodensity in the right cerebellar hemisphere adjacent to the remote craniotomy (acoustic neuroma). A MRI of the head was planned to better evaluate the posterior fossa, however it was determined that the patient was too unstable to leave the floor after an episode of tachycardia and tachypneic followed by bradycardia. The patients foley was replaced and began to drain dark bloody urine with clots. It flushed easily, confirming its placement in the bladder. Urology was consulted and felt that a clot from his previous procedure may have been dislodged and that the bladder should be hand irrigated. A renal ultrasound did not reveal hydronephrosis. The following day, the patient's labs continued to be consistent with ARDS/[**Doctor Last Name **] and he was placed on ARDSnet protocol ventilation. He had some difficulty tolerating the vent settings, and had to have an increase in his tidal volume transiently. A bronchoscopy was done which revealed bloody fluid in the left lower lobe. The patient had difficulty maintaining his oxygen saturation and appeared dyssynchronous with the vent, even with the higher tidal volumes. It was decided that it order to better ventilate his lungs, he would require the lower tidal volumes and he was paralyzed. During this time, the patient also began to be hypotensive and required pressors. Over the course of the evening, he became increasing acidotic requiring bicarbonate. His conditioned continued to deteriorate and he became anuric. He became asystolic around 710am and it was felt hat CPR was not medically indicated. As the family was [**Name (NI) 653**], ACLS was initiated as the decision to stop resuscitation was made. Resuscitation was then stopped and the patient was taken off the ventilator. Time of death was 715 am. Medications on Admission: Medications on transfer: insulin sliding scale methylpred. 40 mg q12hr IV furosemide 40 mg IV PRN propofol drip pantoprazole 40 mg IV metochlopramide 10 IV q6hr digoxin 0.125 IV calcium carbonate 500 TID ceftaz 2g iv q8hr to finish on [**10-12**] TPN Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "560.1", "434.91", "250.00", "287.49", "530.85", "276.2", "486", "185", "785.50", "E878.8", "518.51", "427.31", "041.7", "E934.2", "311", "244.9", "285.9", "553.3", "584.9", "205.00", "788.5", "401.9", "530.81", "372.30" ]

icd9cm

[ [ [] ] ]

[ "33.24", "41.31", "38.91", "96.71", "99.15", "38.97" ]

icd9pcs

[ [ [] ] ]

9901, 9910

7379, 9567

300, 405

9961, 9970

3896, 7356

10026, 10162

2895, 2935

9869, 9878

9931, 9940

9593, 9593

9994, 10003

2950, 3877

241, 262

433, 2684

9618, 9846

2706, 2805

2821, 2879

32,061

118,014

43245

Discharge summary

report

Admission Date: [**2121-4-11**] Discharge Date: [**2121-4-17**] Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 7333**] Chief Complaint: weakness and fatigue for three days Major Surgical or Invasive Procedure: [**Company 1543**] Pacemaker insertion History of Present Illness: Mrs. [**Known lastname 93123**] is a [**Age over 90 **] yo female with a history of COPD, HTN, and HL who presented to the ED complaining of weakness and fatigue for three days. She describes going to sleep on Tuesday night and not being able to get up off of her sofa. She called her lifeline who helped her take her meds and get her to bed. Then again Wednesday she felt weak all day. By Friday she felt so weak, fatigued, and malaised that she decided to come to the ED. . In the ER, vitals were: 98.7 96 176/82 (SBP as high as 200 in ED) 16 97% RA. EKG revealed RBBB and 2nd degree heart block with 3:1 conduction and heart rate of 33 (Baseline normal PR, with RBBB and LAFB). She was given atropine x 1. She was sent to the EP lab for urgent paceaker placement. She is now status post pacemaker placement [**2121-4-11**] and transferred to CCU for further management of her hypertensive urgency. . On evaluation on the floor, the patient denied any symptoms and felt relatively well. Cardiac review of systems was notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, weight gain, palpitations, syncope or presyncope. . . REVIEW OF SYSTEMS: She denies any prior history of stroke, TIA, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: - multiple pulmonary nodules- slow growing. Thought to be non-malignant per pulmonary note of 4/[**2119**]. - endometrial cancer, s/p TAH [**2097**] - spinal stenosis - hypertension - emphysema - deviated septum - hemorrhoids (recent colonoscopy [**11-9**])- - s/p left shoulder replacement - s/p right hip replacement - right rotator cuff tear - hyperlipidemia Social History: Social history is notable for the fact that she is widowed and lives alone in a community in [**Location (un) **]. Her daughter lives nearby and is very involved in her care. She was a former SSI claims representative and is currently retired. She does not drink alcohol, but reports that she smoked 5 cigarettes a day for 61 years. She quit at age 67. There are no known exposures to asbestos or other inhaled toxins. She has a HHA 7 days a week for 3.5 hrs per day to bathe her. Walks with a walker in am then without walker? She takes her pills independently. She is served lunch and dinner 5 days a week and then has brunch on Sunday. Dtr does [**Name2 (NI) 14994**], shopping. Widowed x 19 years. Family History: heart and thyroid problems in her mother. [**Name (NI) **] father had prostate cancer. Physical Exam: PHYSICAL EXAMINATION: VS: T= 98.6 BP= 140-160/70-80's HR=70's-80's SR RR=16-20 O2sat=96% RA weight 57.5 GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with flat JVPs. CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. [**Month (only) **] BS, no crackles appreciated, occ exp wheeze, strong cough with wite to clear sputum. ABDOMEN: Soft, NTND. NABS. Obese, well-healed vertical abdominal scar from endometrial CA EXTREMITIES: No c/c/e. +2 DP bil LEs. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . Pertinent Results: [**2121-4-16**] 06:00AM BLOOD WBC-8.0 RBC-4.43 Hgb-13.6 Hct-41.5 MCV-94 MCH-30.8 MCHC-32.8 RDW-13.6 Plt Ct-219 [**2121-4-16**] 06:00AM BLOOD Glucose-115* UreaN-36* Creat-0.8 Na-144 K-4.0 Cl-104 HCO3-32 AnGap-12 [**2121-4-12**] 04:41AM BLOOD CK(CPK)-81 [**2121-4-11**] 09:58PM BLOOD CK(CPK)-63 [**2121-4-11**] 01:05PM BLOOD CK(CPK)-73 [**2121-4-12**] 04:41AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2121-4-11**] 09:58PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2121-4-11**] 01:05PM BLOOD cTropnT-0.02* Micro: Legionella Urinary Antigen (Final [**2121-4-15**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. BC x2 [**4-16**]: NGTD Urine cx negative Sputum cx contaminated. [**2121-4-14**] 05:22PM URINE Blood-SM Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2121-4-14**] 05:22PM URINE RBC-[**6-12**]* WBC-[**3-7**] Bacteri-FEW Yeast-NONE Epi-0 . CXR [**2121-4-14**]: SINGLE SEMI-UPRIGHT PORTABLE VIEW OF THE CHEST: Lung volumes are low, there is new obscuration of the right hemidiaphragm which is concerning for infectious airspace consolidation. There are numerous pulmonary nodules from metastatic disease throughout the chest, in the right hilar, and left upper and lower lobes. Hilar adenopathy is better apreciated on recent CT. There is moderate right pleural effusion and new bibasilar atelectasis. The aortic arch is heavily calcified. Sclerotic foci seen in the upper thoracic vertebral bodies on prior CT are not as well appreciated. Left chest pacing device terminates with two intact leads in unchanged positions. IMPRESSION: 1. New right pleural effusion, and right greater than left atelectasis. 2. Extensive findings of metastatic disease as on prior radiograph. Brief Hospital Course: Mrs. [**Known lastname 93123**] is a [**Age over 90 **] yo female with a history of COPD, HTN, and HL who presented to the ED complaining of weakness found to have 2nd degree heart block with 3:1 conduction on EKG. She is now status post pacemaker placement [**2121-4-11**]. P/ #1 Second degree Heart Block and Bradycardia: S/P [**Company 1543**] sensia dual chamber (VDD lead) pacer via left cephalic vein. No complications. Mild ecchymosis and tenderness at site, stable. Has completed her 3 day course of prophylactic antibiotics. See Page 1 for care of pacemaker site and activity restrictions. She will follow up with the device clinic in 1 week and Dr. [**Last Name (STitle) **] in 6 weeks. #2 Hypertensive urgency: Baseline SBP 140's per primary care. SBP here has been 140-200 during pacemaker placement and throughout rest of hospital stay. Possible etiologies have included use of ibuprofen, use of albuterol for COPD exacerbation and anxiety. Amlodipine, HCTZ, and Hydralazine was added to her regimen and her Metoprolol was increased to 200mg. Benazepril was d/ced as non formulary here. Noted that BP in left arm is 20-30 points lower than in right arm. No headache or dizziness. Goal of SBP should be 140 to avoid watershed injury. BP needs to be followed closely to avoid SBP < 140. Her medicines can hopefully be tapered in the next 2 weeks. #3 Hypoxia: Thought [**2-4**] COPD exacerbation with loud wheezes, productive cough and no leukocytosis. Occ low grade temps noted that would quickly resolve. Azithromycin and Prednisone was started on [**4-15**] for total of 5 day course. Her Advair and Spiriva was continued, Albuterol nebs prn for wheezing. On day of discharge, she had no O2 requirement or fever. #4 Hyperlipidemia: statin was continued at home dose. cont statin #5 Communication: with daughter (currently in [**Country 14635**]) and [**First Name9 (NamePattern2) 93161**] [**Doctor First Name 3692**] [**Telephone/Fax (1) 93162**] Medications on Admission: MEDICATIONS: 1. Ipratropium-Albuterol 1-2 puffs Q6H prn. 2. Senna 8.6 mg [**Hospital1 **] PRN constipation. 3. Docusate Sodium 100 mg [**Hospital1 **]. 4. Omeprazole 20 mg daily. 5. Aspirin 81 mg daily. 6. Fluticasone-Salmeterol 250-50 [**Hospital1 **]. 7. Simvastatin 20 mg daily. 8. Benazepril 20 mg [**Hospital1 **]. 9. Alendronate 70 mg QWED. 10. Acetaminophen 650 mg QHS. 11. Ibuprofen 400 mg daily. 12. Tiotropium Bromide 18 mcg inh daily. 13. Metoprolol succinate 75 mg daily Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: every Wednesday. Pt needs to be upright and NPO for one hour after taking. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO at bedtime. 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for pain. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation every six (6) hours as needed for cough, SOB, wheeze. 11. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day: Hold SBP < 100. 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold SBP < 100. 13. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Stop on [**4-19**]. 14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days: Stop after [**4-19**]. 15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily): Hold SBP < 120. 16. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): Hold SBP < 120. 17. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous 15 minutes before meals: Stop after prednisone is finished. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Hypertensive Urgency Heart Block/Bradycardia . Secondary Diagnosis: COPD Gait Disorder Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were weak and tired and your heart rate was 33. You received a pacemaker and there were no complications. You will need to refrain from raising your left arm over your head and lifting more than 5 pounds for 6 weeks. You can remove the pacer dressing tomorrow and keep the steristrips in place. You may take a shower for the next week but please do not swim or take a bath. No dressing or ointments on the pacer site. You will be seen in the device clinic on [**4-28**] to check the pacer site and pacer function. Your blood pressure has been very high while you are here. We have increased your BP medicines and have added new ones. WE hope that you will be able to wean off these medicines over the next few weeks. . Medication changes: 1. Stop taking Combivent, Ibuprofen and Benezepril 2. Start Albuterol nebulizers for wheezing or severe cough 3. Increase Metoprolol to 200 mg 4. Start Lisinopril, hydrochlorothiazide, Amlodipine, and Hydralazine to lower your blood pressure. Your goal BP is 130-140 over 80's. 5. Start Azithromycin and Prednisone to treat the COPD exacerbation you developed here in the hospital. You will need 3 more days of this, then discontinue. Followup Instructions: Electrophysiology: DEVICE CLINIC, [**Hospital Ward Name 23**] 7, [**Hospital Ward Name 516**], [**Hospital1 18**]. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-4-28**] 1:00 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital Ward Name 23**] 7, [**Hospital Ward Name 516**], [**Hospital1 18**] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**5-22**] at 9:00 am. . Neurology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 1690**] Date/time: [**5-30**] at 8:00 am . Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 60246**] Date/Time: Please make an appt to see when you get out of rehabilitation. Completed by:[**2121-4-17**]

[ "491.21", "719.7", "272.4", "721.0", "276.0", "401.9", "V43.64", "V43.61", "518.89", "737.10", "356.9", "426.13" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

10087, 10157

5763, 7733

251, 292

10303, 10303

3721, 5740

11688, 12441

2838, 2927

8267, 10064

10178, 10225

7759, 8244

10486, 11209

2942, 2942

2964, 3702

1523, 1711

11229, 11665

176, 213

320, 1504

10246, 10282

10318, 10462

1733, 2097

2113, 2822

77,873

143,428

47699+59023

Discharge summary

report+addendum

Admission Date: [**2157-5-19**] Discharge Date: [**2157-6-3**] Date of Birth: [**2091-4-30**] Sex: M Service: CARDIOTHORACIC Allergies: Nicobid / Lovastatin / Pravachol / Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2157-5-19**] Cardiac catheterization [**2157-5-24**] Coronary artery coronary artery bypass graft x4 left internal mammary artery to the left anterior descending artery and saphenous vein graft to the diagonal obtuse marginal and posterior descending artery History of Present Illness: 66 year old male who presented to primary care physician office for routine office visit today and reported chest pains which have been ongoing for one month and progressively worsening. He reported 4 "bad episodes" requiring nitrospray. He also reports ICD firing once. He acknowledges dyspnea and lower extremity edema. He was transferred for cardiac evaluation and underwent cardiac catheterization. Past Medical History: Coronary artery disease s/p stents Myocardial infarction Hypertension Dyslipidemia Diabetes mellitus type 2 Atrial fibrillation ICD- Biotronik Lumos single-chamber ICD Obstructive sleep apnea (uses CPAP) COPD GERD Claudication Spinal stenosis Social History: Lives with:wife Occupation:from owning a convenient store in [**Location (un) 86**] Tobacco:Quit smoking 20 years ago ETOH:drinks 3 alcoholic beverages daily. Family History: Brother passed away from MI age 64 Sister alive with CAD, age 74 Physical Exam: Pulse:66 Resp:13 O2 sat:97/RA B/P Right:140/68 Left:136/74 Height:5'8" Weight:224 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] L infraclavicular AICD Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Appy incision Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right:cath site Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [**2157-5-19**] Cath: 1. Coronary angiography in this right-dominant system demonstrated three-vessel disease. The LMCA had distal eccentric 70-80% stenosis. The LAD had mild diffuse disease. The LCx had 60-70% origin stenosis. The RCA had proximal 80-90% and mid 60% in-stent stenosis. 2. Limited resting hemodynamics revealed systemic arterial normotension. The rhythm was paced with frequent VPCs. [**2157-5-20**] Carotid U/S: Bilateral 40-59% carotid stenosis [**2157-5-24**] Echo: PRE-CPB: The left atrium is markedly dilated. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35-39 %). There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There are filamentous strands on the ventricular side of the aortic leaflets consistent with Lambl's excresences (normal variant). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The leaflets appear mildly tethered. Mild to moderate ([**1-23**]+) central mitral regurgitation is seen. POST-CPB: LV systolic function remains impaired, estimated EF=35-40% with patient on Epi, Norepi, and phenylephrine infusions. RV systolic function appears mildly improved from pre-bypass. Valvular function remains unchanged. There is no evidence of aortic dissection. Dr. [**Last Name (STitle) **] was notified in person of the results at time of study. Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was a 66 year old mane complaining of worsening chest pain. Upon transfer, he underwent cardiac catheterization which revealed left main and three vessel coronary artery disease. Cardiac surgery was consulted and he underwent usual pre-operative work-up. He underwent preoperative workup, which also included carotid ultrasound and pulmonary function test. Echocardiogram showed a good EF with normal valvular function. Electrophysiology was consulted for ICD management peri-operatively. The patient was brought to the operating room on [**2157-5-24**] and underwent a coronary artery bypass graft x 4 with Dr. [**First Name (STitle) **]. Please see operative report for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was transferred to the floor for the remainder of his stay. Physical therapy worked with him on strength and mobility. On [**5-28**] he developed a distended abdomen with question of ileus on abdmominal film. He had nasogastric tube placed and was started on intravenous hydration. Surgery was consulted for evaluation due to worsening abdominal film and continued distention. After gastric decompression and multiple enemas he improved. His nasogastric tube was removed [**5-31**] and he was restarted on liquid diet with serial abdominal exams. At the time of discharge his ileus was resolved, he was tolerating a reg diet and passing stool. He was discharged to home on POD#10. All instructions and appointments were advised. Medications on Admission: AMLODIPINE 10 mg once a day ATORVASTATIN 80 mg once a day EZETIMIBE 10 mg once a day ISOSORBIDE MONONITRATE 30 mg Extended Release 24 hr once a day LISINOPRIL 40 mg once a day NITROGLYCERIN 0.4 mg/dose Spray 1 spray Q 5 minutes x3 as needed for chest pain SITAGLIPTIN 100 mg once a day SOTALOL 120 mg twice a day ASPIRIN 325 mg once a day MAGNESIUM CHLORIDE 64 mg once a day MULTIVITAMIN once a day NIACINAMIDE 500 mg once a day OMEGA-3 FATTY ACIDS-VITAMIN E 3,000 mg once a day Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. multivitamin Oral 8. niacinamide 500 mg Tablet Sig: One (1) Tablet PO once a day. 9. omega-3 fatty acids-vitamin E Oral 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft x 4 Past medical history: Hypertension Dyslipidemia Diabetes mellitus type 2 Atrial fibrillation Obstructive sleep apnea (uses CPAP) Chronic obstructive pulmonary disease Gastric esophageal reflux disease Claudication Spinal stenosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg - Left - healing well, no erythema or drainage. Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**First Name (STitle) **] on [**6-27**] at 1:15 pm - [**Telephone/Fax (1) 170**] Cardiologist: Dr [**Last Name (STitle) **] on [**7-4**] at 10 am [**Telephone/Fax (1) 62**] Wound check in the cardiac surgery office [**Telephone/Fax (1) 170**] on [**2157-6-8**] 10:15am Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 17918**] in [**4-26**] weeks [**Telephone/Fax (1) 17919**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2157-6-3**] Name: [**Known lastname **],[**Known firstname 63**] P Unit No: [**Numeric Identifier 16181**] Admission Date: [**2157-5-19**] Discharge Date: [**2157-6-3**] Date of Birth: [**2091-4-30**] Sex: M Service: CARDIOTHORACIC Allergies: Nicobid / Lovastatin / Pravachol / Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 265**] Addendum: Mr. [**Known lastname **] was sent home with 7 days of lasix 20mg daily and potassium supplement. Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2157-6-3**]

[ "V17.3", "560.1", "V15.82", "496", "E878.2", "414.01", "V45.82", "724.00", "272.4", "411.1", "412", "250.00", "327.23", "530.81", "E878.1", "997.4", "V45.02", "401.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.56", "38.93", "36.15", "36.13", "37.22" ]

icd9pcs

[ [ [] ] ]

10075, 10248

4008, 5830

378, 640

7694, 7916

2295, 3985

8756, 10052

1531, 1597

6359, 7282

7381, 7442

5856, 6336

7940, 8733

1612, 2276

328, 340

668, 1073

7464, 7673

1355, 1515

4,521

149,582

4884

Discharge summary

report

Admission Date: [**2103-11-4**] Discharge Date: [**2103-11-7**] Date of Birth: [**2025-11-26**] Sex: M Service: VSU HISTORY OF PRESENT ILLNESS: This is a 77 year old gentleman with peripheral vascular disease who underwent a right below knee amputation on [**2100-7-15**]. The patient's postoperative course was significant for multiple infections of the stump and he returned to the clinic on multiple occasionswith swelling and erythema of this site with several large gangrenous ulcers of the stump and at the knee despite multiple courses of IV antibiotics. He had developed infection with resistent organisms due to prolonged IV antibiotic therapy. The decision was made given his long course of infections to proceed with a right above knee amputation. Of note, the patient had been admitted about a month prior and has had an increase in the drainage from the stump site since then, with exposed bone. He had refused AKA previously but accepted due to steadily advancing erythema and the risk of involvement of the AK amputation site and eventual systemic sepsis and death without amputation. He also refused any intervention for his cardiac disease. PAST MEDICAL HISTORY: Diabetes mellitus, end stage renal disease on hemodialysis, gastroesophageal reflux disease, peripheral vascular disease, atrial fibrillation, congestive heart failure with an ejection fraction of 40 percent, severe mitral regurgitation with 3 plus mitral regurgitation on recent echocardiogram, aortic stenosis with a valve area of .7 to .8, depression, hypothyroidism and history of asbestos exposure. ALLERGIES: Patient has no known drug allergies. MEDICATIONS ON ADMISSION: Calcium, Sevelamer 800 mg by mouth 3 times daily, amiodarone 400 mg once daily, aspirin 81 mg by mouth daily, pyridoxine 150 mg by mouth daily, Zoloft 75 mg by mouth daily, Levoxyl 150 mcg by mouth daily, ritodrine 2.5 mg by mouth at dialysis, Prilosec 20 mg by mouth daily, NPH 12 units subcutaneously in the morning, 6 units subcutaneously in the evening, Nephrocaps and Epogen at dialysis. INITIAL PHYSICAL EXAMINATION: He was afebrile with normal vital signs and in no acute distress. His heart was irregularly irregular. His chest was coarse with crackles. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. His right stump had multiple areas of necrotic tissue with exposed bone. There was erythema extending to the level of the mid knee. The left stump had a well healed wound. He had palpable femoral pulses bilaterally. INITIAL LABORATORY DATA: White blood cell count 11.3, hematocrit 35.6, platelet count 283, PT 15.5, PTT 31.2, INR 1.5, potassium about 3.0. BRIEF HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the Vascular Service. The Renal Service was consulted given his hemodialysis needs and it was felt on hospital day number two that he would require additional dialysis preoperatively. The patient had received broad spectrum antibiotics. He was started on linezolid, meropenem and Flagyl to cover previous VRE and multiresistant Acinetobacter which had grown from his wound. He was dialyzed preoperatively and was taken to the operating room on [**2103-11-5**] for conversion of a right below knee amputation to an above knee amputation. This was done under general endotracheal anesthesia. He received 400 cc of Crystalloid in the procedure and tolerated it well. However, he was transferred to the recovery room requiring some Neo-Synephrine to maintain the systolic blood pressure in the 90s. He remained intubated immediately postoperatively and was extubated in the recovery room. However, within five minutes of extubation the patient failed to initiate respiratory effort and had additional drop in his blood pressure and oxygen saturation. He was emergently reintubated and was at one point weaned off his Neo- Synephrine. His CK, MB and troponins were checked and of note his CKs were in the 20 to 30 range with a troponin of .3 going up to .5 Cardiology was consulted and recommended consideration of a Swan-Ganz catheter to further guide his volume status. He dialyzed that afternoon and over the course of the night because more hypotensive with drop in his blood pressure to the 70s. He also did spike a temperature up to 39.3 degrees Celsius. He was having Swan-Ganz catheter placed during the night which revealed high filling pressures and a wedge of 33. However, he did have a low cardiac index of 1.3 with an SVR of 1800. He remained on antibiotics and on ventilator support. He was initially started on dobutamine with attempts to optimize his cardiac index. However, he did not tolerate this well, became tachycardic with low blood pressure and vasopressin was added to the regimen. However, after reconsultation with cardiology the decision was made given the patient's known 3 plus mitral regurgitation and aortic stenosis that an alpha agonist would be a more appropriate choice. The change was made. However, he became more and more acidotic over the course of postoperative day number two with the lactate rising to 23. Although his wound was clean with no erythema it was opened to be certain this was not a source of possible infection. There was no purulence and the tissue appeared well perfused. His hematocrit remained in the mid 30s. He continued on pressor support and received several liters of fluid. He also received fresh frozen plasma for coagulopathy and had evidence of shock liver. Around 2 o'clock he became again hypotensive and within 20 minutes went into pulseless electrical activity. Cardiopulmonary resuscitation and ACLS protocol were instituted and he expired shortly thereafter. We were still awaiting additional culture results and concern was that he succumbed to a combination of cardiogenic and septic shock. The family was notified and they declined a postmortem examination. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**] Dictated By:[**Last Name (NamePattern1) 13030**] MEDQUIST36 D: [**2103-11-7**] 16:34:43 T: [**2103-11-7**] 17:51:00 Job#: [**Job Number 20388**]

[ "707.12", "785.51", "250.40", "785.52", "570", "995.92", "398.91", "583.81", "396.2", "585", "427.31", "244.9", "038.9", "440.24", "730.26" ]

icd9cm

[ [ [] ] ]

[ "96.04", "00.14", "99.60", "96.71", "89.64", "84.17", "39.95", "99.07" ]

icd9pcs

[ [ [] ] ]

2715, 6189

1689, 2091

2114, 2691

166, 1184

1207, 1662

25,546

163,224

19431

Discharge summary

report

Admission Date: [**2150-12-24**] Discharge Date: [**2150-12-29**] Date of Birth: [**2074-10-2**] Sex: M Service: SICU/[**Company 191**] MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old male with a history of coronary artery disease status post coronary artery bypass grafting, hypercholesterolemia, and congestive heart failure, admitted from an outside hospital on [**12-24**] with possible gastrointestinal bleed secondary to sphincterotomy. The patient was at [**Hospital3 **] between [**12-21**] and [**12-24**] for fatigue, shortness of breath, anorexia, and congestive heart failure. He was noted to have a hematocrit drop from 32 to 26 with melena. The patient had undergone ERCP with sphincterotomy on [**12-15**] at which time a ................... bile duct stone was removed. Upon transfer to [**Hospital6 256**], the patient underwent EGD with ERCP. A vessel was found at the papillotomy site that despite multiple injections with epinephrine, hemostasis could not be achieved. The patient was admitted to the Intensive Care Unit for maximal supportive care and close monitoring of hemodynamic and laboratory parameters. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass grafting (? [**2124**]). 2. Congestive heart failure (treated with diuretics since [**2149**]). Last known ejection fraction in [**2143**] was 50%. 3. Gastroesophageal reflux disease. 4. Benign prostatic hypertrophy. 5. Hypercholesterolemia. 6. History of celiac screw. 7. Status post cholecystectomy in [**2150-11-26**] complicated by retained stone in the common bile duct. On [**12-15**], the patient underwent ERCP at [**Hospital6 1760**] with stone extraction and sphincterotomy. 8. Status post right hip replacement. 9. History of atrial flutter. 10. History of chronic sinusitis. 11. Hernia repair. MEDICATIONS ON TRANSFER: Protonix 40 mg IV t.i.d., Lopressor 50 mg p.o. b.i.d., Proscar 5 mg q.d., Flomax 0.4 mg q.d., Nitrostat 0.4 mg q.d., Tylenol 650 mg p.o. q.i.d., Milk of Magnesia p.r.n., Lasix 20 IV x 1. ALLERGIES: PENICILLIN, CHOCOLATE, NUTS, WHEAT, GLUTEN, DUST, POLLEN. SOCIAL HISTORY: The patient is an ex-smoker and quit approximately four years ago. He lives with his wife with whom he has been married for 46 years. He is a retired salesman in the oil business. He drinks approximately one gallon of alcohol over ten days. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 96.3??????, pulse 131, blood pressure 100/66, respirations 22, oxygen saturation 100% on 4 L nasal cannula. General: The patient was a sleepy, elderly male, sedated following ERCP. He was arousable and opened eyes to voice. He was in no apparent distress. HEENT: Dry mucous membranes. Pupils equal, round and reactive to light and accommodation. Neck: Jugular venous distention at 8 cm. Cardiovascular: Normal S1 and S2. Regular rhythm. Tachycardiac. There was a 3 out of 6 holosystolic murmur at the left upper sternal border. Pulmonary: Clear to auscultation anteriorly and laterally with poor inspiratory effort and questionable mild bibasilar rales. Abdomen: He had hyperactive bowel sounds. Soft, nontender, nondistended. Extremities: No lower extremity edema. Warm, 2+ dorsalis pedis pulses bilaterally. He had old healed vein graft scars. The right forearm was with a strong brachial arterial pulse and well-healed scar. LABORATORY DATA: On admission upon transfer from the outside hospital, hematocrit was 26.8, platelet count 128; LFTs were elevated with an ALT of 51, AST of 97, alkaline phosphatase 281; bicarb 26, creatinine 1.9; PT 12.4, INR 1.0, PTT 31.9; ABG on 4 L oxygen by nasal cannula revealed a pH of 7.35, pCO2 44, pO2 110. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient was transferred from an outside hospital with a gastrointestinal bleed and a hematocrit drop from 32 to 27. The etiology of the gastrointestinal bleed is the bleeding vessel found at the papillotomy site viewed via ERCP. The patient underwent ERCP but attempts at controlling the bleeding with epinephrine were unsuccessful. The patient the underwent arteriogram with gelform embolization by Interventional Radiology which was able to control the bleeding. The patient required intravenous fluid resuscitation, as well as 2 U of peripheral red blood cells. Following arteriogram and embolization, the patient's systolic blood pressure was in the 80s, and the patient was intubated and started on Neo-Synephrine drip for hypotension. The patient was extubated the following day, and his hematocrit remained stable in the low 30s throughout the remainder of the hospitalization. The patient continued to have melanotic stools; however, GI consult felt that it would take several days to resolve given the size of the bleed. The patient was initially started on clears, which he tolerated well, and his diet was advanced as tolerated. The patient remained hemodynamically stable through the remainder of the hospitalization. 2. Pulmonary: The patient was intubated upon transfer to the SICU while he was hemodynamically stabilized. He was extubated the following day. Chest x-ray while intubated revealed a possible left lower lobe infiltrate. Sputum culture obtained at that time grew gram-positive cocci in pairs and clusters. The patient was treated with Vancomycin intravenous fluids empirically. Vancomycin intravenous was stopped four days later when the sputum sample revealed growth of bacterium most consistent with oral flora. A repeat chest x-ray was performed which was believed to be most consistent with atypical congestive heart failure. The patient was not continued on any antibiotics since the patient never spiked a fever nor did he develop a white blood cell count. The patient also denied any shortness of breath. 3. Cardiovascular: The patient has a history of coronary artery disease and is status post coronary artery bypass grafting. The patient was slowly restarted on Metoprolol following hemodynamic stabilization; however, both Aspirin and Lipitor were held with plans to possibly restart these at a later date. Aspirin was held due to concern for recent gastrointestinal bleed. Lipitor was held due to the patient's elevated liver enzymes. DISPOSITION: A Physical Therapy consult was obtained to assist with disposition. Physical Therapy felt that the patient required rehabilitation placement prior to discharge to home. The patient will be discharged to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. DISCHARGE STATUS: The patient is discharged to rehabilitation at [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. CONDITION ON DISCHARGE: Hematocrit stable, ambulating with assistance, hemodynamically stable. DISCHARGE DIAGNOSIS: 1. Gastrointestinal bleed/blood loss anemia secondary to bleeding at the sphincterotomy site. 2. Status post esophagogastroduodenoscopy. 3. Status post arteriogram with gelform embolization. 4. Coronary artery disease status post coronary artery bypass grafting. 5. Congestive heart failure. 6. Gastroesophageal reflux disease. 7. Benign prostatic hypertrophy. 8. Hypercholesterolemia. 9. Celiac sprue 10. Atrial Flutter DISCHARGE MEDICATIONS: Pantoprazole 40 mg p.o. q.24 hours, Tamsulosin 0.4 mg p.o. q.h.s., ............... 5 mg p.o. q.d., Lasix 40 mg p.o. q.d., Spironolactone 25 mg p.o. q.d., Metoprolol 25 mg p.o. b.i.d. Before admission to the outside hospital, the patient was also on Aspirin, Lipitor, and Procrit. All of these medications were held with the plan to possibly restart them at a future date. FOLLOW-UP: The patient is discharged to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. He was asked to follow-up with his primary care physician upon discharge from rehabilitation. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**Name8 (MD) 52816**] MEDQUIST36 D: [**2150-12-28**] 15:36 T: [**2150-12-28**] 15:42 JOB#: [**Job Number 52817**]

[ "272.0", "998.2", "V45.81", "428.0", "998.11", "530.81", "285.1", "427.32", "458.29" ]

icd9cm

[ [ [] ] ]

[ "44.43", "88.47", "38.91", "99.04", "45.13", "44.44" ]

icd9pcs

[ [ [] ] ]

2453, 2471

7353, 8194

6898, 7329

3825, 6780

2494, 3807

195, 1179

1915, 2174

1202, 1889

2191, 2436

6805, 6877

29,769

179,221

2791

Discharge summary

report

Admission Date: [**2178-2-25**] Discharge Date: [**2178-4-15**] Date of Birth: [**2122-9-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: s/p arrest Major Surgical or Invasive Procedure: Intubation Central venous line insertion History of Present Illness: 54 yo M without any known PMH was brought in by EMS for respiratory distress after being notified by neighbor. History was consistent with having been down for a considerable time before being seen by EMS. He was brought in on BiPAP ventilation, sats in low 90s and unresponsive. He had a narrow complex tachycardia in the 140s. He had a difficult intubation with 3 attempts complicated by vomiting and witnessed aspiration. After intubation, O2 sat noted to be 90%, pt developed PEA arrest. He had several rounds of epi/atropine, CPR with subsequent wide complex tachycardia treated with DCCV and amiodarone bolus. He was started on amiodarone drip, levophed drip, received 3L NS for hypotension. He had a R femoral TLC placed. He was started on cooling protocol. Head CT unremarkable, CXR performed. Received ceftriaxone, clindamycin. . On arrival, he was in normal sinus rhythm at 78 bpm, BP 113/68, pt unresponsive, with the team unable to obtain any further direct or supporting information. Past Medical History: IDDM CAD s/p MI [**8-16**] s/p DES to D1 and prox LAD Hypertension Hyperlipidemia Schizophrenia Social History: Previous smoking history, unclear how long Family History: non-contributory, was not able to be obtained Physical Exam: Initial exam: VS: T 35 C on cooling, BP 113/68, HR 78, RR 26, TV 500 on 100% FIO2, PEEP 5. Gen: middle aged male intubated, unresponsive with ocassional myoclonic movements. HEENT: pupils 3mm b/l, unresponsive. Neck: Supple, JVP not visualized in flat position CV: RRR nl s1, s2, no murmur, heart sounds obscured by respirator sounds. Chest: breath sound b/l with loud wet upper airway sounds, frothy sputum in respirator tube. Abd: Obese, soft, no HSM Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: tr DP pulses b/l, cool skin. Pertinent Results: [**2178-2-25**] 06:35AM BLOOD WBC-16.3* RBC-5.56 Hgb-16.8 Hct-50.9 MCV-92 MCH-30.2 MCHC-32.9 RDW-13.0 Plt Ct-541* [**2178-2-28**] 05:01AM BLOOD WBC-11.2* RBC-3.10* Hgb-9.5* Hct-27.8* MCV-90 MCH-30.6 MCHC-34.1 RDW-14.0 Plt Ct-243 [**2178-2-25**] 06:35AM BLOOD PT-12.0 PTT-26.4 INR(PT)-1.0 [**2178-2-26**] 05:42AM BLOOD PT-14.4* PTT-39.1* INR(PT)-1.3* [**2178-2-25**] 06:35AM BLOOD Glucose-322* UreaN-23* Creat-1.5* Na-138 K-5.4* Cl-101 HCO3-13* AnGap-29* [**2178-2-25**] 09:33PM BLOOD Glucose-222* UreaN-24* Creat-0.7 Na-137 K-4.1 Cl-108 HCO3-18* AnGap-15 [**2178-2-28**] 05:01AM BLOOD Glucose-166* UreaN-32* Creat-0.9 Na-141 K-4.0 Cl-109* HCO3-24 AnGap-12 [**2178-2-25**] 06:35AM BLOOD ALT-84* AST-84* LD(LDH)-574* CK(CPK)-442* AlkPhos-189* Amylase-39 TotBili-1.0 [**2178-2-25**] 01:23PM BLOOD CK(CPK)-644* [**2178-2-26**] 05:42AM BLOOD ALT-63* AST-49* LD(LDH)-255* CK(CPK)-452* AlkPhos-94 Amylase-38 TotBili-1.6* [**2178-2-25**] 06:35AM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-1627* [**2178-2-25**] 01:23PM BLOOD CK-MB-18* MB Indx-2.8 cTropnT-0.14* [**2178-2-26**] 05:42AM BLOOD CK-MB-20* MB Indx-4.4 cTropnT-0.08* [**2178-2-26**] 05:42AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.2 Mg-2.0 Cholest-85 [**2178-2-26**] 05:42AM BLOOD Triglyc-45 HDL-54 CHOL/HD-1.6 LDLcalc-22 LDLmeas-<50 [**2178-2-26**] 05:42AM BLOOD %HbA1c-7.8* [**2178-2-28**] 05:01AM BLOOD Valproa-74 [**2178-2-25**] 06:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2178-2-25**] 06:40AM BLOOD Glucose-280* Lactate-4.4* Na-138 K-3.8 Cl-100 calHCO3-20* [**2178-2-28**] 08:50AM BLOOD Lactate-1.0 CT Head: 1. No acute intracranial hemorrhage. 2. Mild sinomucosal disease in the ethmoid sinus. 3. Opacification of some of the left mastoid air cells; correlate clinically. CXR: Heart size is mildly enlarged given technique and mediastinal and hilar contours are normal. There is diffuse airspace opacification. An ET tube is in place with its tip located 4 cm from the carina. An NG tube is seen with its tip projecting over the gastric bubble; the side-hole port is not clearly identified. There is no significant pleural effusion, pneumothorax, or obvious osseous abnormality. IMPRESSION: 1. Standard position of ET tube and likely of the NG tube, although side-hole port is not clearly demonstrated below the diaphragm. 2. Diffuse airspace opacification likely represents pulmonary edema, in this clinical context. EEG: This telemetry showed a continued burst suppression record. There were frequent truncal myoclonic jerks evident on video. These correlated with movement artifact on EEG. Although there were sharp waves as part of the bursts during the burst suppression record, sharp activity was not particularly rhythmic nor suggestive of ongoing electrographic seizures or status epilepticus. Overall, the recording is most suggestive of anoxic myoclonus and an extremely severe encephalopathy. Brief Hospital Course: # s/p PEA arrest: The patient was successfully revived after his PEA arrest. The causative [**Doctor Last Name 360**] for his arrest was thought to be hypoxia in the setting of fluid overload. His hemodynamics improved with diuresis and positive pressure ventilation. . # Post anoxic myoclonus/ Status epilepticus: The patient underwent arctic sun cooling protocol. EEG consistent with seizure activity. Patient was loaded with valproate and phenytoin which were adjusted based on level. Repeat EEG showed disorganized function. Given his anoxic brain injury and non-convulsive status, his prognosis for meaningful recovery was very poor. He was appointed a guardian by the court. Prior to this the team was prepared to place PEG and trach, but delayed this given that the team was recommending to the guardian, once she could be appointed, that the patient should be made CMO. Ultimately, a PEG was not placed. He did not show any signs of responsiveness or meaningful indepedent motor or verbal activity during any part of the admission. . # Coronary Artery Disease: The patient was maintained on a regimen of aspirin 325, clopidogrel 75, lisinopril 10, atorvastatin 80, and metoprolol throughout his stay until he was CMO. . # Fevers: The patient had an observed aspiration in the context of his emergent intubation. He was initially treated with ten days of azithromycin, ceftriaxone, and clindamycin. He continued to have fevers. BCx showed GPC and he was started on vancomycin, which was discontinued when cultures failed to grow organisms. Sputum culture grew pseudomonas and enterococcus. He was given zosyn and cipro for VAP per with defervescence lasting > 10 days. However, he became febrile again. Repeat culture showed GNR by gram stain, thought likely to be a colonizer. CT of his sinuses showed miltifocal opacities possibly demonstrating acute sinusitis. Antibiotics were continued. He had significant eosinophilia later in the admission suggesting the possibility of a drug reaction but ultimately as this was not clearly creating clinical consequences antibiotics and other medications were continued until he was made CMO. . # Red eye: developed red eye on [**3-15**], began having serosanguinous drainage on [**3-16**]. optho saw patient and believe is chemosis. Recommended non-antibiotic ointment. This improved with diuresis. . # Pump: Earlier in the admission he became total body fluid overloaded and was diuresed with improvement. He was kept euvolemic for the remainder of his stay. . # DM: During much of his stay he was strikingly insulin resistant. He was managed with ISS and glargine. . # Proph: PPI, bowel regimen, pneumoboots. dc'd sc heparin for elevated PTT and oozing from injection sites. . # Goals of care and code status: Patient was initially full code. After guardian was appointed, it was ultimately made comfort measures only after a court order to appoint a guardian and allow DNR/CMO late in the day on the [**10-14**]. On the 6th of [**Month (only) 116**], after consultation with the guardian, he was extubated, most medications were discontinued and he was kept on a morphine drip for respiratory comfort. He was breathing without apparent distress and ultimately died while remaining apparently comfortable; at 10:55 AM on [**4-15**] he was pronounced. Prior to this a chaplain was called to administer last rites in keeping with what appeared to have been the religious beliefs of the patient. . # Disposition: Patient died on [**2178-4-15**]. Medications on Admission: aspirin 325mg daily clopidogrel 75mg daily atenolol 10mg daily ezetemibe 10mg daily glyburide 5mg daily atorvastatin 80mg daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: PEA arrest anoxic brain injury status epilepticus ventilator associated pneumonia chemosis of left eye Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a

[ "250.02", "272.4", "295.90", "410.12", "428.21", "453.8", "428.0", "372.73", "482.1", "427.1", "584.9", "V66.7", "507.0", "285.9", "288.3", "414.01", "401.9", "518.81", "427.5", "999.9", "V45.82", "348.1", "333.2" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.62", "38.93", "38.91", "96.72", "96.04", "99.04", "99.81" ]

icd9pcs

[ [ [] ] ]

8903, 8912

5184, 8697

325, 368

9059, 9068

2261, 3849

9120, 9126

1597, 1644

8875, 8880

8933, 9038

8723, 8852

9092, 9097

1659, 2242

275, 287

396, 1402

3858, 5161

1424, 1521

1537, 1581

5,104

112,881

16699

Discharge summary

report

Admission Date: [**2179-10-29**] Discharge Date: [**2179-11-26**] Service: Vascular CHIEF COMPLAINT: Ischemic left first toe HISTORY OF PRESENT ILLNESS: This is an 81-year-old male transferred from [**Last Name (un) 4068**] Emergency Room with a two day history of painful left great toe and ischemic changes of his left forefoot. He has a history of transient ischemic attacks with work up at [**Hospital3 1280**], unclear if carotid duplex was obtained. Denies history of coronary artery disease. Has a history of hyperlipidemia. The patient has known end stage renal disease secondary to hypertension. Last dialysis was [**2179-10-29**]. The patient is inactive and can rarely walk with assistance and does not use a walker. There is no respiratory pain. He was not on aspirin for any medication. He is now admitted for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Hypertension 2. End stage renal disease on hemodialysis 3. Status post right shoulder surgery 4. Subdural hematoma two years ago status post fall 5. History of cataracts 6. History of transient ischemic attacks, multiple 7. Bilateral vessel visual symptoms 8. Drooping of mouth but no residual 9. Left AV fistula three years ago ALLERGIES: He has no known drug allergies. MEDICATIONS: 1. Hydralazine 100 mg tid 2. [**Last Name (un) **] 240 mg [**Hospital1 **] 3. Lisinopril 40 mg qd 4. PhosLo 3 tablets tid 5. Avapro 300 mg qd 6. Renagel 800 mg tablets 2 3x a day 7. Epogen with dialysis PHYSICAL EXAM: VITAL SIGNS: Temperature 97.8??????, 64, 180/70, 95% on 2 liters of O2. CHEST: Clear to auscultation bilaterally. HEART: Regular rate and rhythm with normal S1 and 2 and a 4/6 systolic ejection murmur radiating to the carotids and to the pericardium. There are no carotid bruits. ABDOMEN: Soft, nontender, nondistended with a prominent abdominal aorta, but it is not aneurysmal. PULSE EXAM: Femoral pulses are palpable bilaterally. Popliteals are palpable bilaterally. The right DP is palpable. The right PT is monophasic dopplerable signal. The left DP is palpable, but diminished in intensity. The left PT is a monophasic dopplerable signal. ADMITTING LABS: CBC: White count was 7.0, hematocrit 36.0, platelets 130,000, normal differential. BUN 19, creatinine 3.3, potassium 3.6. IMAGING: Electrocardiogram normal sinus rhythm, first degree AV block, normal axis, no acute changes, left ventricular hypertrophy. Chest x-ray unremarkable. HOSPITAL COURSE: The patient was admitted to the vascular service. He was intravenous hydrated and began on intravenous heparin. Beta blockers were began. Carotid ultrasound was obtained which demonstrated 60% to 69% left internal carotid artery stenosis and less than 40% on the right internal carotid artery. Renal service was consulted to manage his hemodialysis needs. He was dialyzed on Mondays, Wednesdays and Fridays. He underwent an arteriogram on [**2179-11-1**] which demonstrated atherosclerotic changes to the abdominal aorta. There is severe stenosis of the right proximal renal artery. There is multiple stenosis of the left SFA and popliteal artery. There are two focal stenoses severe of the proximal AT. There is occlusion of the PT and peroneal. The DP is patent. He was given a Mucomyst protocol for this. There was no bump in his BUN and creatinine post angio. He continued to be dialyzed. Echocardiogram was done to assess a ventricular function for valvular disease. The left atrium was markedly dilated. The right atrium was moderately dilated. There was symmetrical left ventricular hypertrophy. The left ventricle cavity was moderately dilated. There was severe global hypokinesis with relative sparing of the septum. The ................ ventricular systolic function is severely depressed. The right ventricular chamber size is normal. The systolic function appears depressed. The ascending aorta is mildly dilated. The aortic valve three leaflets were mildly thickened. There was mild aortic stenosis and 1+ aortic regurgitation. The mitral valve leaflets are mildly thickened with 1+ mitral regurgitation and 2+ tricuspid regurgitation. There was moderate pulmonary systolic hypertension. There is no pericardial effusion. Ejection fraction was calculated at 25%. The patient underwent on [**2179-11-5**] a left profunda femoris to anterior tibial bypass with situ saphenous vein. He tolerated the procedure well. He was transferred to the PACU in stable condition with a palpable DP. At the conclusion of the procedure, he required 2 units of packed red blood cells intraoperatively. He was extubated to the SICU for hemodialysis. His PA pressures were 55/18. Cardiac output was 6.18, SVR 1500, CVP 1. Blood pressure was 204/64. He required neomycin during his hemodialysis for low systolic PA pressures. His electrocardiogram postoperatively was unremarkable. His blood gas was 7.27, 58, 125, 28, minus 1. He was continued on a heparin drip and remained in the SICU for continued care. Postoperative day #1, there were no overnight events. He was dialyzed, maintained his systolic pressure between 160 and 180. His PA pressure 75/32. Cardiac index was 4.3. Cardiac output was 7.7. SVR could not be measured. O2 saturations were 96%. Postoperative hematocrit 33.9 down from 36.5, white count 15.3 up from 13.0. BUN 25, creatinine 5.1 which is stable, potassium 5.0. PT/INR were normal with a PTT of 38.1. His physical exam was unremarkable. His graft pulse was palpable. His morphine and Benadryl were discontinued because of sedation and he was placed on a fentanyl prn patch. Ambien was discontinued. He remained NPO on Protonix. Intravenous fluids were Hep-Locked. He remained in the SICU. Postoperative day #2, he was in the SICU. His swan was discontinued. A triple lumen was placed. He continued on hemodialysis. A knee immobilizer was placed to protect the graft. His postoperative hematocrit was 34.3 up from 33.9. BUN 17, creatinine 3.9 which is down from 5.1. His abdomen was with bowel sounds. His lower extremity incisions were clean, dry and intact. The distal pulses were dopplerable. Feet were warm. He had good capillary refill. Chest x-ray was without pneumothorax. Haldol was given for agitation. Narcotics, opiates and antilytics were held. Protonix was continued and he was transferred to the VICU for continued monitoring and care. Postoperative ultrasound of the graft was done which showed an area of high velocity in the upper groin. The patient returned to the Operating Room on [**2179-11-8**] and underwent a venotomy with excision of competent valve. He tolerated the procedure well. He had a 2+ DP pulse and graft pulse at the end of the procedure. He was transferred to the PACU in stable condition. He had CK/MB cycled. Electrocardiogram was without changes. His cycled enzyme totals were flat. He continued to be followed by the renal service for dialysis needs. His diet was advanced as tolerated and ambulation was began on postoperative day 4 and 1. He was transferred to the floor. Ambulation was begun on postoperative day [**4-8**]. Kefzol was completed once the patient was .............. The remaining hospital course was remarkable for intermittent episodes of confusion requiring a sitter or small doses of Haldol. He did require a blood transfusion on [**2179-11-10**] for his hematocrit with improvement of hematocrit of 26.5 to 28.4 post transfusion. Case management followed the patient for screening and speech swallow requested to see the patient for bed side swallow evaluation. It was difficult to assess his swallowing mechanisms because of his severe lethargy throughout the trials. Their recommendations were to continue diet as tolerated, would recommend small sips versus straw sips when given liquids. Encourage po's. Do not attempt to feed the patient while he is drowsy. Put him at a 90 degree angle upright for all meals. Make his medications pureed and will follow for further assessment. Diet was tolerated and was advanced to soft solids and thick liquids. On [**11-20**], the patient had a low grade temperature of 102??????. Blood cultures and chest x-ray obtained which were both negative. Physical therapy strongly recommended that the patient had impaired balance and functional mobility and strength and severely deconditioned, will recommend rehabilitation facility once medically stable. The patient was transferred to rehabilitation. Remaining hospital course is unremarkable. Awaiting appropriate rehabilitation facility for transfer. The patient was discharged on [**2179-11-26**] in stable condition. Wounds were clean, dry and intact. The skin sutures removed from the DP incision. The wound was Steri-Stripped. The patient should follow up with Dr. [**Last Name (STitle) 1476**] in three weeks. DISCHARGE MEDICATIONS: 1. Losartan 50 mg qd, hold for systolic blood pressure less than 100 2. Nephrocaps 1 qd 3. Hydralazine 4. Hydrochlorothiazide 100 mg tid, hold for systolic blood pressure less than 120 5. Lisinopril 40 mg qd 6. Colace liquid 100 mg [**Hospital1 **] 7. Allopurinol 1 mg [**Hospital1 **], to give the afternoon dose at 3 p.m. 8. Allopurinol 0.5 to 1 mg intravenous q4h prn 9. Protonix 40 mg qd 10. Metoprolol 50 mg [**Hospital1 **], hold for systolic blood pressure less than 110, heart rate less than 50 11. Aspirin 325 mg qd 12. Thiamine 100 mg qd 13. Folic acid 1 mg qd 14. Acetaminophen 325 to 650 mg po pr q 4 to 6 hors prn for pain 15. Mupirocin cream 2% [**Hospital1 **] to rectal area for a total of five days. This was started on [**11-8**] and was discontinued on [**2179-11-13**]. 16. Nitroglycerin ointment 2% 1 inch topical q6h prn for systolic blood pressure greater than 150, wipe off for systolic blood pressure less than 125. 17. Calcium acetate 3 tablets tid with meals DISCHARGE DIAGNOSES: 1. Ischemic left first toe status post left PFA to AT bypass with in situ saphenous vein 2. Graft stenosis, status post venotomy, valvulectomy 3. Postoperative confusion improved 4. End stage renal disease on dialysis 5. Hypertension treated and controlled 6. Coronary artery disease asymptomatic 7. Blood loss anemia corrected [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2179-11-25**] 11:04 T: [**2179-11-25**] 11:10 JOB#: [**Job Number 47262**]

[ "996.1", "V45.1", "425.4", "440.22", "403.91", "276.7", "285.1", "443.9", "293.0" ]

icd9cm

[ [ [] ] ]

[ "89.64", "39.29", "39.95", "88.42", "88.48", "39.49", "88.45" ]

icd9pcs

[ [ [] ] ]

9930, 10547

8912, 9909

2504, 8889

1529, 2486

114, 139

168, 881

903, 1514

40,904

104,777

42391

Discharge summary

report

Admission Date: [**2168-3-6**] Discharge Date: [**2168-3-25**] Date of Birth: [**2091-1-19**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: Biliary Obstruction Major Surgical or Invasive Procedure: 1.ERCP and PTBD placement in right biliary system [**2168-3-7**] 2. CT guided omental biopsy [**2168-3-11**] 3. Internalization of right PTBD [**2168-3-13**] 4. PTBD placement into left biliary system, exchange of prior right biliary PTBD [**2168-3-15**] 5. Right PTBD replacement and brushings, PTC of both drains History of Present Illness: Ms. [**Known lastname 91793**] is a 77 year old lady admitted to [**Hospital3 29691**] on [**2-29**] for new painless jaundice and pruritis,found to have a possible obstructive mass on CT and underwent ERCP x2. This showed a hilar stricture and cytology concerning. Final cytology was still pending at time of transfer. A 15cm plastic stent was placed but requires repeat ERCP evaluation for repeat stenting. Her course has been complicated by a post ERCP Pancreatitis (without pain) that appears to be rapidly resolving. She is transferred on [**Hospital1 18**] on Unasyn in prepartion for a repeat ERCP. Medical record from Sturdy reviewed and confirmed with the patient. Past Medical History: Ulcerative Colitis, Hypothyroidism, Breast Cancer with Left modified radical mastectomy >17 yrs ago, also received chemo Social History: Widowed, lives alone with her dog. Has 2 sons. Quit smoking >50 years ago, occasional alcohol use. Family History: Mother: Breast CA Father: Goiter Physical Exam: Admission PE: GENERAL: Well-appearing woman in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae mildly icteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. 2 capped PTBD drains in place EXTREMITIES: bilateral LE edema per patient's norm,non pitting. no c/c/e, 2+ peripheral pulses. SKIN: mildly icteric LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-11**] throughout, sensation grossly intact throughout Discharge PE: VS:98.8 hr 84 134/74 rr 20 O2 95% rA wt 71.9kg A&O mild scleral icterus rrr lungs diminished 1/3 up on Right otherwise clear abd soft, non-distended. Non tender. R and L PTCs capped. Dressings clean/dry ext 2+edema Pertinent Results: MICROBIOLOGY: Biopsy Brushings: concerning for malignancy. STUDIES: AT OSH: Labs notable for WBC 9, hct 35.2,AST 106, ALT 143, AP 238, T bili 8.2, D bil 6.6, nl Cr 0.6, Lipase had been 14,680. Hepatitis serologies at OSH pos only for Hep A EKG: Reviewed from OSH, no abnormalities CTABD/PEL [**2168-3-7**]: IMPRESSION: 1. Diffuse intrahepatic biliary obstruction due to an irregular, 6.2-cm mass centered in the region of the gallbladder and extending to the hepatic hilum. The appearance is suggestive of primary gallbladder carcinoma with involvement of the liver, or cholangiocarcinoma with involvement of the gallbladder. 2. No evidence of pancreatic ductal dilation or a primary pancreatic mass. Stranding about the pancreatic tail with apparent nodularity is concerning for omental infiltration by tumor at this location. 3. Stranding and apparent soft tissue density adjacent to the hepatic flexure of the colon could represent omental/serosal metastatic disease. No evidence of bowel obstruction. 4. 9-mm left adrenal nodule, not fully evaluated on this examination due to its small size and partial volume averaging effect, but could represent an adenoma. Attention at next followup imaging is recommended. CT TORSO [**2168-3-10**]: IMPRESSION: 1. Diffuse intrahepatic biliary dilatation secondary to a large hypodense mass within the inferior right liver. The invasive nature of this lesion is suggestive of primary gallbladder carcinoma versus cholangiocarcinoma. Stranding seen within the mesentery and omentum is concerning for carcinomatosis. 2. Sclerotic lesion within the body of T7 could be a metastatic focus. 3. Small left adrenal nodule which may represent an adenoma. Attention on followup imaging is recommended. 4. Small right pleural effusion, which is larger than prior. CXR [**2168-3-12**]: FINDINGS: Frontal and lateral views of the chest demonstrate some linear atelectasis on the frontal view not visualized on the lateral, blunting of the CP angles that could be due to a small amount of pleural thickening or small effusion. No focal infiltrate. Mild degenerative changes of the spine with sclerosis and anterior osteophytes. There is residual contrast in the bowel. Tubing projects over the right side of the abdomen. Bone scan [**2168-3-18**]: Single focus of tracer uptake in the thoracic spine corresponding to T7 mixed lytic and sclerotic lesion seen on recent CT likely represents osseous metastasis. No other site of osseous metastatic disease is seen. Attemped US guided biopsy [**2168-3-21**]: IMPRESSION: Biopsy not performed since no mass could be identified adjacent to the gallbladder or arising from the gallbladder wall and extending into the liver. MRI [**2168-3-21**]: IMPRESSION: 1. Focal T1 hypointense nonenhancing lesion involving the T7 vertebral body with adjacent area of intrinsic T1 hyperintensity likely represents a bone island with adjacent hemangioma. However, given the history of primary gallbladder cancer/cholangiocarcinoma, possibility of a metastatic lesion cannot be entirely excluded and attention on followup imaging is recommended. 2. Right pleural effusion. OSH RADIOLOGY: CT ABD PELVIS: neoplastic lesion in the porta hepatis most likely cholangiocarinoma invading common biliary duct, surrounded GB with significant abnormality in the right lobe of the liver most likely infiltration by neoplasm vs liver necrosis. OSH US ABD: fatty liver, cholelithiasis with borderline thickness of GB wall, no evidence of acute cholecystitis [**2168-3-12**] 9:30 pm BLOOD CULTURE 1 OF 2. **FINAL REPORT [**2168-3-21**]** Blood Culture, Routine (Final [**2168-3-15**]): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. Daptomycin = 3.0 MCG/ML. Daptomycin Sensitivity testing performed by Etest. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. LINEZOLID Susceptibility testing requested by DR.[**Last Name (STitle) 2324**],GOWRI PAGER [**Numeric Identifier 38654**] [**2168-3-21**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [**2168-3-13**]): GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS. Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 15723**] [**2168-3-13**] 1751. Aerobic Bottle Gram Stain (Final [**2168-3-13**]): GRAM POSITIVE COCCI IN PAIRS AND IN SHORT re [**2168-3-12**] 10:00 pm BILE **FINAL REPORT [**2168-3-17**]** GRAM STAIN (Final [**2168-3-13**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2168-3-16**]): ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R PENICILLIN G---------- =>64 R VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [**2168-3-17**]): NO ANAEROBES ISOLATED. [**2168-3-13**] 6:00 am URINE Source: CVS. **FINAL REPORT [**2168-3-16**]** URINE CULTURE (Final [**2168-3-16**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. DR. [**Last Name (STitle) **] ([**Numeric Identifier 91794**]) REQUESTED SENSITIVITIES TO Piperacillin/Tazobactam [**2168-3-15**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R [**2168-3-25**] 04:52AM BLOOD WBC-6.0 RBC-3.64* Hgb-10.2* Hct-30.8* MCV-85 MCH-28.0 MCHC-33.2 RDW-17.6* Plt Ct-284 [**2168-3-24**] 06:00PM BLOOD PT-14.6* PTT-52.5* INR(PT)-1.4* [**2168-3-25**] 04:52AM BLOOD PT-13.5* PTT-58.8* INR(PT)-1.3* [**2168-3-25**] 08:46AM BLOOD PT-14.0* PTT-55.1* INR(PT)-1.3* [**2168-3-25**] 04:52AM BLOOD Glucose-112* UreaN-19 Creat-1.0 Na-138 K-3.6 Cl-109* HCO3-21* AnGap-12 [**2168-3-7**] 06:45AM BLOOD ALT-123* AST-113* AlkPhos-226* TotBili-14.3* [**2168-3-25**] 04:52AM BLOOD ALT-61* AST-70* AlkPhos-305* TotBili-3.8* [**2168-3-9**] 01:40PM BLOOD AFP-3.2 [**2168-3-25**] 04:52AM BLOOD Vanco-22.9* [**2168-3-9**] 13:40 CA [**75**]-9 Test Result Reference Range/Units CA [**75**]-9 191 H <37 U/mL Brief Hospital Course: 77 year old woman with a history of ulcerative colitis who presented with painless jaundice. CTA report ([**2168-3-7**]) found diffuse intrahepatic biliary obstruction due to an irregular, 6.2-cm mass centered in the region of the gallbladder and extending to the hepatic hilum. The appearance was suggestive of primary gallbladder carcinoma with involvement of the liver, or cholangiocarcinoma with involvement of the gallbladder. Stranding about the pancreatic tail with apparent nodularity was concerning for omental infiltration by tumor at this location. Ms. [**Known lastname 91793**] was admitted to Dr.[**Name (NI) 1369**] service on [**2168-3-8**]. She underwent CT guided biopsy of the omentum on [**2168-3-11**]. Biopsy was without evidence of lymphoma or metastases. She was febrile to 101 on [**3-12**]. CXR was negative for pneumonia. Blood and bile culture from [**3-12**] isolated vanco sensitive Enterococcus faecium. Vanco and Zosyn were started on [**3-13**]. On [**3-13**], cholangiogram was done noting complete occlusion of the proximal CBD adjacent to the confluence of the right and left biliary ducts. An 8 French internal-external drain was placed through the right anterior biliary system into the duodenum. She spiked a temperature to 101 post procedure. Repeat blood cultures were negative. Urine culture isolated <10,000 colonies of yeast. LFTs trended down with t.bili decreasing from 12.3 to 4.1. Right PTC (biliary drain)remained open to gravity drainage. Urine culture from [**3-13**] isolated highly resistant E.coli sensitive to [**Last Name (un) 2830**], gent and cefepime. Zosyn was switched to Cefepime on [**3-15**]. On [**3-15**], cholangiogram was performed and an internal-external drain was placed into the left biliary system. The right-sided biliary drain was exchanged with another internal-external 8 French biliary drain. Both biliary drains were left to gravity drainage. LFTs continued to trend down. Ursodiol was started. On [**3-15**], a bone scan was performed to assess for metastases. A single focus of tracer uptake in the thoracic spine was noted corresponding to T7 mixed lytic and sclerotic lesion seen on CT was concerning for osseous metastasis. No other site of osseous metastatic disease were seen. Neuro-interventional consult was obtained. Recommendations were to obtain MRI to further evaluate. MRI to T spine demonstrated Focal T1 hypo intense non enhancing lesion involving the T7 vertebral body with adjacent area of intrinsic T1 hyperintensity likely representing a bone island with adjacent hemangioma. Neuro-intervention felt this was not consistent with a met and a biopsy was deferred. On [**3-22**], a cholangiogram was done to obtain brushings as attempt to biopsy under repeat liver US did not demonstrate any liver mass adjacent to the stone-filled gallbladder or elsewhere in the liver. Biliary brushings from cholangiogram demonstrated atypical glandular/ductal epithelial cells. A liver duplex US was done to evaluate CT finding from [**3-21**] of new thrombosis of the right portal vein. Duplex did reveal occlusion of the posterior right portal vein branch and a Heparin drip was started. Coumadin was then started on [**3-23**] at 3mg a day. She received this on [**3-23**] and [**3-24**]. INR was 1.3 on [**3-25**]. Heparin was stopped on [**3-25**] and Lovenox 70mg sq started. PICC line was placed on [**3-23**]. CXR confirmed right PICC catheter tip projects over cavoatrial junction. Percutaneous transhepatic catheters (PTCs)were capped with LFTs remaining stable. She remained afebrile. ID was consulted and noted hospital course of fever, RUQ pain, and hyperbilirubinemia consistent with cholangitis and associated VSE bacteremia s/p biliary decompression with antibiotics for biliary pathogen fever. Antibiotic course was set for minimun of 3 weeks. Duration will depend on surgical/oncologic plan, which has not yet been determined. She will follow up as an outpatient with both ID and hepatobiliary [**Last Name (LF) 5059**], [**First Name3 (LF) **] W. [**Doctor Last Name **]. Of note, surveillance blood cultures prior to [**3-21**] and [**3-22**] were finalized as negative. Blood cultures from [**3-21**] and [**3-22**] were negative to date at time of discharge. Diet was tolerated fairly well. Appetite improved over the course of the hospital stay. Carnation instant breakfasts with meals was recommended by Nutrition. Of note, she did receive a IV fluid and experienced fluid retention. Lasix was given on [**3-23**] and [**3-25**] (Lasix 20mg iv)with good diuresis. Weight was 71.9 on [**3-25**]. Admission weight was 71.5kg. PT worked with her and recommended rolling walker which she used with supervision. The plan was to send her to rehab near her son's home. Life Care in [**Location (un) 8545**] had a bed available and she will transfer there today to continue IV antibiotics via PICC line. Weekly labs will be required and [**3-11**] time per week INR checks as she is currently on Lovenox and Coumadin. Medications on Admission: MEDICATIONS: Mesalamine 1200mg PO TID MVI 1 tab PO daily Naproxen 220mg PO BID Probiotic (Risaquad) Prilosec 20mg PO daily Levothyroxine 75mcg PO daily . Transfer Medications: Lidocaine patch TP Daily Heparin 5000 units SQ TID Synthroid 75mcg PO daily Ativan 0.5 IV Q6 PRN anxiety Asacol 1200mg PO TID MVI 1 Cap PO daily Zofran 4mg IV Q4 PRN nausea Pantoprazole 40mg IV Daily Unasyn 1.5g IV Q6 hours Discharge Medications: 1. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. levothyroxine 75 mcg Capsule Sig: One (1) Capsule PO once a day. 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heart burn. 6. Lovenox 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous twice a day: until inr therapeutic. 7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day: for thrombosis of right posterior portal vein. inr goal [**3-11**]. 8. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours): stop date to be determined by [**Hospital1 18**] ID in follow up. 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours): stop date to be determined by [**Hospital1 18**] ID in follow up. 12. clobetasol 0.05 % Gel Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): please apply to oral ulcer . 13. Outpatient [**Hospital1 **] Work Weekly labs: cbc with diff, BUN, creatinine, ast, alt, alk phos, tbili and trough Vanco level with results fax'd to [**Hospital 18**] [**Hospital **] clinic attn: RN [**Telephone/Fax (1) 1419**] and [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] RN [**Telephone/Fax (1) 22248**] Vancomycin trough, CBC with differential, BUN, creatinine, and liver enzyme panel 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Outpatient [**Name (NI) **] Work PT/INR [**3-11**] x per week goal [**3-11**] Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 8545**] Discharge Diagnosis: Jaundice with presumed gall bladder malignancy cholangitis E.coli uti, highly resistant Vanco sensitive bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You will be transferring to Life Care Rehab in Attelboro for IV antibiotics thru the IV PICC line You will need weekly blood work for [**Location (un) **] monitoring You were also prescribed a 3 week antibiotic course. You may shower, but should pat drain sites dry and cover with dry gauze dressing daily. Observe for redness or drainage. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2168-4-1**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2168-4-6**] 3:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2168-4-20**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2168-3-25**]

[ "995.91", "155.1", "577.0", "576.1", "041.49", "997.49", "V45.71", "599.0", "V58.61", "556.9", "783.21", "V10.3", "576.2", "537.3", "112.2", "452", "038.0", "244.9" ]

icd9cm

[ [ [] ] ]

[ "97.05", "54.24", "51.98", "51.12", "45.13" ]

icd9pcs

[ [ [] ] ]

17938, 18009

10349, 15387

322, 638

18168, 18168

2583, 10326

18684, 19315

1623, 1658

15838, 17915

18030, 18147

15413, 15567

18319, 18661

1673, 2329

2343, 2564

262, 284

15589, 15815

666, 1344

18183, 18295

1366, 1488

1504, 1607

1,740

133,186

12718

Discharge summary

report

Admission Date: [**2177-9-11**] Discharge Date: [**2177-9-16**] Date of Birth: [**2110-3-26**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 67-year-old male has a known history of coronary artery disease. He is status post left anterior descending artery percutaneous transluminal coronary angioplasty and subsequent repeat PTCA and atherectomy in [**2168**] for exertional angina. Since then he has been essentially asymptomatic though his level of activity has been slightly decreased secondary to low back pain. A routine cardiac evaluation in [**2177-8-15**] revealed exercise induced ischemia and he underwent cardiac catheterization on [**9-9**] at [**Hospital1 69**] which revealed a tight distal left main stenosis involving the ostium of the LAD and the circumflex. He had no significant right coronary artery disease. He had preserved left ventricular function and he was admitted for a coronary artery bypass graft. PAST MEDICAL HISTORY: Significant for history of coronary artery disease status post left anterior descending artery percutaneous transluminal coronary angioplasty and atherectomy, status post appendectomy, tonsillectomy, history of calf claudication and rest pain at night. ALLERGIES: He has no known allergies. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q. day and Lipitor. SOCIAL HISTORY: He does not smoke cigarettes. He drinks alcohol occasionally. Lives at home with his wife. REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION: He is well-developed, well-nourished white male in no apparent distress. Vital signs stable, afebrile. HEENT examination: Normocephalic, atraumatic. Extraocular movements intact. Oropharynx benign. Neck was supple. Full range of motion. No lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs were clear to auscultation and percussion. Cardiovascular examination: Regular rate and rhythm, normal S1, S2 with no murmurs, rubs or gallops. The abdomen was soft and non-tender with positive bowel sounds. No masses or hepatosplenomegaly. Extremities were without clubbing, cyanosis or edema. Neuro examination was nonfocal. HOSPITAL COURSE: On [**9-11**] he underwent an off-CAB times three with left internal mammary artery to the left anterior descending artery, reverse saphenous vein graft to OM-2 and diagonal one. He was transferred to the CSIU in stable condition. He had a stable postoperative night. He was extubated. On postoperative day one he was transferred to the floor in stable condition. On postoperative day three he had his chest tubes discontinued. He also had some nausea and vomiting, was not obstructed and this eventually resolved. He also ___________ to rapid atrial fibrillation which converted easily on beta blockers and amiodarone. On postoperative day five he was discharged to home in stable condition and had his echocardial pacing discontinued. LABS ON DISCHARGE: White count 11,300, hematocrit 30.1, platelet count 299,000. Sodium 143, potassium 4.1, chloride 106, CO2 30, BUN 17, creatinine 1.0, blood sugar 100. MEDICATIONS ON DISCHARGE: Lasix 20 mg p.o. b.i.d. times ten days, KCl 20 mEq p.o. b.i.d. times ten days, Colace 100 mg p.o. b.i.d., Ecotrin 325 mg p.o. q. day, Plavix 75 mg p.o. q. day, amiodarone 400 mg p.o. b.i.d. times one week and then 400 mg p.o. q. day times one week and then 200 mg p.o. q. day times two weeks, Percocet one to two p.o. q. 4-6h. p.r.n. pain, Lipitor 40 mg p.o. q. day, Lopressor 50 mg p.o. b.i.d. FOLLOW UP: He will be seen by Dr. [**Last Name (STitle) **] in one to two weeks and Dr. [**Last Name (STitle) 1537**] in four weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 32413**] MEDQUIST36 D: [**2177-9-16**] 15:18 T: [**2177-9-16**] 14:20 JOB#: [**Job Number 39246**]

[ "997.4", "V45.82", "427.31", "997.1", "443.9", "414.01", "560.1" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.12", "89.68" ]

icd9pcs

[ [ [] ] ]

3142, 3538

1302, 1343

2196, 2942

3550, 3956

1508, 2178

1474, 1485

2962, 3115

160, 958

981, 1275

1360, 1454

2,647

127,845

16260

Discharge summary

report

Admission Date: [**2194-2-13**] Discharge Date: [**2194-2-17**] Date of Birth: Sex: Service: ICU HISTORY OF PRESENT ILLNESS: This is a 46 year old gentleman with a history of hepatitis C, alcohol abuse, who was transferred from an outside hospital to the endoscopic retrograde cholangiopancreatography suite for evaluation of pancreatitis and common bile duct dilatation. In endoscopic retrograde cholangiopancreatography suite, he was noted to be tachypneic with saturations of 94 percent on four liters nasal cannula, having emesis of coffee grounds. His endoscopic retrograde cholangiopancreatography was delayed and he was transferred to the Intensive Care Unit for further monitoring. He presented to an outside hospital on [**2194-2-12**], with severe abdominal pain, nausea and vomiting for four days. At that time, his laboratories demonstrated an amylase of 1018, hematocrit 50.0, ALT 126, AST 100, total bilirubin 6.8. He was treated at the outside hospital with intravenous fluids and Morphine. A right upper quadrant ultrasound demonstrated sludge in his gallbladder, and a thickened gallbladder wall with the common bile duct measuring 8.0 millimeters. A CT of his abdomen demonstrated moderate pancreatitis with a small amount of ascites. Today, his liver function tests are improved with an AST of 42, ALT 66, total bilirubin 3.0, alkaline phosphatase 152, amylase 399. He is sent to [**Hospital1 188**] for endoscopic retrograde cholangiopancreatography. Currently, in the endoscopic retrograde cholangiopancreatography suite, he complains only of thirst and mild nausea as well as some shortness of breath. He denies chest pain, abdominal pain. He is an extremely poor historian, however, and is unable to describe his full medical history. PAST MEDICAL HISTORY: Hepatitis C. Alcohol abuse. Intravenous drug use. History of left partial nephrectomy for stone disease. Pancreatitis. Question of bipolar disease. History of partial paralysis several years ago, status post intensive physical therapy (from accident). MEDICATIONS ON ADMISSION: 1. Quetiapine 200 mg twice a day and 300 mg q.h.s. 2. Divalproex 500 mg twice a day. 3. Fluphenazine 5 mg p.o. once daily. ALLERGIES: Allergy to Penicillin. SOCIAL HISTORY: Two pack a day tobacco times eighteen years. Quit alcohol twenty-five years ago. History of intravenous drug use, Heroin, Cocaine, and is a resident of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) 86**]. PHYSICAL EXAMINATION: Temperature is afebrile, pulse 113, oxygen saturation 94 percent on five liters with a respiratory rate of 25. Examination is notable for decreased breath sounds at the left base of his lungs. Abdomen is distended without bowel sounds, no rebound, tympanitic to percussion. Extremities with good pulses. Neurologically, he moves all four extremities and is alert and oriented times three. Skin is warm and moist. LABORATORY DATA: Laboratories are notable for a white blood cell count of 23.2 and a low magnesium of 1.4. Electrocardiogram showed normal sinus rhythm. Chest x-ray with hazy infiltrate in the left lower lobe and a portable KUB with gas still pattern and multiple surgical clips in his left upper quadrant. No thumb printing. Nasogastric lavage demonstrated coffee grounds that cleared with 300cc of normal saline and a green bilious material was elicited. HOSPITAL COURSE: The patient was admitted to the [**Hospital 12573**] Medical Intensive Care Unit for further monitoring. The plan was to hydrate aggressively, treat his pain with Morphine, start Ceftriaxone and Flagyl, maintain two large bore intravenous at all times, and check blood cultures. The patient was admitted overnight and was stable, however, he continued to desaturate overnight. At 5:30 a.m. I was called to see the patient for an increased respiratory rate to 40 and 50 with agitation and fatigue. His oxygen saturations were 93 percent on 100 percent nonrebreather and an arterial blood gas was 7.34, 43, 89. Over the next hour, he continued to be tachypneic with worsening mental status. The patient consented to elective intubation and anesthesia was contact[**Name (NI) **]. As the patient became increasingly lethargic and unresponsive, I called the patient's sister, [**Name (NI) 8797**] [**Name (NI) 46368**], to obtain consent from anesthesiologist. We initiated intubation at approximately 7:15 a.m. However, the patient had copious amounts of emesis of coffee ground material and became bradycardic to the 20s with blood pressure dropping to below the 70s to 80s systolic. The patient then continued to arrest with multiple different rhythms with bradycardia, PEA, ventricular tachycardia. We administered Atropine, Epinephrine, normal saline. We were unable to obtain an airway for approximately twenty to twenty-five minutes. However, when an airway was obtained, the patient soon after went into normal rhythm and maintained his blood pressure. The family was immediately notified and came to the Intensive Care Unit and were updated of the events. The family clearly stated that they knew that their brother would never want to be kept alive if there was no hope of meeting full recovery. Over the next 72 to 96 hours, it became clear that his neurological function was severely decreased and that he had taken a significant anoxic insult. Electroencephalogram on [**2194-2-15**], demonstrated severe encephalopathy and repeat electroencephalogram on [**2194-2-17**], demonstrated nearly no brain activity. The family immediately after the event made him DNR, however, as the patient did not have a power of attorney, the family was not able to immediately reverse the intubation. He remained unresponsive entirely during this time. On [**2194-2-17**], a family meeting was held with all members of family, social worker, Intensive [**Name2 (NI) **] Unit attending, Dr. [**First Name (STitle) **] [**Name (STitle) **], and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 122**] from the legal department. The family all decided that the patient would not want this and they were no other members of the family that would be in disagreement with this. It was decided to remove the patient from life support at that time with all in agreement. Ventilator support was removed and at 1:00 p.m. on the same day, [**2194-2-17**], the patient expired. Time of death is [**2194-2-17**], at 1:00 p.m. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(1) 27108**] Dictated By:[**Last Name (NamePattern1) 46369**] MEDQUIST36 D: [**2195-7-15**] 19:42:31 T: [**2195-7-15**] 20:51:37 Job#: [**Job Number 46370**]

[ "070.54", "518.81", "348.0", "577.0", "348.1", "507.0", "518.0", "530.7" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

2111, 2272

3459, 6771

2559, 3441

157, 1803

1826, 2085

2289, 2536

81,660

198,618

29538

Discharge summary

report

Admission Date: [**2144-2-3**] Discharge Date: [**2144-3-4**] Date of Birth: [**2093-11-21**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 2042**] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: Nephrostomy tubes changed [**2144-2-10**]. History of Present Illness: Ms. [**Known lastname 70847**] is a 50 female HIV positive (most recent CD4 count 126) on HAART, h/o rectal adenocarcinoma (s/p radiation/chemotherapy/surgery), complicated by lower extremity paralysis [**1-16**] spinal cord radiation injury, LE DVT on Coumadin, radiation-induced b/l ureteral fibrosis requiring b/l nephrostomy tubes, who presents with abdominal pain and distention. Pt was referred to the ED from her PCP after her home [**Month/Day (2) 269**] drew labs today with evidence of renal failure, hyperkalemia to 6.7 and supratherapeutic INR to 6.3. Per note from PCP, [**Name10 (NameIs) **] discussion with ED resident, pt was getting large doses of Dilaudid 16mg po q2hr prn pain, but continued to have abdominal pain despite this. Per discussion with her and her husband, she started to develop crampy pain across her upper abdomen a couple days prior. When they saw her PCP on [**Name9 (PRE) 2974**], they thought a large component of her abdomenal pain was gas given that her ostomy bag was full of gas. When she has had obstructions in the past the output has stopped, but she continued to have loose, brown output at home, without blood. Then, starting tonight after dinner, she pain became more severe. Notes bilateral nephrostomy tubes have been patent although urine output has been decreased over past several days. . In the ED, initial VS were: Pain 10 96.6 136 99/67 17 99% RA. Per ED exam, pt had extreme abdominal pain, but relatively benign abdomen. Nephrostomy tubes seemed to be draining well. Labs notable for hyponatremia with Na to 130, K 6.0, repeated 5.0, Cr 2.8 (up from baseline 0.9-1.1), WBC to 18. Lactate was not drawn. CT abdomen showed "Extensive portovenous gas and air in mesenteric vessels with probable pneumotosis in the bowel, highly concerning for bowel infarct/ischemia." Surgery was consulted who reviewed the films and deemed that she was not a surgical candidate since they thought she would not survive surgery. At signout, discussed with resident that surgery resident discussed poor prognosis with pt and husband, though she was not [**Name (NI) 3225**]. The resident was going to readdress this again with patient before transfer. She was given 8mg IV dilaudid, chasing with 2mg IV repeat dilaudid without much improvement. She was given 10mg IV vitamin K and 2 units FFP. She was also given CTX, Vanc, Flagyl. At the time of signout, she was newly draining blood from her ostomy site, mixed with stool. She was starting her third liter of NS at time of transfer. Her most recent VS were HR 121 BP 110/46 RR 14 100%RA. . On arrival to the MICU, VS T 97.4 HR 124 BP 133/82, RR 16, O2 sat 91%RA. Pt is tearful and in severe abdominal pain. Her husband is at her bedside. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: ONCOLOGIC HISTORY: 1) Rectal cancer: - late [**2139**]: 6 months of intermittent rectal bleeding, rectal pressure and a sensation of incomplete emptying. - [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and a 2.5 cm distal rectal mass arising from the anal verge in the posterior rectum with a large area of induration. - [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring 4.8 x 3.8 cm, bulging posteriorly into the presacral space and anteriorly towards the uterus. There were enlarged lymph nodes in the perirectal fat adjacent to the mass, a 9-mm enhancing lymph node in the left pelvic sidewall, and enhancing lymph nodes in the right external iliac region. There was also a 7-mm hypodensity in the caudate lobe of the liver. Rectal ultrasound on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3 disease. There were at least four abnormal perirectal lymph nodes seen on MRI, in addition to multiple bilateral enlarged pelvic sidewall lymph nodes, concerning for extensive disease. - [**2141-2-20**]: began chemoradiation - [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia, and abdominal cramping - [**2141-3-13**]: 5-FU was restarted at a reduced dose - [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal skin changes, diarrhea, and electrolyte abnormalities. - [**Date range (3) 70844**]: Radiation was also held - [**2141-3-27**]: 5-FU was restarted at a further reduced dose - [**2141-3-31**]: completed radiation - [**2141-4-3**]: completed chemotherapy - [**Date range (3) 70845**]: hospitalized for bowel rest and the initiation of TPN due to presumed radiation enteritis. - [**2141-5-31**]: found to be HIV positive and began on HAART - [**Date range (1) 70846**]: required hospitalization for an SBO, underwent laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed severe radiation-induced acute ischemic enteritis. She recovered from this surgery, but continued to require TPN. - [**7-/2141**]: Once her CD4 count had recovered, she underwent laparotomy, lysis of adhesions, ileal resection, proctosigmoidectomy, colonic jejunal pouch to near-anal anastomosis with EEA, takedown splenic flexure, resection of ileostomy and creation of new end-ileostomy. Pathology from the surgical specimen revealed no residual carcinoma and all 14 lymph nodes sampled were free of disease. - [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis showed no evidence of recurrence. - [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen near the anastomatic site, new since the earlier study. Local recurrence cannot be excluded, although possibly the appearance is associated with endoluminal debris." . OTHER MEDICAL HISTORY: 2) HIV CD4 count 124 on [**12/2143**] 3) Short gut syndrome secondary to bowel surgery for CA. 4) Obstructive renal failure from radiation fibrosis, in the past necessitating b/l nephrostomy tubes which have required multiple revisions. 5) Lower extremity neuropathy, likely secondary to radiation fibrosis, uses a wheelchair since 4/[**2141**]. 6) Pancreatic insufficiency. 7) Anemia. 8) Chronic pain. 9) DVT in LE X2: requires lifelong coumadin, most recent [**4-24**]. Social History: Lives with her husband and 4 children in [**Location (un) 17566**], does not smoke or drink alcohol. On long-term disability. Has [**First Name9 (NamePattern2) 269**] [**Location (un) 5871**], as well as [**Location (un) 511**] Home Therapy for Port maintenance. Family History: Her father died at 72 of MI. Her mother alive and well. Remote family history of breast, colon cancer. Her daughter has ulcerative colitis. Physical Exam: Admission Physical: Vitals: T: 97.4 BP: 133/82 P: 124 R: 16 O2: 91% General: Alert and oriented Neck: supple, JVP not elevated CV: tachycardic, Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: distended, rigid, tender, ostomy bag with blood and gas GU: nephrostomy tubes in place with clear urine in bags Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moving all 4 extremeties Pertinent Results: Admission Labs: [**2144-2-3**] 08:04PM BLOOD WBC-18.8*# RBC-4.19*# Hgb-11.8*# Hct-35.7*# MCV-85 MCH-28.1 MCHC-33.0 RDW-18.0* Plt Ct-407 [**2144-2-3**] 08:04PM BLOOD Neuts-74.5* Lymphs-20.3 Monos-3.5 Eos-0.6 Baso-1.1 [**2144-2-11**] 06:09AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [**2144-2-3**] 10:40PM BLOOD PT-64.8* PTT-67.9* INR(PT)-6.5* [**2144-2-3**] 08:04PM BLOOD Glucose-185* UreaN-41* Creat-2.8*# Na-127* K-6.0* Cl-93* HCO3-21* AnGap-19 [**2144-2-3**] 08:04PM BLOOD Albumin-3.4* [**2144-2-4**] 01:39AM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9*# Mg-1.5* [**2144-2-4**] 02:38AM BLOOD Lactate-2.0 [**2144-2-3**] 08:04PM BLOOD ALT-25 AST-22 AlkPhos-210* TotBili-0.2 . Micro: Blood cultures [**2144-2-4**]: [**2144-2-3**] 8:04 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final [**2144-2-4**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by [**Doctor First Name **] [**Doctor Last Name 10280**] #[**3-/3402**] [**2144-2-4**] 2255. . Imaging: [**2144-2-3**] CT ABDOMEN: IMPRESSION: 1. Dilated loops of small bowel with fecalization and pneumatosis with extensive portal venous air, and air in the superior mesenteric vein and mesenteric vessels, consistent with bowel ischemia/infarct. Vascular evaluation is otherwise limited by non-contrast technique. 2. Apparent celiac origin stenosis with post-stenotic aneurysmal dilatation, assessment limited due to non-contrast technique. 3. Status post proctosigmoidectomy and ileal resection and extensive revision, now with an end-ileostomy without evidence of obstruction. 4. Status post bilateral translumbar nephrostomy tube placement for obstructive renal failure secondary to radiation fibrosis following treatment for rectal adenocarcinoma. No current evidence of hydronephrosis. Appropriate nephrostomy tube positioning. 5. Hepatosteatosis. 6. Sheet-like bladder wall calcification, suggestive of sequela of radiation cystitis. 7. Coccygeal erosion/osteomyelitis secondary to decubitus ulcer. . [**2144-2-3**] CXR: IMPRESSION: No acute cardiopulmonary process. . [**2144-2-14**] CXR: Bilateral opacifications concerning for new multifocal pneumonia. . CT Abd [**2144-2-16**]: IMPRESSION: 1. No evidence of hydronephrosis. The bilateral nephrostomy tubes are well positioned. Perinephric foci of air, likely related to recent instrumentation. 2. 3-mm stone identified within the left ureter at the level of the pelvic brim. No hydroureter, not unexpected given nephrostomy tube. 3. Extensive dilated fluid filled loops of bowel, similar to [**2143-6-14**], and without definitie transition point. [**Month (only) 116**] represent baseline post-surgical changes but cannot exclude partial mechanical obstruction. Please correlate with clinical picture and ostomy output. 4. Significant stable radiation enteritis changes of large bowel with possible stricture identified shortly after ileostomy anastomosis, of doubtful clinical significance. 5. Hepatic steatosis. 6. Bladder wall calcifications likely related to radiation cystitis. 7. Minimally improved soft tissue inflammation and stable osseous erosions associated with known coccyx decubitus ulcer. . CXR [**2144-2-16**]: There are persistent low lung volumes. Cardiac size is top normal. Right upper lobe opacity has worsened. Bibasilar consolidations larger on the right side and left perihilar opacities are stable. There is no pneumothorax or pleural effusion. Right Port-A-Cath tip is in the mid SVC. IMPRESSION: Worsening pneumonia. . [**2144-2-20**] CXR: IMPRESSION: 1. Slight improvement of right upper and lower zone consolidations. 2. Unchanged left lower zone consolidation. . [**2144-2-20**] CT HEAD: IMPRESSION: No acute intracranial pathology. . [**2144-2-20**] EEG: PRELIMINARY: Abnormal EEG due to the very disorganized and usually slow background rhythm and due to the frequent bursts of generalized slowing, some assuming a sharp wave morphology. The findings indicate a widespread encephalopathy vertebral cortical and subcortical structures. There were no areas of prominent focal slowing but encephalopathies may obscure focal findings. There were several generalized sharp waves. There were no repetitive epileptiform discharges or electrographic seizures. . [**2144-2-21**] MRI BRAIN: IMPRESSION: 1. No findings that might explain the patient's mental status change. 2. Incidental note is made of a partially empty sella. . . [**2144-3-2**] Pelivc Ultrasound: IMPRESSION: Limited views of the pelvis unable to visualize the uterus for evaluation of the endometrial stripe. Other imaging modalities such as MRI would be helpful. DISCHARGE LABS: [**2144-3-4**] 05:30AM BLOOD WBC-6.4 RBC-3.25* Hgb-8.5* Hct-29.2* MCV-90 MCH-26.0* MCHC-28.9* RDW-17.8* Plt Ct-307 [**2144-3-4**] 05:30AM BLOOD PT-18.6* PTT-40.6* INR(PT)-1.8* [**2144-3-4**] 05:30AM BLOOD Glucose-81 UreaN-18 Creat-1.4* Na-141 K-4.9 Cl-104 HCO3-27 AnGap-15 [**2144-2-29**] 05:30AM BLOOD ALT-12 AST-13 AlkPhos-88 TotBili-0.1 [**2144-3-4**] 05:30AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 Brief Hospital Course: 50yo woman with HIV and h/o rectal CA s/p chemoXRT currently in remission, with multiple complications including radiation fibrosis and radiation enteritis admitted for abdominal pain and ischemic bowel. Given vitamin K and FFP when she presented and admitted to the ICU. Surgery was not an option due to the radiation enteritis and fibrosis. She then developed fever and infiltrates c/w hospital-acquired pneumonia, treated with vanco/cefepime, and ARF and encephalopathy. . # Encephalopathy: Likely medication induced (pregabalin, hyoscyamine, and zolpidem stopped, methadone dose decreased, and lorazepam changed to PRN). CT and MRI head negative. Neuro consulted. EEG showed generalized encephalopathy. B12, folate, TSH normal, lactate normal, guaic negative. Encephalopathy resolved. Restarted pregabalin at lower dose [**2144-2-25**]. . # Ischemic/infarcted bowel/abdominal pain: Treated conservatively as no surgical options, completed 7 day course of cipro/metronidazole [**2144-1-11**]. Normal lactate, guaic now normal. . # Pain control: Remains stable. Due to changes in mental status, methadone decreased to 10/15/10/15 and stopped pregabalin and hyoscyamine (Levsin). Palliative Care consulted. Given her continued frequent reliance on PRN hydromorphone q2-4HR, methadone was increased from 10/15/10/15 to 15mg q6HR [**2144-2-26**] while the PRN hydromorphone dose was decreased (from a range 4-8 to [**1-20**] with an aim for 3mg with each PRN dose, down from her usual 4mg). Her outpatient liquid supply of hydromorphone at 1mg/mL was not practical given her enormous usage. Concentrated hydromorphone 20mg/mL was given and then she was transitioned from IV to PO. Restarted pregabalin at lower dose 50mg TID for renal dosing and to avoid recurrent delirium. She has had good pain control with Oral Dilaudid 20 mg Q2H:PRN increasing to 30mg Q2H:prn during the night from 2200 to 0600 then back to a 20 mg Q2H:PRN at 0800. Palliative care has been involved to assist in managment. . # Hospital-acquired pneumonia: Completed 7 day course of cefepime [**2144-2-20**]. Vancomycin stopped [**2144-2-16**]. Repeat CXR showed improvement and symptoms resolved. . # Nausea and diarrhea: Chronic diarrhea due to short gut syndrome. However output increased to 5L/d last week with non-AG hyperchloremic metabolic acidosis. C diff negative [**2144-2-16**] and [**2144-2-20**]. Stool output decreasing, but still nauseous. Norovirus negative. Anti-emetics PRN. . # Thrush: Improved with nystatin. . # Sacral decubitus ulcer and coccygeal osteomyelitis: No surgical management, continued wound care, recent CT showed minimal improvement. Will continue daily dressing and packing with visiting nurses at home. . # Vaginal Bleeding: Has a history of radiation vaginitis documented on EUA on [**2143-11-13**]. Seen by Gyn consult without plans for intervention or further diagnostics. Will treat expectantly. Suspect this is due to radiation vaginitis and her anticoagulation with both lovenox and coumadin while bridging coumadin reinitiation. . # Nephrostomy tubes: Exchanged tubes [**2144-2-10**]. Then developed acute renal failure. CT showed no obstruction and urine output increased with IVFs. Serosanguinous fluid likely related to stone in setting of anticoagulation; no need for intervention. . # Acute renal failure: No obstruction on CT. Lytes consistent with prerenal cause. Muddy brown casts seen consistent with ATN from recent hypotension. Creatinine improved initially on IVFs, but now stabilizing at 1.5-1.7; IV fluids stopped. Ucx growing yeast, likely colonization. Nephrology consulted. . # Metabolic acidosis: Non-anion-gap. Repeat lactate normal. Likely due to high stool output and dilutional +/- RTA. Stool output slowing. Nephrology consulted. Acidosis improving after starting sodium bicarbonate 650mg PO BID [**2144-2-23**], stopped [**2144-2-28**]. . # Anemia/blood loss: Normocytic, likely due to chronic disease as well as acute hematuria. Transfused 2U RBCs ([**2144-2-19**] and [**2144-2-20**]). No evidence of hemolysis. Continued anticoagulation. . # Leukocytosis: Due to pneumonia and ischemic colitis. Resolved. . # Rectal CA: No evidence of recurrence by CT [**11/2142**] or CEA [**2143-2-12**]. Palliative care and Social Work consulted. DNR/DNI, but continue maximal medical therapy. . # HIV: CD4 count 263. Continued HAART therapy. No PCP prophylaxis for now due to appropiate CD4. . # Chronic DVTs: Restarted enoxaparin and warfarin which were held due to hematuria. Increased warfarin dose from 4 to 5mg daily, but changed back to 4mg once near therapeutic at INR 1.8. The plan for patient's coumadin management was confirmed with her primary physician by phone on [**2144-3-3**]. . # Difficulty swallowing: Bedside swallow eval normal. . # FEN: Regular diet (per patient's wishes). Repleted hypomagnesemia and hypokalemia. . # DVT PPx: On warfarin 4mg QPM (last dose in hospital on [**3-4**] with 5 mg). . # Precautions: Fall, contact ([**Name (NI) **] in urine). . # Lines: Port. . # CODE: DNR/DNI. . Transitional Issues: 1. Coumadin titration: will have INR checked on Mon and Thurs by [**Name (NI) 269**] and results sent to Dr. [**Last Name (STitle) 48223**]. Have confirmed these plans by phone with Dr. [**Last Name (STitle) 48223**] on [**3-3**]. 2. Sacral decubitus ulcer and coccygeal osteomyelitis: No surgical management. Will continue daily dressing and packing with visiting nurses at home. 3. Assessment of volume status and electrolyte abnormalities: has required Mg supplementation ~ twice weekly as inpatient. She will have electrolytes and CBC drawn STAT on Mon and Thurs and results sent to Dr. [**Last Name (STitle) 48223**]. She will take po Mg supplements and has IV Mg supplements available with home IV through [**Location (un) 511**] Home therapies. If needed she can also receive IVF at home. These plans have been confirmed by phone with Dr. [**Last Name (STitle) 48223**] on [**3-3**]. 4. Pain management: Have been using Dilaudid oral elixir 20mg/ml. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] of palliative care is available to Dr. [**Last Name (STitle) 48223**] to assist with pain control by email or page. Medications on Admission: -abacavir-lamivudine [[**Last Name (STitle) 70848**]] 600 mg-300 mg Tablet daily -albuterol sulfate every 4-6 hours as needed for wheezing -chlorhexidine gluconate 0.12 % Mouthwash swish and spit twice a day -darunavir [Prezista] 400 mg Tablet 2 Tablet(s) by mouth once a day -ergocalciferol (vitamin D2) [Vitamin D] 50,000 unit Capsule daily -folic acid 1 mg Tablet 1 Tablet(s) by mouth QDAY -hydromorphone 4 mg Tablet 3 Tablet(s) by mouth q 2 hours as needed for pain during severe GI symptoms -hydromorphone [Dilaudid-5] 1 mg/mL Liquid 15 milligrams(s) by mouth q.2hours as needed for p.r.n. [**2144-1-31**] -IVF NS at 125 cc/hr for NPO orders please have 8 hr pump start IVF with NS over 8hrs for 1000cc as needed for go to ER if persists -lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 56864**] 5 mg Tablet 1 Tablet(s) by mouth day -lorazepam 1 mg Tablet 2 Tablet(s) by mouth q2 hr and 2 qhs as needed for insomnia [**2144-1-31**] -magnesium sulfate 16 mEq (2 g)/ 500 cc NS please deliver over 4 hours once per week [**2144-1-2**] -methadone 10 mg Tablet 1 Tablet(s) by mouth 5 times/day [**2144-1-21**] Renewed [**Doctor Last Name **] -mirtazapine 15 mg Tablet One Tablet(s) by mouth Q.h.s. -nortriptyline 25 mg Capsule 1 Capsule(s) by mouth once a day may increase to two tabs per day -nystatin (bulk) 100 million unit Powder applied to affected area t.i.d. as needed for p.r.n. [**2144-1-16**] -potassium chloride 20 mEq/15 mL Liquid 1 tbsp(s) by mouth twice a day [**2143-11-28**] -pregabalin [Lyrica] 150 mg Capsule 1 Capsule(s) by mouth three times a day (Dose adjustment - no new Rx) [**2143-11-25**] -ritonavir [Norvir] 100 mg Capsule 1 Capsule(s) by mouth once a day -warfarin 5 mg Tablet 1 Tablet(s) by mouth at bedtime -warfarin 2 mg Tablet 2 Tablet(s) by mouth once a day [**2143-11-5**] Renewed [**Doctor Last Name **], -zolpidem 10 mg Tablet 1 Tablet(s) by mouth at bedtime [**2143-11-21**] -cyanocobalamin (vitamin B-12) 500 mcg Tablet 2 Tablet(s) by mouth once a day -ferrous sulfate 325 mg (65 mg iron) Tablet 1 Tablet(s) by mouth twice a day [**2143-10-10**] -lactobacillus rhamnosus GG [Culturelle] 10 billion cell Capsule 1 Capsule(s) by mouth once a day [**2144-1-31**] -loperamide [Lo-Peramide] 2 mg Tablet 2 tablets Tablet(s) by mouth as needed (Prescribed by Other Provider; OTC) -magnesium chloride [Slow-Mag] 71.5 mg Tablet, Delayed Release (E.C.) 2 Tablet(s) by mouth twice a day (OTC) -magnesium [Magtab] 84 mg Tablet Extended Release 1 Tablet(s) by mouth twice a day [**2143-11-25**] -miconazole nitrate [Aloe Vesta] 2 % Ointment apply to perineum, inguinal region twice a day as needed for prn Discharge Medications: 1. hydromorphone 20mg/mL [**Year (4 digits) **]: 20-30 mg Q 2 hours prn as needed for pain: 20mg = 1mL. Use 20mg every two hours as needed from 8AM until 10PM. Use 20-30 mg every two hours as needed after bedtime until 6AM. DO NOT USE MORE THAN 20MG Q2Hours prn DURING THE DAY AND EARLY EVENING. . [**Year (4 digits) **]:*250 mL* Refills:*0* 2. abacavir-lamivudine 600-300 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*2* 3. darunavir 400 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO DAILY (Daily). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*2* 4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 5. ritonavir 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 6. Hospital Bed semi electric hospital bed patient has a medical condition that requires positioning of the body not feasible in an ordinary bed to alleviate pain Dx: bilateral lower extremity paralysis, chronic pain, stage IV sacral ulceration with likely osteomyelitis 7. Hydrate IVF: Normal Saline at 125 cc/hr for NPO orders please have 8 hr pump start IVF with NS over 8hrs for 1000cc as needed daily for dehydration or NPO go to ER if persists 8. Hydrate IVF: Normal saline 500 cc bolus please deliver bolus over 2 hours for acute dehydration due to small bowel obstruction qd as needed for dehydration 9. Lab Draw from Port a cath please flush portacath and draw stat labs Na, K, cl, co2, Mg, Bun, Cr, CBC twice each week on Mondays and Thursdays report labs to Drs [**Name5 (PTitle) 48223**] [**Telephone/Fax (1) 18820**] 10. IV magnesium magnesium sulfate 16 mEq (2 g)/ 500 cc NS please deliver over 4 hours twice per week 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Telephone/Fax (1) **]: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. [**Telephone/Fax (1) **]:*1 inhaler* Refills:*2* 12. chlorhexidine gluconate 0.12 % Mouthwash [**Telephone/Fax (1) **]: Five (5) cc Mucous membrane twice a day: swish and spit. [**Telephone/Fax (1) **]:*300 cc* Refills:*2* 13. Vitamin D2 50,000 unit Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO once a day. [**Telephone/Fax (1) **]:*30 Capsule(s)* Refills:*2* 14. folic acid 1 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO once a day. [**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2* 15. lorazepam 0.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: [**Month (only) 116**] take 2 at bedtime. [**Month (only) **]:*60 Tablet(s)* Refills:*1* 16. methadone 10 mg Tablet [**Month (only) **]: 1.5 Tablets PO Q6H (every 6 hours). [**Month (only) **]:*180 Tablet(s)* Refills:*0* 17. mirtazapine 15 mg Tablet [**Month (only) **]: One (1) Tablet PO HS (at bedtime). [**Month (only) **]:*30 Tablet(s)* Refills:*1* 18. pregabalin 25 mg Capsule [**Month (only) **]: Two (2) Capsule PO TID (3 times a day). [**Month (only) **]:*180 Capsule(s)* Refills:*2* 19. warfarin 2 mg Tablet [**Month (only) **]: Two (2) Tablet PO Once Daily at 4 PM. [**Month (only) **]:*60 Tablet(s)* Refills:*2* 20. nortriptyline 25 mg Capsule [**Month (only) **]: Two (2) Capsule PO at bedtime. [**Month (only) **]:*30 Capsule(s)* Refills:*2* 21. B complex vitamins Capsule [**Month (only) **]: One (1) Cap PO DAILY (Daily). [**Month (only) **]:*30 Cap(s)* Refills:*2* 22. multivitamin Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily). [**Month (only) **]:*30 Tablet(s)* Refills:*2* 23. prochlorperazine maleate 5 mg Tablet [**Month (only) **]: 1-2 Tablets PO every six (6) hours as needed for nausea. [**Month (only) **]:*30 Tablet(s)* Refills:*0* 24. thiamine HCl 100 mg Tablet [**Month (only) **]: One (1) Tablet PO once a day. [**Month (only) **]:*30 Tablet(s)* Refills:*2* 25. miconazole nitrate 2 % Ointment [**Month (only) **]: One (1) application Topical twice a day as needed for rash: perineum and inguinal area as needed. [**Month (only) **]:*60 grams* Refills:*0* 26. Outpatient Lab Work Check stat INR every [**Month (only) 766**] and Thursday and report to Dr. [**Last Name (STitle) 48223**] [**Telephone/Fax (1) 18820**] 27. Heparin Flush (100 units/ml) [**Telephone/Fax (1) **]: 5 ml IV prn Desccessing port. Flush port with 10 ml normal saline followed by Heaparin as above per lumen. 28. Heparin Flush (10units/ml) [**Telephone/Fax (1) **]: flush with 10ml normal saline followed by 5 ml of heparin at above concentration daily and prn per lumen. 29. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release [**Telephone/Fax (1) **]: One (1) Capsule, Extended Release PO twice a day. [**Telephone/Fax (1) **]:*60 Capsule, Extended Release(s)* Refills:*2* 30. loperamide Oral 31. Slow-Mag 71.5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2) Tablet, Delayed Release (E.C.) PO twice a day. [**Telephone/Fax (1) **]:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Abdominal pain. Bowel infarct/ischemia. Acute kidney failure. Shortness of breath. Hypoxia (low oxygen levels). Pneumonia. Sacral decubitus ulcer and coccyx osteomyelitis (bone infection). Radiation fibrosis. Radiation enteritis (radiation damage to the bowels). Obstructive uropathy (blocked ureters). History of rectal cancer. HIV. Chronic DVT (deep vein thrombosis, old clots in legs). Acute kidney failure. Metabolic acidosis. Encephalopathy (delirium, confusion). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for abdominal pain. CT scan showed bowel ischemia/infarct (bowel wall damage due to lack of blood supply). You were evaluated by the surgeons who did not feel that surgery was an option. Therefore, you were evaluated by the palliative care team to help you focus on pain control related to you abdominal pain. Unexpectedly, you recovered from this, so your pain medications were changed to an oral form. During this process, you developed shortness of breath and low oxygen levels (hypoxia) due to pneumonia. This was treated with IV antibiotics. Wound Care also helped dress the ulcer between the buttocks (sarcral decubitus ulcer). The Plastic Surgeons felt that surgery to this area including debridement would not be helpful at this time, but may be needed in the future depending on the infection. During the hospital stay, your course was complicated by acute kidney failure and a metabolic acidosis, for which you were given IV fluids and sodium bicarbonate. You were also seen by the kidney doctors and your [**Name5 (PTitle) 4006**] function slowly improved. You also had a period of altered mental status (acute delirium, confusion). To evaluate this, you had a head CT and MRI, EEG, and a Neurology consultation. The cause was likely due medications and the doses of methadone, pregabalin (Lyrica), and lorazepam (Ativan) were all decreased. Eventually, you were able to transition from IV pain medication to oral and discharged to home with [**Name5 (PTitle) 269**] nursing services. . Medication changes: 1. STOP Lisinopril 2. DECREASE lorazepam (ativan) to 0.5 mg every 4 hours as needed. you may take 1.0 mg at bedtime if needed 3. INCREASE Methadone to 15 mg every 6 hours 4. STOP Nystatin 5. STOP Potassium Chloride liquid 6. STOP Zolpidem 7. START Dilaudid 20mg/ml elixir. You may take 20 mg (1 ml)every 2 hours as needed through the day and early evening to 10PM. You may take 30 mg (1.5ml) every 2 hours as needed beginning at 10PM until 6AM. YOU SHOULD NOT TAKE MORE THAN 20mg (1 ml)EVERY 2 HOURS DURING THE DAY AND EARLY EVENING. 8. DECREASE Pregabalin (lyrica) to 50 mg three times daily Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) 48223**] at the [**Location (un) 620**] office on Thursday [**3-12**] at 10:10 AM. . Please call the ostomy clinic at [**Telephone/Fax (1) 23664**] to coordinate a follow up appointment in the outpatient ostomy clinic when you return for other appointments at the medical center. . Draw stat labs from PORT every [**Telephone/Fax (1) 766**] and Thursday including Na, K, Cl, CO2, Mg, BUN, Cre, and CBC. Report labs to Dr. [**Last Name (STitle) 48223**] F[**Telephone/Fax (1) 18820**]. . Draw INR stat every [**Telephone/Fax (1) 766**] and Thursday and report to Dr. [**Last Name (STitle) 48223**] F[**Telephone/Fax (1) 18820**].

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356, 3088

11648, 12587

7855, 8632

27798, 27935

3506, 6871

6887, 7153

14,765

141,204

50973

Discharge summary

report

Admission Date: [**2184-5-12**] Discharge Date: [**2184-5-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4052**] Chief Complaint: Black stools Major Surgical or Invasive Procedure: EGD History of Present Illness: [**Age over 90 **] y/o Hispanic male with a h/o CAD s/p stent to LAD in '[**72**], PVD, and HTN who was referred from his PCP's office on [**2184-5-12**] with complaints of melena x 2 days. Pt was in his usual health until 2 days PTA when he noted black tarry stools. He denied any chest pain, SOB, LH, N/V, hematemasis, diarrhea, constipation, and abdominal pain. He was lightheaded prior to having a bowel movement the day PTA but resolved after drinking 1L of [**Location (un) 2452**] juice. Denies any recent stress, NSAID use, or illness. Per PCP, [**Name10 (NameIs) 5348**] hct 43. BUN/creat 24/1.2, PLT 130s x years. . In ED, NGL was grossly positive with fresh blood and blood clots but cleared with 250 mL NS. Pt was initially admitted to the MICU for an UGIB and then transferred to the medical floor when hemodynamically stable. . ROS is negative. He is active at [**Name10 (NameIs) 5348**] and walks 30 minutes daily without any problems. . Pt underwent an EGD on [**2184-5-13**] which revealed a duodenal ulcer which was successfully cauterized. Pt arrived to the medical floor hemodynamically stable without any complaints. Past Medical History: CAD s/p proximal LAD stent in 7/96 Moderate to severe MR [**First Name (Titles) **] [**Last Name (Titles) **] PVD Kidney stones Basal cell CA L ear Glaucoma Social History: Lives alone, daily ADLS, no tobacco, ETOH, or illicit drug abuse. Family History: No gastric cancer, colon ca, DM or CAD. Physical Exam: PE: T 97.6 BP 122/44 HR 69 97% 2L NC GEN: Pleasant, elderly male in NAD. HEENT: NC/AT. MMM. OP clear. NECK: No LAD or JVD. CV: S1, S2 with Grade II/VI holosystolic murmur, heard best at apex. PULM: CTAB without wheezes or crackles. ABD: Soft, NT/ND with normoactive BS. EXT: No c/c/e. NEURO: A/O x 3. Pertinent Results: [**2184-5-12**] 01:55PM BLOOD WBC-14.3*# RBC-3.42* Hgb-11.7* Hct-33.7* MCV-99* MCH-34.2*# MCHC-34.7 RDW-14.8 Plt Ct-168 [**2184-5-14**] 06:35AM BLOOD WBC-11.6* RBC-3.36* Hgb-11.4* Hct-32.6* MCV-97 MCH-33.8* MCHC-34.9 RDW-15.7* Plt Ct-129* [**2184-5-12**] 01:55PM BLOOD Glucose-117* UreaN-70* Creat-1.3* Na-137 K-4.6 Cl-105 HCO3-24 AnGap-13 [**2184-5-14**] 06:35AM BLOOD Glucose-82 UreaN-26* Creat-0.9 Na-140 K-3.7 Cl-110* HCO3-19* AnGap-15 [**2184-5-12**] 01:55PM BLOOD ALT-13 AlkPhos-58 Amylase-66 TotBili-0.4 [**2184-5-13**] 04:26AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.2 [**2184-5-15**] 08:45AM BLOOD WBC-8.5 RBC-3.11* Hgb-10.4* Hct-30.0* MCV-96 MCH-33.5* MCHC-34.8 RDW-15.8* Plt Ct-127* [**2184-5-15**] 08:45AM BLOOD Glucose-102 UreaN-17 Creat-0.9 Na-137 K-4.0 Cl-106 HCO3-22 AnGap-13 . EGD with evidence of a duodenal ulcer which was cauterized. Brief Hospital Course: [**Age over 90 **] y/o M with CAD and PVD who was initially admitted to the MICU for UGIB now s/p EGD with the finding of a duodenal ulcer which was successfully cauterized. The following issues were addressed during this admission. . 1. UGIB Pt presented to the ED after melena x 2 days. The pt was admitted to the MICU intially for intensive management of his UGIB. He underwent an EGD with the GI service and a duodenal ulcer was found which was successfully cauterized. The pt was then monitored on the medical floor for any evidence of re-bleeding. His HCT remained stable and he had no further black stools. His outpatient PCP will follow up on his H. pylori serologies. Medications on Admission: Atenolol 25 mg daily Lisinopril 5 mg qday ASA 325 mg daily Trusopt 2% both eyes TID Xalatan 0.005% L eye qhs Discharge Medications: 1. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Upper GI bleed from duodenal ulcer . Secondary: CAD HTN Discharge Condition: The patient was discharged hemodynamically stable afebrile with appropriate follow up. Discharge Instructions: You were admitted with upper stomach bleeding from a duodenal ulcer. You are to avoid all anti-inflammatory medications (Ibuprofen, Motrin, Aleve, Advil, etc) as these may worsen your bleeding. Please take medications as below. You were started on an anti-acid medication which you should continue to take twice daily until instructed to stop by a physician. [**Name10 (NameIs) 357**] do NOT restart your Atenolol, Lisinopril, or Aspirin until you see your doctor. If you develop new abdominal pain, nausea or vomiting blood, diarrhea, bloody stools, or any other concerning symptoms, please call Dr. [**Last Name (STitle) 1266**] or report to the nearest ER. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1266**] 2-4 weeks after discharge. Call [**Telephone/Fax (1) 608**]. You may require a course of antibiotics based on a blood test that was still pending at time of discharge. Your previously scheduled appointments: Provider: [**Name10 (NameIs) 3833**] Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2184-9-15**] 9:30 Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2184-11-4**] 9:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**] Completed by:[**2184-5-20**]

[ "403.90", "414.01", "V45.82", "443.9", "600.00", "288.60", "424.0", "532.40", "585.9" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

4165, 4223

2974, 3652

275, 281

4332, 4421

2104, 2951

5134, 5785

1727, 1768

3811, 4142

4244, 4311

3678, 3788

4445, 5111

1783, 2085

223, 237

309, 1448

1470, 1628

1644, 1711

78,061

179,483

43425

Discharge summary

report

Admission Date: [**2165-9-9**] Discharge Date: [**2165-9-11**] Date of Birth: [**2113-11-15**] Sex: M Service: MEDICINE Allergies: Simvastatin Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: cardiac catheterization with bare metal stent to the mid left anterior descending artery History of Present Illness: Patient is a 51 year-old male with a past medical history of NSTEMI in [**2161**] s/p POBA to the culprit occluded ramus and DES to the LAD, depression presenting with acute onset chest pain beginning at around 8 AM as his car was getting towed and he was running. He describes the pain as pressure-like beginning substernally, radiating to the back and right side of the chest, initially an [**6-26**], associated with SOB and some nausea. Of note, he had not taken his aspirin this morning. The pain went down slightly after this event, and he went to his psychiatry appointment at [**Hospital1 **]. While at the appointment, the pressure was present at roughly [**5-26**]. The appointment ended, and he was walking to the car when the pressure, SOB, and nausea became so severe that he could not walk. He thus presented to the ED. . On arrival to the ED, initial vitals were 96.3 73 142/91 16 100%. Initial ECG showed NSR, no ST changes compared with prior. Patient received aspirin and NG, and the pain came down to [**2-24**], became more comfortable. A half an hour, patient was sleeping, but upon awakening reported worsening 7/10 chest pain, not relieved with 3 x NG. A repeat ECG showed NSR, new RBBB, right asix deviation, [**Street Address(2) 1766**] depressions V2/V3 with a deep S wave in V4/V5, 1-2 mm STE in v3/v4. Code STEMI called, patient started on a heparin gtt, given Plavix 600 mg, started on an integrillin gtt, and taken to the cath lab. In the cath lab, cath showed aneurysm formation within the DES to the LAD, with stents widely patent except for a 70-80% stenosis in the mid LAD. This lesion was ballooned and a BMS (Integrity) placed. He arrived to the CCU pain free and comfortable. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He is normally very active, walking 30-40 min several days a week, walking flights of stairs without issue. . Of note, after his NSTEMI, he was started on metoprolol and lisinopril. The lisinopril was discontinued after symptoms of lightheadedness, and metoprolol discontinued in [**2162**] after he had fatigue and lightheadedness. He has had intolerance to lipitor, zetia in the past secondary to vague symptoms (abdominal pain, fatigue). Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD, PTCA to Ramus in [**2161**] - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: . 1. Status post penile surgery. 2. Perioral vitiligo. 3. Erectile dysfunction. 4. CAD: Acute MI [**9-16**], s/p stenting to LAD and PTCA to ramus 5. Depression Social History: Lives at home with wife. [**Name (NI) **] 4 children. Manages a [**Doctor Last Name 9381**] gas station. He denies tobacco, ETOH, or drug use. Family History: No history of premature cardiac disease in family. Otherwise noncontibutory. Physical Exam: ADMISSION PHYSICAL EXAM: . Tm: 36.6 ??????C (97.9 ??????F), Tc: 36.6 ??????C (97.9 ??????F) HR: 77 (73 - 102) bpm BP: 125/77(90) {112/69(82) - 131/80(91)} mmHg RR: 25 (19 - 25) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 65 Inch General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal, No(t) Widely split ), No(t) S4 Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed . DISCHARGE PHYSICAL EXAM: . Tm: 36.8 ??????C (98.2 ??????F), Tc: 36.8 ??????C (98.2 ??????F)HR: 78 (73 - 102) bpm BP: 102/61(65) {94/51(58) - 131/113(117)} mmHgRR: 19 (19 - 25) insp/min SpO2: 97% General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Cardiovascular: RRR, nl S1/S2, no m/r/g S4, no elevated JVP Peripheral Vascular: 2+ peripheral pulses in UE??????s and LE??????s Respiratory / Chest: CTAB, no rales Abdominal: Soft, Non-tender, Bowel sounds present Extremities: No significant LE edema Skin: Not assessed Neurologic: CN??????s III-XII intact, [**3-21**] motor in BUE and BLE??????s, no gross sensory deficits Pertinent Results: ADMISSION LABS: . [**2165-9-9**] 10:20AM BLOOD WBC-10.2 RBC-5.15 Hgb-16.1 Hct-45.2 MCV-88 MCH-31.2 MCHC-35.5* RDW-12.5 Plt Ct-278 [**2165-9-9**] 10:20AM BLOOD Neuts-73.5* Lymphs-18.7 Monos-5.3 Eos-1.9 Baso-0.5 [**2165-9-9**] 10:20AM BLOOD Plt Ct-278 [**2165-9-9**] 06:15PM BLOOD Plt Ct-308 [**2165-9-9**] 10:20AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-138 K-3.6 Cl-102 HCO3-25 AnGap-15 [**2165-9-9**] 10:20AM BLOOD Lipase-61* [**2165-9-9**] 10:20AM BLOOD CK-MB-4 [**2165-9-9**] 10:20AM BLOOD cTropnT-<0.01 [**2165-9-9**] 06:15PM BLOOD CK-MB-48* cTropnT-2.64* [**2165-9-10**] 04:25AM BLOOD CK-MB-34* MB Indx-8.0* cTropnT-1.66* . PERTINENT LABS: . [**2165-9-10**] 04:25AM BLOOD CK(CPK)-423* [**2165-9-9**] 10:20AM BLOOD Lipase-61* [**2165-9-9**] 10:20AM BLOOD CK-MB-4 [**2165-9-9**] 10:20AM BLOOD cTropnT-<0.01 [**2165-9-9**] 06:15PM BLOOD CK-MB-48* cTropnT-2.64* [**2165-9-10**] 04:25AM BLOOD CK-MB-34* MB Indx-8.0* cTropnT-1.66* [**2165-9-10**] 04:25AM BLOOD %HbA1c-5.4 eAG-108 [**2165-9-10**] 04:25AM BLOOD Triglyc-150* HDL-38 CHOL/HD-3.6 LDLcalc-67 LDLmeas-79 . DISCHARGE LABS: . [**2165-9-11**] 06:00AM BLOOD WBC-9.1 RBC-4.98 Hgb-15.2 Hct-44.5 MCV-90 MCH-30.5 MCHC-34.1 RDW-12.4 Plt Ct-298 [**2165-9-11**] 06:00AM BLOOD Plt Ct-298 [**2165-9-11**] 06:00AM BLOOD PT-11.8 PTT-27.9 INR(PT)-1.0 [**2165-9-11**] 06:00AM BLOOD Glucose-105* UreaN-11 Creat-0.8 Na-136 K-4.1 Cl-103 HCO3-25 AnGap-12 [**2165-9-11**] 06:00AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1 . MICRO/PATH: . MRSA Screening: PENDING . IMAGING/STUDIES: . Cardiac Cath [**2165-9-9**]: FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful PCI of ISRS proximal LAD with BMS. 3. Successful RRA TR band. . ECG [**2165-9-6**]: Sinus rhythm. Resolution of anterior ST segment elevation. Morphology of this tracing is identical to that seen on tracing #1. Right bundle-branch block is no longer seen. . TTE [**2165-9-10**]: LVEF 60% The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). However, the midventricular segment of the anterior and lateral walls appears hypokinetic. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is mild bileaflet mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2162-9-17**], the findings are similar. Brief Hospital Course: 51 year-old male with a past medical history of NSTEMI in [**2161**] s/p POBA to the culprit occluded ramus and DES to the LAD, hyperlipidemia, depression presenting with acute onset chest pain this morning, symptoms indicative of unstable angina, new RBBB, J point elevations on ECG, now s/p BMS to mid LAD lesion. . ACTIVE DIAGNOES: . # NSTEMI S/P BMS to LAD: Pt presented same day with acute severe anginal chest pain, ECG showed NSR, new RBBB, right asix deviation, [**Street Address(2) 1766**] depressions V2/V3 with a deep S wave in V4/V5, 1-2 mm STE in v3/v4. Code STEMI was called, patient started on ASA 325mg, heparin drip, loading dose of Plavix, started on an integrillin drip, and taken to the cath lab. Cath showed aneurysm formation within the DES to the LAD, with stents widely patent except for a 70-80% stenosis in the mid LAD. This lesion was ballooned and a BMS (Integrity) placed to mid LAD. His pain rapidly improved and follow-up EKG's showed resolution of his RBBB and normal sinus rhythm. TTE showed LVEF of 60% but the midventricular segment of the anterior and lateral walls appear hypokinetic. He was discharged on 325 aspirin daily, 75mg plavix, 25 metoprolol tartrate [**Hospital1 **], and re-started on his prior home crestor with follow-up arranged with his outpt PCP and cardiologist. He was instructed to to stop his niacin and ibuprofen. . CHRONIC DIAGNOSES: . # HLD: Stable. Total Chol 135, Trigs 150, HDL 38, LDL 79. He was re-started on his home crestor 5mg PO 3 days weekly. He did not previously tolerate atorvaststain (developed weakness and abdominal pain) and has had trouble with other statins previously. . # Depression: Stable. Continued on his home citalopram. . TRANSITIONAL ISSUES: . 1)Pt has new BMS to mid LAD, on plavix and ASA 325mg. Follow-up set up with his home cardiologist who will manage his cardiac meds. 2)Pt has history of poor medication compliance especially with statin drugs. His LDL was 79 here, would likely benefit from aggressive lowering to <70. He is on the largest dose of crestor that we think he will presently tolerate. Would attempt to uptitrate as an outpatient. Medications on Admission: - Citalopram 20 mg - Ibuprofen 400 TID PRN - Niacin [Niaspan Extended-Release] 500 mg PO BID - NG .4 SL PRN - Crestor 5 mg once a day - Tacrolimus [Protopic] 0.1 % Ointment apply to affected areas [**Hospital1 **] - Aspirin 81 mg Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Disp:*25 tablets* Refills:*0* 3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO three times a week. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Non ST Elevation myocardial infarction Dyslipidemia Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 93439**], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted to the hospital because you were having a heart attack. You had a catheterization of your heart, and you were found to have a blockage in your left anterior descending artery that was cleared and a bare metal stent was placed. You will need to take plavix and aspirin every day for at least one month and likely for much longer. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s or stop taking Plavix unless Dr. [**Last Name (STitle) **] tells you that it is OK. You should continue to take your other medicines as noted below. Please follow physical therapy instructions for activity for the next few weeks. . We made the following changes to your medicines: 1. STOP taking Ibuprofen, take tylenol as needed for pain instead 2. Increase aspirin to 325 mg daily 3. START taking clopidogrel (Plavix) to keep the stent from clotting off and causing another heart attack. Only Dr. [**Last Name (STitle) **] will tell you when it is OK to stop this medicine 4. START taking metoprolol twice daily to help your heart recover from the heart attack. 5. Continue Crestor at 5 mg daily to lower your cholesterol. Please try to take every day if you can. 6. STOP taking niacin per Dr. [**Last Name (STitle) **] Followup Instructions: Department: PSYCHIATRY When: MONDAY [**2165-10-21**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1387**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**] Campus: EAST Best Parking: Main Garage Department: [**Hospital3 249**] When: FRIDAY [**2165-9-13**] at 3:00 PM With: [**Doctor First Name 26**] KOPLOW, LICSW [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: THURSDAY [**2165-11-7**] at 9:10 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: MONDAY [**2165-9-16**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2165-9-25**] at 11:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2165-9-11**]

[ "E878.1", "V45.82", "996.72", "V45.89", "309.0", "414.01", "426.4", "412", "410.11", "272.4" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.06", "00.66", "88.56", "00.45", "99.20", "00.40" ]

icd9pcs

[ [ [] ] ]

11182, 11188

8006, 9719

283, 374

11295, 11295

5207, 5207

12841, 14409

3683, 3761

10431, 11159

11209, 11274

10177, 10408

6766, 7983

11446, 12818

6289, 6749

3801, 4536

3200, 3313

9740, 10151

233, 245

402, 3090

5223, 5837

11310, 11422

5853, 6273

3344, 3506

3112, 3180

3522, 3667

4561, 5188

5,372

169,887

23629

Discharge summary

report

Admission Date: [**2196-4-28**] Discharge Date: [**2196-5-4**] Date of Birth: [**2120-7-25**] Sex: F Service: Briefly, this is a 75-year-old female who is otherwise healthy, had 2 months of abdominal pain and an increased amylase. Was found to have a cystic mass in the tail of the pancreas. She was sent to Dr. [**Last Name (STitle) 468**] for evaluation. Her past medical history is that she is otherwise healthy. Takes no medications. Has no allergies. Her physical exam: She was afebrile with stable vitals. Her lungs were clear. Heart was regular. Abdomen was soft, nontender, nondistended. Bowel sounds present. Extremities were warm and well perfused. Her lab values: Her hematocrit was 38. Her BUN and creatinine were 16 and 0.9. Her cystic fluid was drained and a CA19-9 was 3,000 and the amylase was 71,000. Patient was taken to the operating room on [**2196-4-28**] for additional pancreatectomy and splenectomy. Please see operative report for further details. Postoperatively, the patient was transferred to the intensive care unit and was weaned from the ventilator. She did quite well. After extubation, her NG tube was removed, and the patient was transferred to the floor. She continued to do well and stayed on the Whipple protocol and began ambulating. On postop day 3, her diet was slowly advanced, which she tolerated and she continues to do well. She was given her vaccinations prior to discharge. Patient continued to improve and her diet was slowly advanced. Her wounds are clean, dry, and intact and she did well with physical therapy. The patient was thought to be safe to be discharged home when she was done with her medical treatment. She continued to slowly do well and on [**2196-5-4**], patient was tolerating a regular diet and her pain was controlled with p.o. pain medication. It was decided that patient could be discharged home. She was discharged in stable condition. Her postoperative labs were unremarkable. Her JP drain continued to put out small amounts of serosanguineous fluid. The JP continued to put small amounts out, and the JP was removed on [**2196-5-3**]. The patient was discharged home on [**2196-5-4**] after tolerating regular food and having pain well controlled. Her staples were removed prior to discharge. Her discharging medications included Lopressor 25 mg p.o. b.i.d., Protonix 40 mg p.o. daily, Percocet 1-2 tablets p.o. q.4h. p.r.n., Levoxyl 88 mcg p.o. daily, Colace 100 mg p.o. b.i.d. The patient was discharged in stable condition. Instructed to followup with Dr. [**Last Name (STitle) 468**] and to call with any questions. [**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], [**MD Number(1) 7543**] Dictated By:[**Doctor Last Name 11225**] MEDQUIST36 D: [**2196-8-18**] 09:22:02 T: [**2196-8-18**] 09:37:15 Job#: [**Job Number 60457**]

[ "211.6", "E878.6", "244.0", "577.1", "V10.87", "276.2", "786.1", "995.1" ]

icd9cm

[ [ [] ] ]

[ "52.52", "41.5", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

497, 2868

7,809

114,572

48887

Discharge summary

report

Admission Date: [**2135-5-13**] Discharge Date: [**2135-5-18**] Date of Birth: [**2078-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2009**] Chief Complaint: Hyperglycemia, abdominal pain, n/v Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a 56 year old female with hx of DMI (x5 years), b/l dropped feet, [**Doctor Last Name **] disease with frequent admissions for diabetic Ketoacidosis presenting with DKA and gastroparesis flare. . The patient reports that she has had abdominal pain for the past 2-3 days, which is consistent with her gastroparesis. Nausea and vomitting has increased in intensity over the past 3 days. She was unable to tolerated a diet all day yesterday, so her daughter called EMS. The patient reports that she continued to vomit overnight. The patient reports fevers to 102-103. She reports [**10-30**] abdominal pain. She has not had emesis since last night. She reports no chills. some cough, nonproductive. no dysurea. no diarrhea, but reports being chronically constipated, has not had BM in 3 days. The patient was confused in the ER, but on the floor she is A&Ox3. Patient also reports that FS have been increaseing . In the ER, intial vitals were, T 97.7, BP 133/58, HR 110, RR 16, O2sat 100%. Her access was very difficult to obtain in the ER, an eventually a femoral cvl was obtained. After this, she recieved 2L NS, insulin IV bolus of 7units, then drip at 7units/hour. She had a foley placed. Her anion gap was 33. . Review of sytems: (+) Per HPI (-) Denies ,chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: # DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**]. Several episodes of DKA, managed on 28U Lantus [**Hospital1 **] plus HISS - Frequent episodes of DKA - DKA has been complicated by CVA, 3 episodes suspected (including [**2135-5-14**] episode) # Diabetic polyneuropathy and gastroparesis # Hypertension # Grave's disease s/p RAI [**2129**] # Reactive airway disease # Seronegative arthritis, followed in rheumatology # Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, never been on antiviral therapy, acquired via blood transfusion during surgery in [**2110**] # GERD # Migraines # Bilateral knee arthroscopy in [**5-24**] # s/p TAH and pelvic floor surgery with bladder lift # Depression # Bone spurs in feet # Bilateral foot drop requiring wheelchair use Social History: Patient lives in a multi apartment building in the same apartment with a daughter, grandaughter, and grandson. She has a son, daughter and another brother who live on another floor. She is a never smoker and does not use alcohol or drugs. She has not worked for many years. She uses a wheelchair at baseline. Family History: Her mother died of colon cancer. There are multiple family members with DM Physical Exam: Admission: Vitals: T: 96.4 BP: 161/71 P: 120 R: 23 O2: 100% on 2L General: Alert, oriented, no acute distress [**Date Range 4459**]: Sclera anicteric, mucous membranes dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, tender to palpation throughout, no rebound, no acute abdomen GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Patient has b/l drop foot. . On discharge: Vitals: T: 98.1 BP: 124/86 P: 77 R: 16 O2: 97% on 2L General: Alert, oriented, no acute distress [**Date Range 4459**]: Sclera anicteric, mucous membranes moist, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, tender to palpation throughout, no rebound, no acute abdomen GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Patient has b/l drop foot. Right fourth toe with ulcer on the medial aspect, minimal swelling. Pertinent Results: CBC: [**2135-5-13**] 12:30PM BLOOD WBC-14.8*# RBC-4.07*# Hgb-11.3*# Hct-38.0# MCV-93 MCH-27.8 MCHC-29.8* RDW-15.6* Plt Ct-323 [**2135-5-13**] 05:48PM BLOOD WBC-15.7* RBC-3.51* Hgb-9.9* Hct-32.0* MCV-91 MCH-28.2 MCHC-31.0 RDW-15.1 Plt Ct-288 [**2135-5-17**] 06:30AM BLOOD WBC-4.2 RBC-3.30* Hgb-9.6* Hct-29.1* MCV-88 MCH-29.0 MCHC-32.9 RDW-15.6* Plt Ct-194 Chem Panels: [**2135-5-13**] 12:30PM BLOOD Glucose-733* UreaN-33* Creat-1.7* Na-130* K-5.6* Cl-90* HCO3-7* AnGap-39* [**2135-5-13**] 02:50PM BLOOD Glucose-733* UreaN-34* Creat-1.6* Na-135 K-4.2 Cl-98 HCO3-LESS THAN [**2135-5-17**] 06:30AM BLOOD Glucose-144* UreaN-4* Creat-0.7 Na-140 K-3.4 Cl-105 HCO3-28 AnGap-10 [**2135-5-13**] 10:53PM BLOOD Calcium-7.4* Phos-1.3*# Mg-1.7 [**2135-5-14**] 04:24AM BLOOD Calcium-7.1* Phos-2.6* Mg-3.0* [**2135-5-17**] 06:30AM BLOOD Calcium-8.6 Phos-1.8* Mg-1.6 TFTs: [**2135-5-14**] 02:49PM BLOOD TSH-1.4 [**2135-5-14**] 02:49PM BLOOD Free T4-0.93 U/A: [**2135-5-16**] 04:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005 [**2135-5-16**] 04:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [**2135-5-16**] 04:14PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-1 Micro: [**2135-5-16**] Blood Culture, Routine-PENDING INPATIENT [**2135-5-16**] Blood Culture, Routine-PENDING INPATIENT [**2135-5-16**] URINE CULTURE-Negative [**2135-5-13**] MRSA SCREEN-Negative Radiology: CT HEAD W/O CONTRAST 1. Questionable early cytotoxic edema in the right MCA distribution, concerning for acute infarction. Based on clinical symptoms, MR head already been ordered. 2. No evidence of acute hemorrhage. MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST; MRA NECK W&W/O CONTRAST IMPRESSION: 1. No evidence of an acute infarction or other acute intracranial abnormalities. 2. Technically limited head MRV. 3. Slightly limited head MRA without evidence of significant stenosis or aneurysm larger than 3 mm. 4. Normal neck MRA. CHEST (PA & LAT) IMPRESSION: No acute cardiopulmonary findings. . Discharge labs: [**2135-5-18**] 06:40AM BLOOD WBC-5.5 RBC-3.24* Hgb-9.7* Hct-28.7* MCV-89 MCH-30.0 MCHC-33.7 RDW-15.5 Plt Ct-218 [**2135-5-18**] 06:40AM BLOOD Glucose-175* UreaN-9 Creat-0.8 Na-137 K-3.5 Cl-104 HCO3-30 AnGap-7* Brief Hospital Course: This patient is a 56 y/o F with history of DMI with frequent admissions for DKA, [**Doctor Last Name 933**], who presents with DKA and gastroparesis flare. . Diabetic Ketoacidosis: Patient with numerous admissions for DKA. Infectious workup was negative. It appears that patient developed DKA in the setting of a flare of her gastroparesis. She was started on Insulin gtt in the ER 7unit bolus then 7units/hour. She was initially admitted to the ICU. Her gap closed quickly on the insulin drip and she was started on her home dose of lantus 32 units twice daily. She was hypovolemic and was given fluid boluses with potasium. After her anion gap closed she was called out to the floor for ongoing care. Her electrolytes continued to improve, and her bicarb gradually returned to [**Location 213**]. [**Last Name (un) **] was consulted, and assisted with insulin titration. Her lantus dose was changed to [**Hospital1 **] dosing, briefly at 20 units [**Hospital1 **], however she developed recurrent hypoglycemia and her lantus was titrated down to 15 units [**Hospital1 **], with a sliding scale. This can be titrated back up as necessary. . Acute Renal Failure: Patient had acute renal failure on admission due to dehydration in setting of DKA. Creatinine was 1.7 on admission (baseline is 0.8). This resolved over the course of the admission with IV fluids/hydration. . Nausea/[**Hospital1 **]/Gastroparesis: The patient stated that she had a flare of her gastroparesis prior to developing this episode of DKA, with 10/10 abdominal pain and no bowel movement x3 days. Her gastroparesis improved and she was able to tolerate a regular diabetic diet without difficulty. There was no evidence of obstruction. She was continued on her home medications for her gastroparesis. . Right arm weakness: After MICU callout, patient complained of R arm paresthesias, weakness, and loss of coordination. Evaluating MD had concern for possible CNS ischemic event, and thus an urgent Neuro consult was obtained. A repeat head CT was performed, as well as extensive MRI imaging of the head/neck (MRI, MRA, MRV, see results). There was initially concern of a "cortical hand" (cortical CVA) from the Neuro team, and patient was placed on Q2hr neuro checks, the patient was layed flat to promote CNS perfusion, and her antihypertensives were held. However, imaging and further evaluation by the Neurology attending was not consistent with a CNS event. At this time, patient is NOT thought to have had a CVA. Her symptoms gradually improved. Patient did have some R arm edema, due to IV access and aggressive hydration, which may have caused some altered sensation. Note that at the time of initial identification of the neurologic complaints, her calcium level was noted to be low, however this corrected to 8.3 once an albumin level was obtained, and thus not likely to contribute to her symptoms. . Hypertension: Patient was initially somewhat hypertensive, but this improved with continuation of her home blood pressure medications. . [**Doctor Last Name 933**] Disease: - continued Methimazole 10 mg three times a day . Reactive airway disease: currently stable - continued Albuterol inhaler as needed - continued Advair 250/50 twice daily - continued Montelukast 10 mg daily . Diabetic Neuropathy with diabetic ulcer: Patient with known bilateral foot drop. Pt was noted to have a small wound on her left second toe from injury several weeks ago which appeared to be healing well, without any evidence of infection. She was [**Doctor Last Name 1988**] to see podiatry as an outpatient. Pt's Gabapentin was initially decreased to 300 twice daily given her acute renal failure, but this was increased back to her home dose of 900 mg three times daily once her renal function improved back to baseline. . Migraines: none currently - Her Amitriptyline 25 mg Tablet Nightly was initially held given her altered mental status on admission. This medication was later resumed. . Hepatitis C: stable currently. . Pending labs: Blood cx [**5-16**] still pending at discharge. . Key follow up: 1. Podiatry for ulcer evaluation on [**5-31**]. 2. Diabetes management with titration up of lantus. Medications on Admission: Albuterol inhaler as needed Advair 250/50 twice daily Aspirin 81 mg Tablet Daily Amitriptyline 25 mg Tablet Nightly Methimazole 10 mg three times a day Metoclopramide 10 mg Tablet QIDACHS Montelukast 10 mg daily Pantoprazole 40 mg Tablet daily Simvastatin 10 mg Tablet daily Sulfasalazine 500 mg twice daily Hyoscyamine Sulfate 0.125, 3 tabs three times daily Losartan 50 mg daily Docusate Sodium 100 mg twice a day. Humalog sliding scale Toprol 25mg daily Percocet 7.5-500 mg every 6 hours as needed pain Diazepam 5 mg Tablet twice a day. Hxdroxyzine 25mg every 6 hours PRN itching Vitamin D 50,000 weekly Zomig 2.5 mg Tablet daily as needed nausea Gabapentin 900 mg Capsule 3 times a day Insulin Lantus 32 units Sc twice a day Miralax 17gm daily PRN. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette 1-2 drops PRN Prednisolone Acetate 1 % 1 drop twice daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr Sig: One (1) Capsule, Sust. Release 12 hr PO Q 8H (Every 8 Hours). 13. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. 18. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 19. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous twice a day: Give 1/2 dose if NPO. 20. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) mg PO DAILY (Daily) as needed for constipation. 21. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for itching. 22. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 23. Humalog 100 unit/mL Solution Sig: Sliding Scale Subcutaneous QAC and QHS. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 1495**] [**Hospital 11042**] Rehab Discharge Diagnosis: # Diabetic ketoacidosis # Type I Diabetes # Acute renal failure # Gastroparesis flare # Right hand weaknes # Acute encephalopathy # Diabetic foot ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with an episode of your DKA, likely triggered by a flare of your gastroparesis. Please monitor your glucose closely, and follow up with your [**Last Name (un) **] providers. . You have an ulcer on your right fourth toe which does not appear infected. You will see a podiatrist in 2 weeks to evaluate it. Please contact them earlier if it worsens. . You also had right arm weakness and pain. The neurologists recommended an EMG if your symptoms persist. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] H. Appointment: [**Last Name (LF) 766**], [**5-23**], 2pm Location: UPHAMS CORNER HEALTH CENTER Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**] Phone: [**Telephone/Fax (1) 7538**] Department: PODIATRY When: TUESDAY [**2135-5-31**] at 2:45 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Contact Dr. [**Last Name (STitle) 557**], Neurology, ([**Telephone/Fax (1) 13172**] if you continue to have weakness in your right hand for an EMG test.

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icd9cm

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Discharge summary

report

Admission Date: [**2171-2-16**] Discharge Date: [**2171-2-25**] Date of Birth: [**2133-7-4**] Sex: M Service: CHIEF COMPLAINT: Nausea, vomiting, and acute pancreatitis. HISTORY OF PRESENT ILLNESS: A 38-year-old gentleman with history of hypothyroidism and acid reflux who presented with acute abdominal pain, nausea, and vomiting times one day. Pain began a day prior to admission after eating tuna fish and having a glass of wine. He described the pain as severe and crampy with nausea and vomiting, it is bilious. No hematemesis or diarrhea. Denies heavy alcohol use or gallstones or diuretic use. Also denies hypertriglyceridemia. Of note, had recent URI with symptoms of sinusitis and bronchitis and sent home on Advair and Augmentin. On arrival to the emergency room, the patient was afebrile, hypertensive at 160/96 with severe abdominal pain. Labs notable for white count of 19, 79 percent neutrophils, 5 percent bands, and lipase of 1291. All other lab values within normal limits. CT of the abdomen revealed pancreatitis with stranding and abrupt tapering of major papillae, but no visible stones. The patient received Zofran, morphine, levofloxacin, and Flagyl in the emergency room as well as IV fluids. PAST MEDICAL HISTORY: Hypothyroidism. Acid reflux. Recent history of bronchitis. Sinusitis. MEDICATIONS: At home, 1. Synthroid 125 mcg q.d. 2. Nexium q.d. 3. Hydrocodone and Vicodin just times a few days with a recent dental procedure. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Denies heavy alcohol use, drinks occasionally. Denies tobacco use. Married. Lives in [**State 16269**]. FAMILY HISTORY: No significant past family medical history. PHYSICAL EXAMINATION: Temperature 97 degrees, blood pressure 160/96, heart rate 96, and respiratory rate 16, oxygen saturation 98 percent on room air. Physical exam within normal limits, but with abdominal pain with positive hepatomegaly about 3 cm below the costal margin. Also abdomen was tender throughout especially in the epigastric region. The patient, of note, was not jaundiced and without stigmata of chronic liver disease. Positive [**Doctor Last Name 515**] sign. No abdominal distention or fluid shift or hypoactive bowel sounds. Lungs were clear. Cardiac exam within normal limits. Neuro exam within normal limits. DIAGNOSTIC STUDIES: On admission, white count 19, hematocrit 50, and platelets 230. Chemistries within normal limits. Lipase 1291, total bilirubin 0.6, ALT 35, AST 25, and alkaline phosphatase 110. ECG within normal limits except for tachycardiac at 100. Abdominal x-ray without obstruction. Chest x-ray within normal limits. CT of the abdomen was consistent with pancreatitis as mentioned in the HPI. CONCISE SUMMARY OF HOSPITAL COURSE: A 38-year-old man without known risk factors with acute onset of nausea, vomiting, and abdominal pain and workup consistent with acute pancreatitis. Pancreatitis: The patient was admitted to the medical intensive care unit on the [**Hospital Ward Name 516**] for close monitoring. The patient received aggressive IV fluids as well as pain control and blood pressure control in the ICU. The patient improved and was transferred to the medicine floor on [**2171-2-11**] approximately five days after being admitted. Unclear etiology of the pancreatitis. The patient may have passed a stone, also may have more alcohol use than he is admitting to. MRCP was performed and was normal except for 1 cm common bile duct. The patient's CMV and EBV IgM are both negative. The patient was initially n.p.o. with aggressive IV fluids and then tolerated clear liquids for comfort without pain. The patient had an NG tube placed, but this was discontinued on the medicine floor. Abdominal exam improved dramatically and was within normal limits at the time of discharge. The patient was initially on Dilaudid PCA and switched to oral agents with good pain control. The patient and his family requested discharge from the hospital on [**2171-2-25**] stating that he would seek further medical care in [**State 531**] City. The patient did not want to stay in the [**Location (un) 86**] area any further. Due to this, some medical records were faxed over to the patient's doctor in the [**State 531**] area, and he was discharged. Plan, outpatient followup with his regular PCP as well as a gastroenterologist. Hypertension and sinus tachycardia thought to be related to pain and dehydration, but continued despite PCA and IV fluids. Concern over alcohol withdrawal, but the patient was covered with CIWA scale, but did not require any benzodiazepine. ECG was also within normal limits. The patient was started on metoprolol, which was continued with good effect. Plan, outpatient followup with this. Pulmonary: Patient tachypneic with supplemental O2 needed initially likely related to abdominal distention and pain, may also be due to lung injury from pancreatitis, pleural effusion, or atelectasis from pleuritic pain. Repeat chest x- ray after admission showed a left lower lobe collapse/consolidation as well as small pleural effusion. The patient was continued on supplement oxygen, but was stable on room air at the time of discharge. Pain was controlled well. No signs or symptoms of pneumonia. Infectious disease: No signs or symptoms of an acute infection; however, the patient did have a fever of 101 while on the medicine floor likely related to atelectasis. Blood cultures and urine cultures were without growth to date at the time of discharge. Hypothyroidism: The patient was continued on Synthroid and clinically euthyroid. Fluids, electrolytes and nutrition: Positive for about 16 liters in the ICU. Patient with good urine output. The patient was on TPN in the ICU, however, was transitioned over to POs on the medicine floor. The patient's NG tube was initially at low suction, but this was discontinued on the medicine floor. The patient and family was requesting discharge from the hospital, although we recommended further continued hospital stay for close monitoring. The patient refused this stating that he wanted to go back to [**Location 8398**]where he lives and that he would seek medical attention there. Records were faxed over to his primary care physician there who agreed to see the patient upon arrival there. DISCHARGE CONDITION: Fair. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Acute pancreatitis. Malignant hypertension. Hypothyroidism. Hypoglycemia. Fever. DISCHARGE MEDICATIONS: 1. Albuterol p.r.n. 2. Synthroid 125 mcg q.d. 3. Atenolol 100 mg q.d. 4. Hydralazine 25 mg q.6 h. FOLLOW UP: Patient to follow up with the primary care physician as soon as he arrived back in [**State 531**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**] Dictated By:[**Last Name (NamePattern1) 4959**] MEDQUIST36 D: [**2171-8-13**] 14:21:35 T: [**2171-8-14**] 03:57:31 Job#: [**Job Number 52740**]

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icd9cm

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Discharge summary

report

Admission Date: [**2124-1-1**] Discharge Date: [**2124-1-5**] Date of Birth: [**2084-7-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2474**] Chief Complaint: Asthma Exacerbation Major Surgical or Invasive Procedure: None History of Present Illness: 39 y/o f with h/o mild asthma p/w cough starting Friday, which has since worsened to severe wheezing today. No fevers, having slight clear sputum. No rhinorrhea, congestion. No new medications. She has allergies to cats/dogs neither of which she was exposed to. No orthopnea/weight gain. No LE edema, pains, LE trauma. No CP/lightheadedness/diaphoresis/nausea/vomiting/abd pain/hematuria/dysuria. She takes her albuterol almost every day, 1-2 times daily. She has never been hospitalized or intubated for her asthma. She has never been on oral prednisone, just has taken flovent in the past. . In the ED she was initially 95% on a neb. HR 120 sinus, BP 148/80, RR 28-30, speaking in broken sentences. Given albuterol nebs q1h-2h with slight symptomatic improvement but continued tachypnea. CXR showed some hyperinflation but no infiltrates, no CHF. Past Medical History: 1. Asthma - dxed in 95. Treated now episodically c albuterol INH. Has been on Flovent in the past but stopped several months ago because not needed. 2. Nephrolithiasis - Admitted last year; never passed. Social History: Works at [**Hospital3 1810**] in ENT dept, no T/E/D. Family History: Daughter with asthma Physical Exam: PE ON ADMISSION TO [**Hospital Unit Name 153**] 96.7 HR 120 BP 131/56 RR 33 sat 100% high flow neb 10L/min, PF 250cc gen: severe respiratory distress, speaking in broken sentences, using accessory muscles, A+OX3 HEENT: mmm, no JVD CV: tachy, reg, no m/r/g pulm: bilat insp/exp wheezes, good air movement abd: s/nt/nd +BS ext: no edema, 2+ pulses Labs: unremarkable except ABG on continuous high flow neb 7.35/37/140 PE ON TRANSFER TO FLOOR gen: young appearing woman in NAD HEENT: OP clear, no JVD, MMM LUNGS: tight; poor air entry, inspiratory wheeze. no crackles HEART: rrr, s1, s2, no rmg ABD: soft, NT, ND, BS+ EXT: wwp, no cce NEURO: A*O*3 Pertinent Results: labs - see below imaging - [**1-1**] CXR: The lungs are clear. The heart is top normal in size. The mediastinum is within normal limits. micro - negative for influenza A/B by DFA . Labs: unremarkable except ABG on continuous high flow neb 7.35/37/140 . EKG: SR at 112, nml axis, borderline QTc, no ST or TW changes, poor R wave progression . CXR: slight hyperinflation, no infiltrates/CHF . ADMIT LABS: [**2123-12-31**] 09:00PM PT-11.8 PTT-22.2 INR(PT)-1.0 [**2123-12-31**] 09:00PM GLUCOSE-112* UREA N-7 CREAT-0.6 SODIUM-140 POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16 [**2124-1-1**] 03:38AM TYPE-ART PO2-140* PCO2-37 PH-7.35 TOTAL CO2-21 BASE XS--4 INTUBATED-NOT INTUBA [**2124-1-1**] 04:00AM PLT SMR-NORMAL PLT COUNT-263 [**2124-1-1**] 04:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2124-1-1**] 04:00AM NEUTS-90.6* BANDS-0 LYMPHS-8.1* MONOS-0.6* EOS-0.6 BASOS-0.1 [**2124-1-1**] 04:00AM WBC-17.3* RBC-4.02* HGB-11.2* HCT-33.3* MCV-83 MCH-27.8 MCHC-33.6 RDW-13.2 [**2124-1-1**] 04:35AM URINE RBC-1 WBC-1 BACTERIA-MOD YEAST-NONE EPI-[**5-6**] [**2124-1-1**] 04:35AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2124-1-1**] 04:35AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2124-1-1**] 06:20AM PT-12.8 PTT-24.0 INR(PT)-1.1 [**2124-1-1**] 06:20AM PLT COUNT-245 [**2124-1-1**] 06:20AM NEUTS-91.2* BANDS-0 LYMPHS-7.1* MONOS-0.6* EOS-0.9 BASOS-0.2 [**2124-1-1**] 06:20AM WBC-14.0* RBC-3.72* HGB-10.6* HCT-31.4* MCV-85 MCH-28.5 MCHC-33.7 RDW-12.8 [**2124-1-1**] 06:20AM CALCIUM-8.8 PHOSPHATE-2.9 MAGNESIUM-2.1 [**2124-1-1**] 06:20AM GLUCOSE-212* UREA N-6 CREAT-0.7 SODIUM-141 POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-17* ANION GAP-19 [**2124-1-1**] 10:13PM TYPE-[**Last Name (un) **] TEMP-36.1 PO2-34* PCO2-34* PH-7.45 TOTAL CO2-24 BASE XS-0 . DISCHARGE LABS: [**2124-1-5**] 05:55AM BLOOD WBC-25.0* RBC-4.21 Hgb-11.9* Hct-35.8* MCV-85 MCH-28.4 MCHC-33.3 RDW-13.8 Plt Ct-324 [**2124-1-4**] 05:30AM BLOOD WBC-23.2* RBC-4.37 Hgb-12.5 Hct-36.5 MCV-84 MCH-28.6 MCHC-34.3 RDW-12.9 Plt Ct-300 [**2124-1-1**] 06:20AM BLOOD Neuts-91.2* Bands-0 Lymphs-7.1* Monos-0.6* Eos-0.9 Baso-0.2 [**2124-1-5**] 05:55AM BLOOD Plt Ct-324 [**2124-1-4**] 05:30AM BLOOD Plt Ct-300 [**2124-1-1**] 06:20AM BLOOD PT-12.8 PTT-24.0 INR(PT)-1.1 [**2124-1-5**] 05:55AM BLOOD Glucose-85 UreaN-15 Creat-0.6 Na-136 K-3.6 Cl-100 HCO3-26 AnGap-14 [**2124-1-5**] 05:55AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0 Brief Hospital Course: In [**Name (NI) 153**], pt. thought to have asthma exacerbation triggered by viral infection. Blood gas concerning for ? acidosis but never intubated. Repeat gas more reassuring. Treated initially c solumedrol 60 q6 and then prednisone 60 [**Hospital1 **]. Weaned to q4-6 h nebs. Also started on course of azithromycin. On txf, pt. still wheezy but requiring nebs q4-6 hr and maintaining sats > 95% RA. . A/P: 39 yo F c asthma admitted for status asthmaticus now stable but still requiring nebulizer treatments . 1. Asthma - Likely viral etiology given prodrome of URI symptoms. Continued albuterol/atrovent nebs and tapered to q6h and then switched to MDI c spacer. Discharged with nebulizer machine but also tolerating MDI s need for nebs. Added on Flovent. Also discharged with prednisone taper. . 2. Leukocytosis - likely related to prednisone . 3. Nephrolithiasis - stable; U/A clear Medications on Admission: albuterol inh prn flovent inh (not taking regularly) Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day: please take four times daily x 2 days, then three times daily x 2 days, then twice daily, and then as needed. Disp:*1 MDI* Refills:*2* 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q3-4H (Every 3 to 4 Hours) as needed for shortness of breath or wheezing. Disp:*qs neb* Refills:*0* 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*2* 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*qs neb* Refills:*0* 5. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day for 4 days: 40mg (4tabs) x 1 day, 30mg (3tabs) x 1 day, 20mg (2tabs) x 1 day, 10mg (1tab) x 1 day. then off. Disp:*10 Tablet(s)* Refills:*0* 6. Nebulizers Device Sig: One (1) nebulizer Miscell. four times a day as needed for shortness of breath or wheezing. Disp:*1 nebulizer* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation Discharge Condition: Good. comfortable on room air. minimal wheezing. good air movement. no hypoxia. Discharge Instructions: Please take all medications as prescribed and plan to follow-up with Dr. [**First Name (STitle) 1022**] next week. . If you develop worsening shortness of breath or chest tightness please contact your primary care physician [**Name Initial (PRE) **]/or return the emergency department. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-1-14**] 2:00. Dr. [**Last Name (STitle) **] works with Dr. [**First Name (STitle) 1022**]. He will see you in the [**Company 191**] suite on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]

[ "E932.0", "251.8", "079.99", "276.2", "799.02", "493.91", "592.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6867, 6873

4808, 5708

332, 338

6937, 7023

2234, 4162

7357, 7834

1530, 1552

5813, 6844

6894, 6916

5735, 5790

7047, 7334

4178, 4785

1568, 2215

273, 294

366, 1217

1239, 1444

1460, 1514

17,001

165,430

3854+55511

Discharge summary

report+addendum

Admission Date: [**2140-11-28**] Discharge Date: [**2140-12-6**] Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: The patient is an 80 year old Russian speaking male with metastatic pancreatic cancer to the spleen and liver, congestive heart failure, renal insufficiency, who was brought in by EMTs after his wife found him on the floor with a rope around his neck in an apparent attempt to kill himself. He was intubated in the field and brought to the Emergency Department. According to social worker who saw him in the Emergency Department, his granddaughter was enraged by his intubation. She claimed he was DNR/DNI and she was his health care proxy but could not provide documentation. He was transferred to the Intensive Care Unit and sedated with Versed and Propofol overnight while he was medically evaluated. He did not sustain any significant trauma from the suicide attempt. Films were cleared. PAST MEDICAL HISTORY: 1. Pancreatic head mass discovered on imaging about one year ago with metastases to the liver and spleen. Complete full workup was never done, status post multiple biliary stenting procedures. 2. Hypertension. 3. Gout. 4. Diabetes mellitus type 2. 5. History of cerebrovascular accident. 6. Chronic renal insufficiency. 7. Nephrolithiasis. 8. History of right eye injury in war. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Singulair 10 mg q.h.s. 2. Percocet one q4-6hours. 3. Nitroglycerin patch p.r.n. 4. Hydralazine. 5. Protonix. 6. Amaryl. 7. Multivitamins. 8. Lasix. 9. Imdur. 10. Catapres. 11. Norvasc. 12. Toprol. 13. Dulcolax. 14. Colace. SOCIAL HISTORY: The patient was born and raised in [**Country 532**]. He was in the military, married with his current wife 55 years ago. He has one daughter and one son and two grandchildren and a very tightly knit family. He moved here with his wife ten years ago to follow their children and because of persecution from practicing Judaism. PHYSICAL EXAMINATION: On admission to the Surgical Intensive Care Unit, the patient is intubated and sedated. The lungs are clear to auscultation. Cardiac examination is benign. Abdominal examination is soft and nontender, nondistended. The extremities are warm and he is moving all four extremities spontaneously. LABORATORY DATA: White blood cell count 20.2, chronically elevated. Hematocrit 28.3 chronically anemic. Creatinine 2.6, blood urea nitrogen 46. Chest CT was without consolidation. Spine CT was without trauma. Carotids and intracranial vasculature without defects. Head CT with old right parietal occipital lesion. All other films cleared. HOSPITAL COURSE: The patient is an 80 year old male with a history of pancreatic cancer metastatic to liver and spleen, status post failed suicide attempt by hanging, intubated in the field, and initially admitted to the Surgical Intensive Care Unit. 1. Trauma - The patient initially transferred to the Surgical Intensive Care Unit for close observation. The patient's films eventually all cleared without significant trauma. The patient was transferred to the Trauma Service on the floor. The patient was then transferred to Medicine after additional medical problems arose (hyperbilirubinemia and new neurologic findings). 2. Gastrointestinal - The patient has a history of metastatic pancreatic cancer diagnosed in 08/00, with biliary stents placed in 12/00. While on the floor on the Trauma service, the patient was noted to have a bilirubin that increased from 1.1 to 8.6 over one day. The patient's bilirubin continued to increase thereafter up to 15.0. The patient most likely has a biliary obstruction. Right upper quadrant ultrasound was obtained which showed sludging but apparently a patent stent. The patient was clearly jaundiced and complained of some itching. However, his family decided that they did not wish for stenting procedure and instead are opting for comfort care. 3. Infectious disease - With the increase in bilirubin as well as the noted spiking of temperature and an increasing white count, there was concern for biliary infection due to the obstruction and the patient was treated with intravenous Zosyn for appropriate gram negative and anaerobic coverage. The patient's white count thereafter decreased and was maintained afebrile throughout the remainder of his hospital stay. The patient was also on Vancomycin during his hospital stay for Methicillin resistant Staphylococcus aureus positive sputum. The patient was transitioned to p.o. antibiotics, Levofloxacin and Flagyl, prior to discharge. 4. Neurology - The patient was noted to have a new right sided weakness of the upper and lower extremity while on the Trauma service. Magnetic resonance scan to rule out stroke was considered, but the family did not wish for an magnetic resonance scan. Instead, head CT without contrast was performed and ruled out hemorrhagic stroke. Neurology was consulted and no further recommendations were made. 5. Cardiovascular - During the Surgical Intensive Care Unit stay, the patient was noted to have a non Q wave myocardial infarction with positive troponin leak. The patient's hematocrit has been maintained at 30.0 with blood transfusions given presumed heart disease. The patient was on Lovenox for history of right arm clot but was discontinued due to liver dysfunction, increasing INR. The patient also has a history of refractory hypertension on many antihypertensives which include Toprol, Nitroglycerin paste, Lasix, Hydralazine, Clonidine patch, Imdur and Norvasc. The patient's blood pressure while in the hospital remained elevated but controlled. 6. Disposition - Palliative care was consulted and spoke with the family. They were all in agreement that the patient would be transitioned toward Hospice level of care. The patient apparently has never been told of his diagnosis according to the family wishes. The patient also has not been asking any questions. The patient has DNR/DNI status and is moving toward comfort care. The patient was screened for home Hospice care. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged home with home Hospice. DISCHARGE DIAGNOSIS: 1. Metastatic pancreatic cancer. 2. Biliary obstruction. MEDICATIONS ON DISCHARGE: 1. Regular insulin sliding scale. 2. Aspirin. 3. Protonix. 4. Norvasc. 5. Multivitamin. 6. Imdur. 7. Colace. 8. Hydralazine. 9. Clonidine patch. 10. Lasix. 11. Toprol. 12. Levofloxacin p.o. 13. Flagyl p.o. 14. Morphine Elixir. 15. Tylenol. 16. Benadryl. 17. Celexa. 18. Nitroglycerin paste. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2140-12-5**] 17:31 T: [**2140-12-5**] 17:43 JOB#: [**Job Number 17289**] Name: [**Known lastname 2733**], [**Known firstname 2734**] Unit No: [**Numeric Identifier 2735**] Admission Date: [**2140-11-28**] Discharge Date: [**2140-12-13**] Date of Birth: [**2060-4-23**] Sex: M Service: KURLIND ADDENDUM: The patient was discharged to [**Location (un) 176**]/[**Location (un) 407**] per family request for pain and comfort (hospice) management. Please refer to full discharge summary for details. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**] Dictated By:[**Last Name (NamePattern1) 2736**] MEDQUIST36 D: [**2141-2-15**] 10:33 T: [**2141-2-15**] 12:59 JOB#: [**Job Number 2737**]

[ "576.1", "E953.0", "157.8", "780.09", "576.2", "197.8", "994.7", "197.7", "410.71" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

6241, 6301

6327, 7708

1415, 1651

2683, 6115

2022, 2665

143, 940

962, 1389

1669, 1999

6140, 6220

26,858

132,007

34573

Discharge summary

report

Admission Date: [**2134-9-13**] Discharge Date: [**2134-9-20**] Date of Birth: [**2064-1-15**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1271**] Chief Complaint: back pain Major Surgical or Invasive Procedure: L4-L5 LAMINECTOMY, L4-S1 FUSION History of Present Illness: 70 year old gentleman with h/o low back pain for many years presents for L4-L5 lumbar stenosis. Past Medical History: Dyslipidemia, Hypertension ? alcohol abuse Social History: Retired, has grown sons is engaged. Never smoke, questionable alcohol abuse. Family History: Non contributory Physical Exam: Heart ns1, s2, -s3, -s4, no murmurs, no carotid bruits ibl Lungs Clear to Auscultation Abdomen soft,non-tender, no masses Extremities no pedal edema bil., + dp ibl, muscle st. [**Doctor Last Name **] ext. +5/+5 bil., reflexe: patella +3/+2 bil., achilles ( unable to illicit), full dorsi/plantar flexion lower ext. bil., no spinal tenderness, no para-spinal tenderness, limimted spinal flexion, rotation. Other + toe/toe, + heel/heel, denies decreased sensation lower ext. bil., no cervical lymphadenopathy bil., no thyroid masses, trachea midlilne Pertinent Results: [**2134-9-20**] 06:45AM BLOOD WBC-7.4 RBC-3.39* Hgb-10.9* Hct-30.4* MCV-90 MCH-32.1* MCHC-35.8* RDW-12.8 Plt Ct-320 [**2134-9-17**] 02:52AM BLOOD Neuts-72.9* Lymphs-17.9* Monos-7.9 Eos-1.1 Baso-0.2 [**2134-9-20**] 06:45AM BLOOD Plt Ct-320 [**2134-9-20**] 06:45AM BLOOD Glucose-96 UreaN-15 Creat-0.7 Na-142 K-3.6 Cl-108 HCO3-26 AnGap-12 [**2134-9-17**] 02:52AM BLOOD ALT-28 AST-35 AlkPhos-54 TotBili-0.9 [**2134-9-16**] 11:59AM BLOOD CK-MB-5 cTropnT-<0.01 [**2134-9-20**] 06:45AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.2 [**2134-9-17**] 01:54PM BLOOD Type-ART pO2-56* pCO2-50* pH-7.37 calTCO2-30 Base XS-1 [**2134-9-17**] 01:54PM BLOOD Lactate-1.1 [**2134-9-17**] 05:02AM BLOOD O2 Sat-98 Brief Hospital Course: 70-yo man w/ HTN, HL, LBP s/p L4-S1 decompression / fusion, w/ post-op course was complicated by delirium as well as an event of hypotension, tachycardia, and hypoxia. Hypotension and tachycardia resolved, hypoxia and delerium were persistent for several days. Ultimately Pt delerium resolved with conservative management and improvement of O2 status. He required transfer to the MICU service on [**9-16**]. During that time they felt his hypoxia - Concern for PE given timing w/ significant HD compromise including hypotension and tachycardia, both of which have now resolved. CT was negative for major pe but could not rule out small subsegmental PEs. Lungs clear on exam and CXR clear. Pt may have aspirated in setting of altered mental status although CXR unchanged. ABG c/w hypoxia as well. Of note patient sounds stridorous moving adequate air and is oxygenating ok. Sleep consult feels that he most likely has OSA but in setting of delirium would be hard to ascertain whether it is contributing to his hypoxia. At this time he is oxygenating well on room air. . His delirium - Post-op delirium. Was thought likely [**2-27**] EtOH withdrawal but actually became clearer when benzos were held. ?paradoxical effect to benzodiazepines in the elderly. Also was much clearer after morphine and when he was clear during his waxing and [**Doctor Last Name 688**] MS o/n he did complain of back pain. Ultimately improved with better O2 status and conservative management. His motor strength in his legs remained full. With normal sensation except left inner thigh. He had developed significant bruising around his left flank area that resoloved by the time he was discharged. He was tolerating a regular diet and voiding without difficulty. He was cleared by PT to go home with supervision which his family can provide. Medications on Admission: ASA (Aspirin) (81 mg ( last dose 8/13)) Atenolol [Tenormin] (50 mg daily) Crestor (Rosovastatin) (20 mg daily) Other (pantaprazole 40 mg daily Discharge Medications: 1. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: L4-L5 Stenosis Discharge Condition: Neurologically stable Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery ?????? If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? If you are required to wear one, wear your cervical collar or back brace as instructed. ?????? You may shower briefly without the collar or back brace; unless you have been instructed otherwise. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow up in 6 weeks with Dr [**Last Name (STitle) 739**] call [**Telephone/Fax (1) 1669**] for an appointment Have your staples removed on Wednesday at your primary care physician [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2134-9-21**]

[ "293.0", "401.9", "738.4", "722.10", "785.0", "518.5", "E878.8", "272.4", "458.29" ]

icd9cm

[ [ [] ] ]

[ "93.90", "80.51", "81.62", "77.79", "81.05" ]

icd9pcs

[ [ [] ] ]

4728, 4779

1929, 3751

286, 320

4838, 4862

1225, 1906

6761, 7068

622, 640

3944, 4705

4800, 4817

3777, 3921

4886, 6738

655, 1206

237, 248

348, 445

467, 512

528, 606

51,798

157,853

32803

Discharge summary

report

Admission Date: [**2141-3-2**] Discharge Date: [**2141-3-14**] Date of Birth: [**2061-12-17**] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 4748**] Chief Complaint: Large abdominal aortic aneurysm as was well as bilateral common iliac aneurysms Major Surgical or Invasive Procedure: Open abdominal aortic aneurysm repair with aortobifemoral bypass using a Dacron 18 x 9 bifurcated graft. History of Present Illness: This is a 79-year-old man who has a large abdominal aortic aneurysm, as well as bilateral common iliac artery aneurysms. He presents for open aneurysm repair with planned aortobifemoral bypass. Past Medical History: PMHx: DM2, Aortic stenosis (mild per [**8-31**] echo), Hypertension, Peripheral Artery Disease, myelodysplasia/leukopenia/thrombocytopenia PSHx: None Social History: Lives with wife, denies ETOH or drug use. Family History: N/C Physical Exam: On discharge: VS: T 98.9, HR 92, BP 122/72, RR 16, O2sat 98%RA Gen: NAD CV: RRR, no m/r/g Resp: CTAB Abd: soft, minimal incisional tenderness, incision c/d/i with steri strips, no signs of infection, +BS. b/l groin incisions c/d/i with staples Ext: dp pt R d d L d d Pertinent Results: [**2141-3-2**] 01:02PM BLOOD WBC-6.5# RBC-3.40* Hgb-9.7*# Hct-29.9* MCV-88 MCH-28.4 MCHC-32.3 RDW-15.0 Plt Ct-146* [**2141-3-2**] 04:50PM BLOOD Hct-38.1*# Plt Ct-131* [**2141-3-3**] 02:04AM BLOOD WBC-5.3 RBC-3.78* Hgb-10.6* Hct-31.2* MCV-83 MCH-28.1 MCHC-34.0 RDW-16.3* Plt Ct-95* [**2141-3-3**] 09:24PM BLOOD Hct-25.4* [**2141-3-5**] 03:35AM BLOOD WBC-3.8* RBC-3.12* Hgb-8.8* Hct-25.9* MCV-83 MCH-28.1 MCHC-33.8 RDW-15.3 Plt Ct-61* [**2141-3-5**] 03:46PM BLOOD WBC-3.7* RBC-3.37* Hgb-9.4* Hct-28.0* MCV-83 MCH-27.8 MCHC-33.5 RDW-15.4 Plt Ct-77* [**2141-3-6**] 05:30AM BLOOD WBC-3.7* RBC-3.29* Hgb-9.4* Hct-27.9* MCV-85 MCH-28.7 MCHC-33.9 RDW-15.6* Plt Ct-95* [**2141-3-2**] 01:02PM BLOOD PT-15.7* PTT-34.3 INR(PT)-1.4* [**2141-3-4**] 03:07AM BLOOD PT-12.3 PTT-28.2 INR(PT)-1.0 [**2141-3-5**] 03:35AM BLOOD Plt Ct-61* [**2141-3-5**] 03:46PM BLOOD Plt Ct-77* [**2141-3-6**] 05:30AM BLOOD Plt Ct-95* [**2141-3-2**] 01:02PM BLOOD Glucose-225* UreaN-20 Creat-1.1 Na-140 K-4.5 Cl-114* HCO3-20* AnGap-11 [**2141-3-6**] 05:30AM BLOOD Glucose-153* UreaN-18 Creat-1.0 Na-139 K-3.3 Cl-100 HCO3-31 AnGap-11 [**2141-3-2**] 01:02PM BLOOD Calcium-8.6 Phos-5.5* Mg-1.4* [**2141-3-6**] 05:30AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.0 [**2141-3-2**] 08:56AM BLOOD Type-ART pO2-221* pCO2-40 pH-7.41 calTCO2-26 Base XS-1 Intubat-INTUBATED [**2141-3-2**] 10:36AM BLOOD Type-ART pO2-129* pCO2-54* pH-7.21* calTCO2-23 Base XS--6 [**2141-3-2**] 01:11PM BLOOD Type-ART PEEP-5 FiO2-100 pO2-408* pCO2-47* pH-7.25* calTCO2-22 Base XS--6 AADO2-281 REQ O2-52 Intubat-INTUBATED [**2141-3-2**] 06:30PM BLOOD Type-ART Tidal V-600 PEEP-5 FiO2-40 pO2-105 pCO2-35 pH-7.34* calTCO2-20* Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [**2141-3-3**] 08:52AM BLOOD Type-ART Temp-36.7 Rates-/20 PEEP-5 FiO2-40 pO2-75* pCO2-38 pH-7.43 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOU [**2141-3-2**] 08:56AM BLOOD Glucose-152* Lactate-2.2* Na-137 K-4.4 Cl-103 [**2141-3-2**] 11:36AM BLOOD Glucose-198* Lactate-6.2* Na-137 K-4.0 Cl-116* [**2141-3-2**] 01:11PM BLOOD Lactate-4.1* [**2141-3-2**] 06:30PM BLOOD Lactate-1.7 [**2141-3-3**] 04:05AM BLOOD Glucose-159* Lactate-2.4* [**2141-3-14**] 06:25AM BLOOD WBC-7.0 RBC-3.71* Hgb-10.6* Hct-32.7* MCV-88 MCH-28.6 MCHC-32.4 RDW-15.5 Plt Ct-269 [**2141-3-14**] 06:25AM BLOOD PT-44.8* PTT-43.0* INR(PT)-4.8* [**2141-3-13**] 06:30AM BLOOD Glucose-134* UreaN-32* Creat-0.4* Na-137 K-3.5 Cl-101 HCO3-20* AnGap-20 [**2141-3-14**] 06:25AM BLOOD UreaN-36* Creat-1.2 K-3.9 [**2141-3-14**] 06:25AM BLOOD ALT-48* AST-57* AlkPhos-86 TotBili-0.7 CXR [**2141-3-12**]: FINDINGS: As compared to the previous radiograph, the lung volumes are increased, likely to reflect improved ventilation. No evidence of focal parenchymal opacities suggesting pneumonia. No overhydration. Borderline size of the cardiac silhouette, tortuosity of the thoracic aorta. Unchanged slight elevation of the right hemidiaphragm with mild blunting of the right costophrenic sinus. No other abnormalities. Brief Hospital Course: Mr. [**Known lastname 76385**] was admitted to the vascular surgery service on [**2141-3-2**] for an elective AAA repair. He was prepped and brought to the operating room. An epidural was placed in the OR for pain control. He tolerated the procedure well but had 5200cc of blood loss during the operation. He was transferred to the PACU intubated and sedated and remained there overnight. In addition to cell [**Doctor Last Name 10105**] and blood given in the OR, he was transfused an additional 2 units of PRBCs on arrival to the PACU. His blood pressure required support with low dose phenylephrine overnight. He was also given multiple NS boluses. Serial blood gasses were drawn and his ventilator was weaned appropriately. On POD 1, he was successfully extubated, his NGT was removed, and he was weaned off pressors. He was transferred to the VICU in stable condition. He remained NPO. His epidural for pain continued with good effect. He continued to require fluid boluses to support his pressure SBP>100. On POD 2, he was transfused 2 more units of PRBC's. On POD3-5, patient's vitals were stable. Diet, PO meds were resumed. Patient's out of bed activity was advanced. Lines were removed and made floor staus with telemetry. On POD5, telemetry was discontinued and planned for discharge to home the next morning. On POD 6, plans of discharge to home was deferred, patient was febrile up to 102. Fever work-up was done. UA was nefative. CXR showed atelectasis, patient was mobilized. Late at night, patient lost distal pulses. Patient was made NPO, and pre-oped and consented for possible OR in the morning. On POD 7, patient was taken to the OR first thing for bilateral groin exploration and embolectomy. Patient tolerated procedure well. Pulses were restored bilaterally. There was a question of HIT, Heparin antibody was sent. Patient started on Argatroban drip. Patient recovered in the PACU, serial PTT's were sent. Patient was transitioned to coumadin over the next several days. He again was febrile to 102 on POD 10. Blood cultures sent that day grew gram negative rods. He was placed on Unasyn on POD 11. Argatroban was stopped on POD 11 when coumadin was therapeutic. At the time of discharge, the patient was afebrile for greater than 24 hours with stable vital signs, tolerating a regular diet, voiding and ambulating without assistance and with his pain well controled. Medications on Admission: atorvastatin 10 bacitracin-polymixin ophth diclofenac 75 mg qd glipizide 2.5 qAM/7.5 qHS lisinopril 40 mg qd actoplus (pioglitazone-metformin) 15/850 [**Hospital1 **] ASA 81 mg qd senna Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Diclofenac Sodium 25 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 10. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 11. Pioglitazone-Metformin 15-850 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for Constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 14. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 15. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 16. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Abdominal aortic aneurysm and bilateral common iliac aneurysm History of: DM2 Aortic stenosis (mild per [**8-31**] echo) Hypertension Peripheral Artery Disease myelodysplasia/leukopenia/thrombocytopenia PSHx: None Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm Repair Discharge Instructions ACTIVITIES: - [**Month (only) 116**] shower pat dry your incision, no tub baths - No driving till seen in FU by Dr. [**Last Name (STitle) 1391**] - No heavy lifting for 4-6 weeks - Resume activities as tolerated, slowly increase activiy as tolerated - Expect your activity level to return to normal slowly - Ambulate as tolerated DIET: - Diet as tolerated eat a well balanced meal - Your appetite will take time to normalize - Prevent constipation by drinking adequate fluid and eat foods [**Doctor First Name **] in fiber, take stool softener while on pain medications WOUND: - Keep wound dry and clean, call if noted to have redness, draining, or swelling, or if temp is greater than 101.5 - Your staples will be removed on your FU with Dr. [**Last Name (STitle) 1391**] MEDICATIONS: - Continue all medications as instructed FU APPOINTMENT: - Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone: [**Telephone/Fax (1) 1393**] Followup Instructions: - Call Dr.[**Name (NI) 1392**] office for a FU appointment. Phone: [**Telephone/Fax (1) 1393**] Please call your primary doctor, Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **], at [**Telephone/Fax (1) 589**] to schedule an appointment. Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2141-5-31**] 3:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2141-5-31**] 3:30 Completed by:[**2141-3-14**]

[ "790.7", "E934.2", "518.0", "424.1", "250.00", "E878.2", "289.84", "041.85", "401.9", "442.3", "996.74", "441.4", "238.75" ]

icd9cm

[ [ [] ] ]

[ "39.25", "88.42", "38.44", "39.49", "88.48" ]

icd9pcs

[ [ [] ] ]

8620, 8706

4269, 6668

354, 461

8964, 8964

1276, 4246

10180, 10763

934, 939

6904, 8597

8727, 8943

6694, 6881

9112, 10157

954, 954

968, 1257

235, 316

489, 684

8979, 9088

706, 859

875, 918

22,106

109,859

26587

Discharge summary

report

Admission Date: [**2195-12-23**] Discharge Date: [**2195-12-31**] Date of Birth: [**2119-6-9**] Sex: F Service: CARDIOTHORACIC Allergies: Tetracycline / Codeine Attending:[**First Name3 (LF) 2969**] Chief Complaint: left upper lobe nodule. Major Surgical or Invasive Procedure: 76 yo F s/p Left thoracotomy, Left upper Lobectomy [**12-23**] Past Medical History: CAD s/p stenting, hypothyroid, hyperchol, GERD, sciatica Social History: lives alone. Former smoker- one ppd quit [**2152**]. no etoh Family History: non-contributory Physical Exam: general: well appearing elderly female in NAD. Reap: CTA bilat. cor: RRR S1, S2 abd: soft, NT, Nd, +BS Extrem: no C/C/E neuro: A+OX3. no focal deficits. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2195-12-29**] 05:20AM 7.5 3.15* 9.4* 25.8* 82 29.7 36.2* 14.1 246 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2195-12-29**] 05:20AM 91 12 1.0 141 4.2 106 231 16 Brief Hospital Course: Pt was admitted on [**2195-12-23**] and taken to the OR for bronch, left VATS wedge biopsy proceeding to left mini thoracotomy for left upper lobectomy for nodule. PT was admitted to the PACU intubated d/t hypothemia nd slow awakening. Once recovered, she was extubated. Left chest tube and [**Doctor Last Name **] to wall sxn w/o leak draining moderate amts serosang drainage. CXR w/o PTX. Pain control in initial post op period unrelieved requiring increased epidural and toradol. POD#[**11-30**] Chest tubes water seal. Improved pain control. [**Last Name (un) **] Reg diet. POD#[**1-30**] pain well controlled. temp spike 103. pan cultured. Lethargic w/ mottled LE. HR and BP stable. CT obatined to eval for INfection vs. PE. Chest CT w/ IMPRESSION: 1. No evidence for pulmonary embolus. 2. Left hydropneumothorax, as described. Infection of this collection cannot be excluded. 3. The presumed residual left upper lobe has an abnormal appearance, as described. There is probable mucous plugging to the bronchus in this region. Differential diagnosis includes infection, post-obstructive pneumonitis, and re-expansion edema post-operatively. Given the probable mucous plugging, bronchoscopy could be considered. 4. Interval increase in the size of the largest right upper lobe nodule from the prior PET- CT from [**2195-11-11**]. The band- like parenchymal opacity also has a more nodular component on the current study. These findings may relate to interval progression of an infectious/inflammatory process, though a neoplastic process cannot be excluded. Correlation with the pathology findings from the left upper lobe is recommended. 5. Small-moderate right pleural effusion. 6. Left renal cyst, incompletely characterized on this study. Based on these findings pt was transferred to the CSRU and was bronched for large mucous plug at take off of LUL. started on Zosyn. POD#5 Mental status improved. Vanco added to zosyn. Repeat bronch w/ bloody secretions- lavaged until clear. Transferred from CSRU to floor. Epidural d/c'd. POD#[**5-4**] Cont's to improve. Chest tube and [**Doctor Last Name **] d/c'd. improved ambulation and activity tolerance. POD#8 d/c'd to daughter -in law's home w/ VNA and PT services. Also will be on po augmentin x 2weeks. Follow up w/ Dr. [**Last Name (STitle) **] in 2weeks. Medications on Admission: fosamax 70 qweek, nexium 20', crestor 10', toprol 100', synthroid 100' Discharge Medications: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: 15-30 MLs PO Q4H (every 4 hours) as needed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Coronary artery disease s/p stents [**2189**] normal EF, hypothyroid, gastric esophogeal reflux disease left thoracotomy, left upper lobectomy Discharge Condition: good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office/ Throacic Surgery office [**Telephone/Fax (1) 170**] for: fever, shortness of breath, chest pain, excessive foul smelling drainage at chest tube site. Take regular medications as prior, take new medications as directed. No driving if taking narcotic pain medication no tub baths for 4 weeks. You may shower 2 days after chest tube removed. VNA Services through Caritas Home Care. Followup Instructions: Call Dr.[**Doctor Last Name 4738**] office/ Throacic Surgery office [**Telephone/Fax (1) 170**] for appointment in [**9-10**] days. please arrive for your follow up appointment 45 minutes early and report to the [**Hospital Ward Name 23**] Clinical center [**Location (un) **] radiology for a follow up CXR before your appointment. Completed by:[**2195-12-31**]

[ "786.3", "V45.82", "414.01", "413.9", "162.3", "272.0", "244.9", "934.1", "530.81" ]

icd9cm

[ [ [] ] ]

[ "32.29", "33.24", "32.3", "96.05", "33.22" ]

icd9pcs

[ [ [] ] ]

4551, 4614

1033, 3354

314, 379

4802, 4809

760, 1010

5280, 5644

554, 572

3475, 4528

4635, 4781

3380, 3452

4833, 5257

587, 741

251, 276

401, 459

475, 538

23,197

190,633

3671+55494

Discharge summary

report+addendum

Admission Date: [**2160-5-5**] Discharge Date: [**2160-5-10**] Date of Birth: [**2090-5-16**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 633**] Chief Complaint: nausea Major Surgical or Invasive Procedure: Central Venous Line History of Present Illness: 69 yo female with T1DM on insulin pump, right BKA [**6-/2159**], chronic lumbar disk disease on chronic narcotics, HTN, HLD, [**Hospital 3593**] transfered to the ICU after short floor stay after admission today for N/V/D and transfer to the ICU for hypertensive emergency. She actually had a similar admission in [**1-/2159**] for HTN urgency and mild DKA. She was on a labetalol gtt for and was transitioned to Chlorthalidone. She was previously on Lisinopril and clonidine patch as an outpatient. Patient and husband as well as [**Name (NI) **] note corroborate that she started having vomiting, nausea on [**5-4**]. Per [**Month/Day (4) **] note, she called on [**5-5**] to PCP, [**Name10 (NameIs) **] prior to admission, c/o nausea, vomiting attributing to possibly withdraw from morphine and oxycodone, and wanted to know if her morphine and oxycodone were ready to pick up. Per note, she said that she ran out of both on Friday morning. Her sxs started Saturday morning w/ nausea and vomiting. Vomiting about 4-5x a day. She denied blood in vomit. Her BS fasting the morning of [**5-5**] was apparently 192. She denied dizzy, syncope, cp, sob, tremor, seizure, fever, chill, abdomen pain, blood in stool or black stool or any other changes in her BMs. In the ED, it was reported that she presented asking for pain medication after she ran out at home. VS were initially, 97.6 62 219/95 16 97. She was given 2 L of IVF, morphine 5mg x1, ativan 1mg and zofran, and had nausea persistent and BP 200/90 prior to transfer. Upon being asked again in the ED she stated that she took oxycodone for pain the day before, not sure how many, denies SI, Bglc 220. She was given hydralazine 10mg IV X 1. She had a CT head w/o elevated ICP, or mass. CXR was done without acute CPP. On the floor, she told the team that she ran out of morphine but was able to take oxycodone at home. In ED SBP in 200s. Given Morphine, Ativan and antiemetics. 220/100 on arrival on the floor, barely arousable but improving so did not get narcan. Now somnolent but arousable. Denied any other ingestions. Given 10mg hydralazine, 10mg labtolol IV without change in BP. She did have an episode of bradycardia to the 30s with vomiting X 1. Most recent finger stick was 230, given 6 Units. On arrival to the MICU, she was somnolent but arousable, oriented X 3. She denied pain though said that she did have a recent HA, now resolved. Denied dyspnea or chest pain, abdominal pain. Does still report nausea and she vomited a couple of times, biliouis material. She received 20mg Labetolol IV X 3 with some initial effect in BP to SBps to 170s but these quickly rose to 190s. Review of systems: (+) Per HPI (-) Denies fever, chills. Denies headache (had recently but not now). Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations or recent symptoms. Denies diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Past Medical History: - h/o DVT, unknown when - DMI on insulin pump, patient unable to say dose. Followed by [**Last Name (un) **]. - Peripheral neuropathy - h/o gastroparesis - Chronic LBP/sciatica - HTN - Hyperlipidemia - Hypothyroidism - PVD/PAD - Autonomic dysfunction, orthostatic hypotension - History of seizure [**2158-1-19**] characterized by becoming less responsive, oriented to name only, gaze deviation and left arm shaking. FS 297 and was in the setting of receiving cipro, Neuro felt [**1-3**] infection vs PRES. - Barretts Esophagus on EGD [**2155**] - Depression - MI [**2157**], no stents PAST SURGICAL HISTORY: [**2159-3-30**] - Malunion right intertrochanteric hip fracture with protrusion of screw s/p revision arthroplasty [**2159-1-7**] Comminuted right intertrochanteric hip fracture s/p right hip fracture open reduction internal fixation (intramedullary nail) [**3-21**] RLE angiography RLE SFA-AT BPG with NRSVG [**2157-9-6**] Angioplasty of vein graft [**2158-10-4**] [**2158-5-30**], L hip hemiarthroplasty - Hiatal hernia - s/p laminectomy - s/p hysterectomy Social History: The patient lives with her husband. She is a former secretary. Former tobacco use, quit in [**8-10**], previous 60 pack/yr history. No history of EtOH or IVDU. Family History: Mother - coronary artery disease with MI in her 50s, died at age 84. Father - coronary artery disease with MI in her 60s, died at age 82. Physical Exam: Admission Exam: Vitals: 99.2, 225/90, 98, 97%, 27, finger stick 243 General: Somnolent but arousable, orientedx3, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, no edema. s/p right BKA well healed. No ulcers Neuro: EOEMI, 4/5 strength hand grip and leg lift Discharge Exam: Vitals: 98.7 98.2 132/56 (120-168/50s-80s) 70s 18-20 96-99% RA +2560/-2275 BSGs 140s General: A&Ox3. NAD. Lying comfortably in bed. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, [**Date Range 1105**]/VI SEM. No rubs or gallops. Lungs: Transmitted upper airway sounds. Otherwise, clear to auscultation bilaterally, no wheezes or rales. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, no edema. s/p right BKA well healed. No ulcers Neuro: Moving all extremities spontaneously. No focal deficits. Pertinent Results: [**2160-5-5**] 12:00PM BLOOD Glucose-331* UreaN-26* Creat-1.0 Na-138 K-4.0 Cl-102 HCO3-23 AnGap-17 [**2160-5-5**] 05:22PM BLOOD Glucose-261* UreaN-23* Creat-0.9 Na-138 K-3.7 Cl-102 HCO3-18* AnGap-22* [**2160-5-5**] 11:57PM BLOOD Glucose-119* UreaN-24* Creat-1.0 Na-142 K-3.2* Cl-107 HCO3-24 AnGap-14 [**2160-5-6**] 05:11AM BLOOD Glucose-289* UreaN-21* Creat-1.0 Na-139 K-4.1 Cl-108 HCO3-21* AnGap-14 [**2160-5-6**] 02:40PM BLOOD Glucose-180* UreaN-17 Creat-1.0 Na-138 K-3.6 Cl-110* HCO3-20* AnGap-12 [**2160-5-7**] 02:07AM BLOOD Glucose-245* UreaN-16 Creat-1.1 Na-137 K-4.1 Cl-107 HCO3-21* AnGap-13 [**2160-5-7**] 04:00PM BLOOD Glucose-202* UreaN-14 Creat-1.1 Na-136 K-3.8 Cl-104 HCO3-24 AnGap-12 [**2160-5-8**] 07:28AM BLOOD Glucose-256* UreaN-13 Creat-1.0 Na-133 K-3.6 Cl-100 HCO3-26 AnGap-11 [**2160-5-8**] 04:45PM BLOOD Glucose-113* UreaN-18 Creat-1.4* Na-134 K-4.0 Cl-101 HCO3-25 AnGap-12 [**2160-5-9**] 07:10AM BLOOD Glucose-231* UreaN-19 Creat-1.2* Na-136 K-4.5 Cl-103 HCO3-24 AnGap-14 [**2160-5-10**] 07:10AM BLOOD Glucose-164* UreaN-24* Creat-1.1 Na-137 K-4.3 Cl-103 HCO3-28 AnGap-10 [**2160-5-5**] 12:00PM BLOOD Calcium-9.3 Phos-3.4 Mg-1.6 [**2160-5-5**] 05:22PM BLOOD Calcium-9.0 Phos-3.3 Mg-1.6 [**2160-5-5**] 11:57PM BLOOD Calcium-8.4 Phos-2.8 Mg-1.5* [**2160-5-6**] 05:11AM BLOOD Calcium-8.1* Phos-1.9* Mg-2.4 [**2160-5-6**] 02:40PM BLOOD Calcium-7.9* Phos-2.1* Mg-1.9 [**2160-5-7**] 02:07AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.3 [**2160-5-7**] 04:00PM BLOOD Calcium-8.3* Phos-2.7 Mg-1.9 [**2160-5-8**] 07:28AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.7 [**2160-5-8**] 04:45PM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8 [**2160-5-9**] 07:10AM BLOOD Calcium-8.0* Phos-3.8 Mg-1.7 [**2160-5-5**] 05:22PM BLOOD CK-MB-4 cTropnT-<0.01 [**2160-5-5**] 11:57PM BLOOD CK-MB-4 cTropnT-<0.01 [**2160-5-6**] 05:11AM BLOOD CK-MB-4 cTropnT-<0.01 [**2160-5-5**] 05:22PM BLOOD ALT-12 AST-21 CK(CPK)-118 AlkPhos-122* TotBili-0.3 [**2160-5-5**] 11:57PM BLOOD CK(CPK)-90 [**2160-5-6**] 05:11AM BLOOD CK(CPK)-107 [**2160-5-5**] 12:00PM BLOOD WBC-7.9 RBC-4.87# Hgb-14.7# Hct-45.4# MCV-93 MCH-30.2 MCHC-32.4 RDW-14.5 Plt Ct-217 [**2160-5-6**] 05:11AM BLOOD WBC-11.9*# RBC-4.07* Hgb-12.4 Hct-37.7 MCV-93 MCH-30.5 MCHC-32.9 RDW-15.0 Plt Ct-239 [**2160-5-7**] 02:07AM BLOOD WBC-8.5 RBC-3.63* Hgb-11.0* Hct-33.8* MCV-93 MCH-30.3 MCHC-32.5 RDW-14.5 Plt Ct-210 [**2160-5-8**] 07:28AM BLOOD WBC-5.5 RBC-3.62* Hgb-11.0* Hct-33.9* MCV-94 MCH-30.4 MCHC-32.4 RDW-14.7 Plt Ct-155 [**2160-5-9**] 07:10AM BLOOD WBC-5.8 RBC-3.71* Hgb-11.2* Hct-36.1 MCV-97 MCH-30.3 MCHC-31.1 RDW-14.3 Plt Ct-159 [**2160-5-10**] 07:10AM BLOOD WBC-6.8 RBC-3.71* Hgb-11.0* Hct-34.8* MCV-94 MCH-29.6 MCHC-31.5 RDW-14.4 Plt Ct-169 [**2160-5-5**] 06:06PM BLOOD Type-ART pO2-102 pCO2-22* pH-7.51* calTCO2-18* Base XS--2 [**2160-5-6**] 12:17AM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-45 pH-7.37 calTCO2-27 Base XS-0 [**2160-5-6**] 05:38AM BLOOD Type-CENTRAL VE pO2-45* pCO2-38 pH-7.42 calTCO2-25 Base XS-0 [**2160-5-5**] 06:06PM BLOOD freeCa-1.04* [**2160-5-5**] 03:10PM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2160-5-5**] 03:10PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-2 RenalEp-<1 [**2160-5-5**] 03:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 [**2160-5-5**] 03:10PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG [**2160-5-9**] 11:00PM URINE METANEPHRINES, FRACTIONATED, 24HR URINE-PND . BCx [**5-5**] x2 NEG MRSA POS Sputum CONTAMINATED . [**5-5**] ECHO The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [**2157-6-23**], the LV systolic function is now hyperdynamic. . [**5-5**] CT Head IMPRESSION: No acute intracranial process. Chronic microvascular ischemic disease, unchanged. . [**5-5**] CXR IMPRESSION: Mild prominence of the interstitium may be technical; however, the possibility of mild pulmonary edema cannot be excluded. Recommend clinical correlation. . [**5-8**] Renal US Normal-sized kidneys with no evidence of renal artery stenosis. Moderately elevated resistive indices bilaterally. . [**5-8**] EKG Sinus rhythm. Borderline left atrial enlargement. Cannot rule out old septal myocardial infarction. Left axis deviation. Compared to the previous tracing of [**2160-5-6**] the heart rate has decreased. QS complexes are now noted in leads VI-V2. Criteria for left anterior fascicular block are no longer seen. . Brief Hospital Course: 69 yo female with T1DM (insulin pump), chronic lumbar disk disease, hypertension, hyperlipidemia, severe peripheral [**Date Range 1106**] disease s/p right BKA ([**6-/2159**]), orthostatic hypotension (on salt tabs) who had been admitted on [**5-4**] for nausea/vomiting/diarrhea in the setting of running out of opioids, was found to be hypertensive and had altered mental status, and mild DKA, so she was transferred to the MICU for ?hypertensive emergency. Her blood pressures improved and confusion resolved. . # Hypertensive urgency: Patient has a history of hypertension, but because of orthostatic hypotension she takes salt tabs and is not on any home antihypertensives. In the ED, Ms. [**Known lastname 5936**] had BP 219/95 P 62. She received 2L NS, morphine 5mg, and IV hydral 20 mg. Head CT was negative for edema. On the floor, she received IV hydral 10mg x1 and labetalol, but her SBPs only temporarily dropped below 200. She was transferred to the MICU, where she was started on labetalol gtt and transitioned to PO labetalol. Her BPs remained elevated (SBPs 160s-180s), but PCP recommended goal ~160 given orthostatic hypotension. She was transferred to the floor, where because of relatively low BPs 120s-140s her labetalol was weaned and she was transitioned to lisinopril 5mg and then lisinopril 2.5mg. She was discharged on lisinopril 2.5 mg. In the AM, prior to getting her medications her BP was as high as 180, but throughout the rest of the day her SBPs were 120s-140s. She underwent a renal artery ultrasound that showed no evidence of renal artery stenosis. Serum metanephrines and 24-hr urine metanephrines were collected and pending at the time of discharge. . # Orthostatic hypotension: Patient with known orthostatic hypotension, which is why she has not been on antihypertensives at home. In MICU SBPs 160->120. Improved on the floor, but still positive on lisinopril 2.5 mg at the time of discharge although asymptomatic (SBP 151->129). Likely a component of autonomic dysfunction due to diabetes. . # Altered mental status: In the ED, the patient was intermittently confused. Her insulin pump was removed, she received morphine 10mg and ativan 2mg IV. Her serum and urine tox screens were negative, except for opioids. On arrival to the floor, she was somnolent but arousable and interactive, but minimally conversational and orientation could not be assessed. In the MICU, she returned to her baseline mental status (A&Ox3, conversational) and remained there for the remainder of this admission. Head CT revealed no hemorrhage, edema, or midline shift. She was afebrile and had negative Bcx x2. EKG showed RBBB, but no ST-changes and cardiac enzymes were negative x3. The mental status changes were likely contributed to by opioid intoxication, mild DKA, and possibly severe hypertension. . # Respiratory alkalosis: On arrival to the floor, the patient had a respiratory alkalosis (pH 7.51, pCO2 22). She was somnolent, but arousable. This was resolved by four hours later and likely was due to opioid intoxication. . # DKA: Patients insulin pump was removed in the ED and by the time she was on the floor she had an anion-gap metabolic acidosis (HCO3 18, anion gap 18). Overall blood was alkalemic due to a primary respiratory alkalosis. She received insulin 6 units, insulin 10 units, and was put on an insulin drip. [**Last Name (un) **] was consulted. The anion gap was corrected by HD3. She was switched over to sliding scale and then restarted on her home insulin pump and regimen. At the time of discharge, her BSGs were stable ranging between 130s and 190s (mostly 140s). She was r/o for an MI and there were no signs of infection. . # EKG changes: Initial EKGs revealed a new RBBB. Cardiology was consulted and thought likely to be rate related. TTE revealed hyperdynamics with no wall motion abnormalities. Cardiac enzymes were negative x3. The RBBB was resolved on HD2. . # [**Last Name (un) **]: Likely pre-renal. On the floor, creatinine bumped to 1.4 (from 1.0). She received 1L NS bolus and her urinary output increased and creatinine was downtrending (1.1 on discharge). . # Chronic pain: Patient has baseline phantom pain in right leg (s/p BKA). Extremities were warm and well perfused with dopplerable pulses. Pain was reasonably controlled on home gabapentin, MScontin [**Hospital1 **], and oxycodone [**4-10**] daily PRN. . # Hypothyroidism: Patient was initially on IV levothyroxine when unable to tolerate PO's, then transitioned back to home dose. . # PVD: Continued on home plavix, zocor while able to take PO. # Depression: Patient without complaints during this admission. Continued on home meds. . # s/p right BKA: Worked with PT, who recommended ambulation [**Month/Year (2) **] and outpatient PT. . # TRANSITIONAL ISSUES: - [**Month/Year (2) 269**] for BP checks. - Continue biweekly PT - Started lisinopril 2.5 mg PO - Stopped salt tabs - Should follow-up with PCP regarding antihypertensive regimen. Medications on Admission: Refresh 1 % Eye Drops prn Plavix 75 mg daily Citalopram 40 mg Tab daily 1 Tablet(s) by mouth once a day Glucagon (Human Recombinant) 1 mg Injection Kit prn low sugar Citracal + D 315 mg-200 unit Tab Fish Oil 1,000 mg Cap Travatan Z 0.004 % Eye Drops 1 drop ou daily Lantus 100 unit/mL Sub-Q 5 units at bedtime Sennosides 8.6 mg Tab, 2 Tablet(s) by mouth once a day Humalog 100 unit/mL SubQ Cartridge on insulin pump basal rate Cyanocobalamin (vitamin B-12) 1,000 mcg Tab daily Morphine ER 15 mg Tab, 3 Tablet(s) by mouth QAM and 2 tab QPM Sodium chloride 1 gram Tab, 1 Tablet(s) by mouth daily Lorazepam 1 mg Tab QHS for anxiety metoclopramide 10 mg Tab by mouth 30 minutes before meals calcitriol 0.25 mcg Cap daily Zocor 40 mg Tab daily Omeprazole 20 mg Cap, Delayed Release daily Docusate sodium 100 mg Cap daily Levoxyl 88 mcg Tab daily Oxycodone 5 mg Tab, [**12-3**] prn pain Gabapentin 400 mg Cap, [**Month/Day (2) **] Restasis 0.05 % Eye Dropperette, 2 drops(s) three times a day Multivitamin Cap daily Folic Acid 400 mcg Tab Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Travatan Z 0.004 % Drops Sig: One (1) Ophthalmic once a day: both eyes. 5. insulin glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Contact your PCP if you feel more lightheaded or dizzy. 7. sennosides 8.6 mg Tablet Sig: Two (2) Tablet PO once a day. 8. Humalog 100 unit/mL Cartridge Sig: 100 units/mL Subcutaneous on insulin pump basal rate. 9. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. morphine 15 mg Tablet Extended Release Sig: Three (3) Tablet Extended Release PO qAM (morning). 11. morphine 15 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO at bedtime. 12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 13. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO [**Month/Day (2) **] (3 times a day). 14. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 18. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. oxycodone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for pain. 20. gabapentin 400 mg Capsule Sig: One (1) Capsule PO [**Month/Day (2) **] (3 times a day). 21. Restasis 0.05 % Dropperette Sig: Two (2) Ophthalmic three times a day. 22. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. 24. Refresh Celluvisc 1 % Dropperette Sig: One (1) Ophthalmic once a day as needed for dry eyes. 25. Glucagon Emergency 1 mg Kit Sig: One (1) Injection once a day as needed for low sugar. 26. Citracal + D Maximum 315-250 mg-unit Tablet Oral 27. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 28. Outpatient Physical Therapy Please resume outpatient physical therapy two days a week. Discharge Disposition: Home With Service Facility: partners [**Name (NI) **] Discharge Diagnosis: Narcotic withdrawal Hypertensive Urgency DKA Discharge Condition: A&Ox3. VSS. BSGs well controlled 130s-180s. Discharge Instructions: Dear Ms. [**Known lastname 5936**], It was a pleasure taking care of you here at [**Hospital1 18**]. When you first arrived you were confused and your blood pressure was very high. We controlled your blood pressure with medications and started you on a new medication lisinopril. Given your history of low blood pressure, you should be careful when getting up quickly and discuss this medication with Dr. [**Last Name (STitle) **]. Your confusion improved when your blood pressures decreased. Prior to your arrival you reported some vomiting and diarrhea. We helped hydrate you with intravenous fluids. Your vomiting and diarrhea resolved and we were able to stop the intravenous fluids. Because of your confusion, we had removed your insulin pump. As you improved we resumed your home insulin pump with corrections and evening lantus, as you did prior to your hospitalization. During your hospitalization, you were seen by physical therapy. They recommended continuing outpatient physical therapy. You will be visited by nurse to help check your blood pressures. The following changes were made to your medications: --START taking lisinopril 2.5mg by mouth daily for high blood pressure. --STOP taking sodium chloride. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2160-5-19**] 10:30 Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2160-6-9**] 1:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2160-6-11**] 9:50 Completed by:[**2160-5-11**] Name: [**Known lastname 2610**],[**Known firstname **] T Unit No: [**Numeric Identifier 2611**] Admission Date: [**2160-5-5**] Discharge Date: [**2160-5-10**] Date of Birth: [**2090-5-16**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 467**] Addendum: (Hospital Course Correction) # Respiratory alkalosis: On arrival to the floor, the patient had a respiratory alkalosis (pH 7.51, pCO2 22). She was not tachypneic at the time and the alkalosis had resolved by four hours later. It was likely related to opioid withdrawal and pain. Discharge Disposition: Home With Service Facility: partners [**Name (NI) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 468**] MD [**MD Number(2) 469**] Completed by:[**2160-5-12**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

22175, 22386

11157, 13199

309, 330

19689, 19735

6000, 11134

21008, 22152

4623, 4764

17207, 19521

19621, 19668

16150, 17184

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3022, 3336

263, 271

358, 3003

13214, 15920

15943, 16124

3358, 3944

4445, 4607

22,746

110,514

7759

Discharge summary

report

Admission Date: [**2120-6-18**] Discharge Date: [**2120-6-26**] Service: Green Surgery HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old female with a 24-hour history of abdominal pain that started the day prior to admission. The patient also complained of urgency to defecate and nausea. The patient had emesis x 2 the night prior to admission. She felt lightheaded and had increasing abdominal pain. She was taken to [**Hospital **] Hospital where she was hypotensive at the time. She was admitted to the unit. A femoral line was placed and volume resuscitation was initiated. She continued to have worsening abdominal pain this morning. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Atrial pacer. 3. Primary pulmonary hypertension. 4. Ischemic heart disease. 5. Atrial fibrillation. 6. Hypertension. 7. Gout. 8. Myocardial infarction. PAST SURGICAL HISTORY: Open cholecystectomy. MEDICATIONS AT HOME: 1. Amiodarone 200 b.i.d. 2. Lopressor 25 b.i.d. 3. Protonix 40 q.d. 4. Nitroglycerin patch 0.2 p.r.n. 5. Plavix 75 q.d. 6. Aspirin q.d. 7. Digoxin 0.125 q.o.d. ALLERGIES: Codeine causes hallucinations. PHYSICAL EXAMINATION: Vital signs were temperature 95.3, heart rate 79, blood pressure 94/41, respiratory rate 18, 96% on two liters nasal cannula. She was on a Neo-Synephrine drip. Her cardiovascular examination showed a paced rhythm with no murmurs, gallops, or rubs. Her lung examination was clear to auscultation bilaterally. On abdominal examination the patient was distended with decreased bowel sounds. She was tender in the lower left lateral abdomen with mild tenderness in the right lower and left upper quadrants. She exhibited voluntary guarding of the left lower quadrant. There was no rebound tenderness. On rectal examination there were no masses and she was guaiac positive. Her extremity examination showed no evidence of cyanosis, clubbing or edema. LABORATORY DATA: White blood cell count was 15 with 34% bands, creatinine 1.6, amylase in the 600s, lipase 15. CAT scan from yesterday showed a contained perforation and mild thickening of the descending colon with stranding of the mesentery. HOSPITAL COURSE: The patient was taken to the operating room on [**2120-6-18**] emergently with a preoperative diagnosis of ischemic left colon. While in the operating room the patient had a left hemicolectomy, a Hartmann pouch and end ileostomy. Details of the procedure can be found in the operative note. She had complete transmural necrosis of the proximal left decending colon with obvious perforation or peritonitis. The SMA pulse was strong. The presumed etiology was an embolis with ischemia vs. a low flow state (less likely given strong SMA pulse). While in the operating room the patient's blood pressure dropped initially. The patient was treated with increasing IV fluids, Neo-Synephrine drip and was transfused two units of packed red blood cells. In addition, the calcium and bicarbonate were repleted for lactic acidosis. The patient was transferred to the surgical intensive care unit postoperatively intubated and on a Neo-Synephrine drip. Vital signs were stable when transferred to the surgical intensive care unit. While the patient was in the surgical intensive care unit, the patient was heparinized for presumed embolic event. A transesophageal echocardiogram was performed to evaluate for cardiac source of embolus. No thrombus was seen, however the echocardiogram was positive for a right-to-left shunt at rest with the bubble study, consistent with a stretched patent foramen ovale. While in the surgical intensive care unit the patient continued to be intubated until mobilizing her fluids. On postoperative day number three in the surgical intensive care unit, it was attempted to extubate the patient, but the patient started to desaturate to the 80s and so the patient was placed back on the ventilator. She was given Lasix with good diuresis and staff was able to extubate the patient in the afternoon post diuresis. The patient was weaned to O2 by nasal cannula at four liters when her oxygen saturations were greater than 95% with no shortness of breath and her arterial blood gas was within normal limits. On postoperative day five the patient was tolerating clear liquids without any nausea or vomiting. Her intake was greater than 400 cc p.o. that day. Her colostomy stoma was pink with small round brown ischemic areas on the outer aspect. Her ostomy was producing stool and the ostomy nurse replaced the appliance. The patient continued to be monitored in the surgical intensive care unit. Her heparin drip was titrated accordingly. The patient continued to be hemodynamically stable and on postoperative day six the patient was transferred to the floor. While on the floor the patient continued to tolerate p.o. without difficulty. Her ostomy stoma was pink, viable and showed good output. Her abdominal examination continued to be soft and nontender. Anticoagulation was continued as the patient was started on Coumadin. Heparin was discontinued when the INR was greater than 2.0. The patient's diet was advanced. She would continue to tolerate a regular diet without difficulty. Physical therapy was consulted and recommended aggressive physical therapy and rehabilitation placement. The patient was discharged on postoperative day 11 with an INR of 2.0 and her last dose of Coumadin prior to discharge was 0.5 mg on that day. The patient's pain was well controlled and the patient had been out of bed with physical therapy help. Arrangements were made by the case manager for the patient to go to rehabilitation at [**Hospital6 25759**] and Rehabilitation Center in [**Location (un) **]. CONDITION ON DISCHARGE: Good, stable. DISCHARGE STATUS: To rehabilitation at [**Hospital6 25759**] and Rehabilitation Center in [**Location (un) **], [**State 350**]. DISCHARGE DIAGNOSES: 1. Ischemic left colon probable cause thromboembolism, status post exploratory laparotomy, left hemicolectomy, Hartmann pouch, and end ileostomy. 2. Coronary artery disease. 3. Atrial pacing. 4. Primary pulmonary hypertension. 5. Ischemic heart disease. 6. Atrial fibrillation. 7. Hypertension. 8. Gout. 9. Myocardial infarction. DISCHARGE MEDICATIONS: 1. Ostomy care. 2. Amiodarone 200 mg q.d. 3. Famotidine 20 mg b.i.d. 4. Metoprolol tartrate 50 mg b.i.d. 5. Digoxin 125 mcg q.d. 6. Coumadin 0.5 mg q.d. 7. Outpatient laboratory work for Coumadin dosing. DISPOSITION: The patient is to go to rehabilitation and then to follow up with Dr. [**Last Name (STitle) **] in one to two weeks for staple removal and follow up. Dr.[**Name (NI) 6218**] number is included in the discharge summary. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28129**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 28130**] MEDQUIST36 D: [**2120-6-27**] 10:01 T: [**2120-6-27**] 10:24 JOB#: [**Job Number 28131**]

[ "414.01", "414.9", "416.0", "276.2", "427.31", "557.0", "274.9", "412", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "46.11", "38.91", "38.93", "45.75" ]

icd9pcs

[ [ [] ] ]

5943, 6274

6297, 7015

2205, 5751

951, 1162

906, 929

1185, 2187

128, 669

692, 882

5776, 5922

28,093

113,560

45584

Discharge summary

report

Admission Date: [**2117-1-12**] Discharge Date: [**2117-2-1**] Date of Birth: [**2038-1-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3531**] Chief Complaint: Acute Hypoxemic Respiratory Failure Major Surgical or Invasive Procedure: thoracentesis and placement of pig-tail catheter in right thorax History of Present Illness: 78M Myelofibrosis, Anemia requiring transfusions, Zenkers Diverticulum, hx of aspiration PNA requiring intubation ([**5-1**])presenting with acute hypoxia in setting of large right sided pleural effusions. . Of note the pt was recently admitted to [**Hospital 8**] Hospital on [**2117-1-2**] following a fall at home during which he had a work-up for head trauma and syncope. ECG at that time revealed RBBB and LAFB. Hct of 20.7, CT Head without acute intracranial pathology. CXR revealed right sided atelectasis vs PNA. The pt was treated for a right facial laceration and admitted. The pt states he received 2 blood transfusions ans was discharged home from the OSH after approximately 2 days. No discharge summary currently available. . The pt states that over the past few days he has noted worsening right sided pain that radiates to his chest. Worse with inspiration [**5-3**]. No palpitations. Denies fevers, but admits to chills. No diaphroses. The pt has had stable 1 pillow orthopnea and has DOE upon walking up one flight of stairs. The pt today presented to his PCP where he was noted to have a BP of 80/P and subsequently brought to the ED. . Upon arrival to the ED 97.9 93/37 70 19 94% (02 not listed). The pt was continued to complain of [**5-3**] back pain. ED exam was notabable for absent BS on right. CXR with low lung volumes on right. CT chest revealed effusion on right with mild ascites. No signs of acute bleed. . The pt received Vancomycin 1mg IV, Levofloxacin 750mg IV x1, Azreonam 1gm IVx1 for suspected right sided PNA in setting of question PCN allergy. A PIV 18g and 20g were placed. The pt received 2L of NS and 1L of D5W with 3 amp of Bicarb. UOP of 250cc. . The pt was seen by interventional pulmonary that who performed a bedside ultrasounded throacentesis during which 1200cc of serosanginous fluid was drained. Initial pH 7.08, pleural LDH of 468 indicative of an exudative process thus a pigtail catheter was placed. Follow-up CXRs without evidence of pneumothorax. . Vitals prior to transfer HR 70 122/58 16 100% on 12L NRB. . . REVIEW OF SYSTEMS: (+)ve: chills, chest pain, orthopnea, 1 episode of BRBPR 3 weeks ago. (-)ve: fever, night sweats, loss of appetite, fatigue, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: # Myelofibrosis - Bone Marrow Bx [**2-/2115**], 20q deletion, JAK-2 mutation # Chronic Anemia: Requiring Blood Transfusions [**1-26**] MF # Aspiration PNA ([**4-/2116**]) with hypoxemic respiratory failure requiring intubation (Unconfirmed Location - Per OSH Records) # Zenker's Diverticulum - hx of aspiration events # Significant macular degeneration and cataracts # Depression # Pruritis # Mild symmetric LVH # Moderate Pulmonary HTN ([**5-1**]) # ?BPH (Per OSH records) Social History: He does not smoke and denies any alcohol abuse. He lives alone, independent of ADLs, although declining. He is a retired english professor [**First Name (Titles) 767**] [**Last Name (Titles) 10358**] [**Location (un) 47997**]. Interest in [**Last Name (un) **]. Family History: Mother deceased - [**Name2 (NI) **] CA Physical Exam: T=97.3 BP=120/44 HR=75 RR=18 98 6L GENERAL: Pleasant, ill cachectic appearing M in NAD HEENT: Right facial laceration. Right purulence from conjunctiva. Mild conjunctival pallor. No icterus. Dry MM. NECK: Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP= flat LUNGS: Clear on left anteriorly. Clear superiorly on right anteriorly. Right pigtail catheter in place. ABDOMEN: NABS. Soft, NT, mild distension, +Hepatosplenomegaly. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: No asterxis. A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**12-26**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant . Exam as of [**2117-1-24**] Vitals: 96.5 101/49 85 18 95%2Lnc Pain: over sacrum and R chest wall Access: PIV and LUE double lumen PICC Gen: thin man, cachectic, weak HEENT: mm dry CV: RRR, no m Chest: R chest tube site dry with dressing Resp: +bibasilar crackles, no wheezing Abd; soft, thin, nontender, +SM Ext; R>L edema (new over past 2days) Neuro: A&OX3, grossly nonfocal Skin: sacral decub stage II with dressing, L 4th toe hyperemic but good distal pulse, area of erythema with darker and irregular border over R hip, pruritic for patient, not clear cellulitis, ?fungal psych: calm, pleasant Pertinent Results: Discharge Day Labs: Other Pertinent Labs: UA [**1-12**]: 6-10wbc, few bacteria, UCx neg UA [**1-21**]: 21wbc, +casts, mod LE, few bac, neg nitrites, 18rbc, UCx neg . [**1-21**]: Una 10, UCreat 98, Uurea 875 [**1-23**]: repeat urine lytes: FeNa 0.7 . BC [**1-12**] NGTD X2 . Pleural fluid Cx [**1-12**] NTD Pleural fluid: wbc 2550 with 89%PMNs, LDH 468, pH 7.08 pleural fluid cytology: neg for malignancy Sputum Cx upper flora . . Imaging/results: EKG: RBBB, LAFB . [**1-12**]: CXR Large right pleural effusion, with consequent lower and middle lobe collapse. . CXR [**1-16**]; Two views of the chest demonstrate a large right-sided pleural effusion with atelectasis/consolidation of the right lower lobe. Left lung is clear. A chest tube is present at the right lung base. There is little interval change with prior studies. Hila and mediastinum within normal limits . CXR [**1-22**] (post pigtail removal) There is a small right lower lobe pneumothorax. Small bilateral pleural effusions, left greater than right, are unchanged. Bibasilar consolidations and right middle lobe opacities are unchanged, as is faint right upper lobe opacity. Cardiomediastinal contours are normal. . CT chest w and w/o contrast [**1-22**] 1. Marked decrease in size of now small complex loculated right pleural effusion. The tip of the catheter remains within the pleural cavity, but the formed pigtail is extrathoracic in location with adjacent subcutaneous emphysema and soft tissue swelling. 2. Slight increase of small simple left pleural effusion. Persistent pneumonia with component of coexisting atelectasis of both lower lobes but improved aeration of the right upper and right middle lobes. Nonspecific ground-glass opacities are noted within the right middle and lower lung which may be related to infection or reexpansion pulmonary edema. 3. Unchanged hypoattenuating hepatic and splenic lesions as described. Many of the hepatic lesions are clearly simple cysts. There is stable hepatosplenomegaly with sequelae of portal hypertension. 4. Known Zenker's diverticulum. . CT chest noncontrast [**1-13**] 1. Decreased right pleural effusion, now moderate in size, status post right pleural pigtail catheter placement. Small left pleural effusion. 2. Multifocal pneumonia involving nearly the entire right lung, and large portions of the left lower lobe. 3. Unchanged hepatosplenomegaly. 4. Unchanged appearance of probable Zenker's diverticulum. . CT c/a/p [**1-12**] c contrast: 1. Large right pleural effusion with resultant compressive atelectasis or the right lung. 2. Hepatosplenomegaly. 3. Ascites. 4. Splenic hypodensity, not fully characterized, possible hamartoma or hemangioma. 5. Nodularity of the left adrenal gland, but no distinct nodule. This finding should be correlated clinically and if indicated, with serum biochemical markers. 6. Collection of fluid and gas at the thoracic inlet in the region of the esophagus, a finding which predisposes the patient to possible aspiration and should be clinically correlated. . Renal US [**1-23**]; 1. No hydronephrosis or nephrolithiasis. 2. Unchanged renal cysts and prostatic enlargement. . . LABS: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2117-1-31**] 12:27PM 6.5 2.73* 8.6* 24.7* 91 31.6 34.9 17.5* 93* Source: Line-PICC [**2117-1-30**] 05:04AM 5.7 2.51* 7.9* 23.0* 92 31.5 34.4 17.4* 70*1 Source: Line-PICC [**2117-1-29**] 08:00AM 4.9 2.51* 7.8* 22.8* 91 30.9 34.0 17.5* 68*2 Source: Line-left picc line [**2117-1-28**] 06:45AM 5.1 2.48* 7.6* 22.7* 92 30.6 33.5 17.4* 66*1 Source: Line-left picc line [**2117-1-27**] 04:06AM 5.1 2.25* 6.9* 21.5* 96 30.5 31.9 18.0* 59*3 Source: Line-PICC [**2117-1-26**] 05:00AM 5.4 2.50* 7.4* 23.0* 92 29.6 32.2 17.8* 72*3 Source: Line-PICC [**2117-1-25**] 08:47AM 5.4 2.59* 7.8* 24.1* 93 30.2 32.4 17.9* 107*1 Source: Line-picc line [**2117-1-24**] 08:00AM 6.0 2.68* 8.1* 25.0* 93 30.0 32.2 17.8* 113*1 [**2117-1-23**] 05:50AM 6.9 2.68* 8.0* 24.9* 93 30.0 32.2 17.9* 132*3 [**2117-1-22**] 06:45AM 7.1 2.77* 8.4* 25.6* 92 30.2 32.7 18.0* 1511 [**2117-1-21**] 06:45AM 9.3 3.09* 9.4* 28.9* 93 30.3 32.5 18.1* 1711 [**2117-1-20**] 10:55AM 12.2*# 3.17* 9.3* 29.6* 93 29.4 31.6 18.2* 187 [**2117-1-19**] 06:10AM 7.3 2.65* 8.0* 24.2* 91 30.2 33.1 18.5* 1703 [**2117-1-18**] 01:00PM 10.9# 3.11*# 9.0*# 28.5*# 92 28.8 31.5 18.4* 203 [**2117-1-17**] 06:00AM 6.9 2.20* 6.5* 20.8* 95 29.6 31.2 18.5* 1753 [**2117-1-16**] 05:40AM 6.1 2.30* 6.8* 21.8* 95 29.7 31.3 18.8* 185 [**2117-1-15**] 05:55AM 7.4 2.35* 6.9* 22.1* 94 29.3 31.2 18.5* 205 [**2117-1-14**] 05:20AM 13.8*# 2.72* 8.1* 25.7* 95 29.9 31.6 18.7* 2081 [**2117-1-13**] 08:35AM 28.2* [**2117-1-13**] 02:53AM 7.9 2.49* 7.4* 24.0* 97#4 29.8 30.9* 18.8* 1511 [**2117-1-12**] 11:16PM 8.5 2.92* 8.8* 30.2* 104*#4 30.3 29.2* 18.7* 1531 [**2117-1-12**] 02:00PM 12.8*#1 2.98*# 9.1*# 28.1*# 94 30.6 32.4 19.3* [**2007**] VERIFIED BY SMEAR LARGE FORMS PRESENT VERIFIED VERIFIED DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2117-1-28**] 06:45AM 80.7* 11.8* 4.8 2.6 0.1 Source: Line-left picc line [**2117-1-25**] 08:47AM 82.8* 0 11.2* 4.7 1.2 0 Source: Line-picc line [**2117-1-12**] 02:00PM 86* 3 4* 7 0 0 0 0 0 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy [**2117-1-12**] 02:00PM 3+ 2+ 2+ 1+ 1+ OCCASIONAL 2+ BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**Name (NI) 11951**] [**2117-1-31**] 12:27PM LOW1 93* Source: Line-PICC [**2117-1-30**] 05:04AM VERY LOW2 70*3 3+ Source: Line-PICC [**2117-1-29**] 08:00AM VERY LOW4 68*5 3+ Source: Line-left picc line [**2117-1-28**] 06:45AM 66*3 Source: Line-left picc line [**2117-1-28**] 06:45AM 16.5* 37.3* 1.5* Source: Line-left picc line [**2117-1-27**] 04:06AM VERY LOW 59*6 Source: Line-PICC [**2117-1-26**] 05:00AM VERY LOW 72*6 Source: Line-PICC [**2117-1-25**] 08:47AM LOW7 107*3 2+ Source: Line-picc line [**2117-1-24**] 08:00AM LOW8 113*3 [**2117-1-23**] 05:50AM LOW 132*6 [**2117-1-23**] 05:50AM 15.7* 1.4* [**2117-1-22**] 06:45AM 1513 [**2117-1-21**] 06:45AM NORMAL 1713 2+ [**2117-1-20**] 10:55AM NORMAL9 187 [**2117-1-19**] 06:10AM NORMAL 1706 [**2117-1-18**] 01:00PM NORMAL10 203 1+ [**2117-1-18**] 01:00PM 15.9* 33.9 1.4* [**2117-1-17**] 06:00AM NORMAL 1756 1+ [**2117-1-16**] 05:40AM 185 [**2117-1-15**] 05:55AM NORMAL11 205 1+ [**2117-1-14**] 05:20AM NORMAL 2083 [**2117-1-14**] 05:20AM 17.0* 39.8* 1.5* [**2117-1-13**] 02:53AM 1513 [**2117-1-13**] 02:53AM 19.0* 39.2* 1.7* [**2117-1-12**] 11:16PM NORMAL 1533 2+ [**2117-1-12**] 02:00PM 17.4* 35.8* 1.6* [**2117-1-12**] 02:00PM NORMAL [**2009**] LOW FEW LARGE PLATELETS VERY LOW WITH LARGE FORMS VERIFIED BY SMEAR VERY LOW LARGE FORMS PRESENT LARGE FORMS PRESENT VERIFIED LOW OCC LARGE FORMS LOW LARGE PLTS SEEN NORMAL OCC LARGE FORMS NORMAL MANY LARGE PLATELETS NORMAL MOD. LARGE PLTS Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2117-1-31**] 08:38AM 317*1 41* 0.8 137 4.7 105 26 11 Source: Line-PICC [**2117-1-30**] 05:04AM 103*1 38* 0.7 138 4.0 105 27 10 Source: Line-PICC [**2117-1-29**] 08:00AM 125*1 30* 0.8 138 3.7 106 28 8 Source: Line-left picc line [**2117-1-28**] 06:45AM 126*1 29* 0.8 140 3.7 109* 28 7* Source: Line-left picc line [**2117-1-27**] 04:06AM 134*1 30* 0.9 137 3.4 106 23 11 Source: Line-PICC [**2117-1-26**] 05:00AM 111*1 34* 0.9 137 4.3 110* 23 8 Source: Line-PICC [**2117-1-25**] 08:47AM 111*1 35* 1.1 140 4.2 111* 25 8 Source: Line-picc line [**2117-1-24**] 08:00AM 881 40* 1.3* 142 4.4 113* 24 9 [**2117-1-23**] 05:50AM 891 48* 1.4* 143 4.7 112* 25 11 [**2117-1-22**] 03:30PM 188*1 51* 1.7* 142 5.5* 112* 23 13 [**2117-1-22**] 06:45AM 971 56* 1.6* 142 5.8* 112* 23 13 [**2117-1-21**] 06:45AM 1001 44* 1.5* 143 5.7* 111* 28 10 [**2117-1-20**] 10:55AM 163*1 35* 1.2 140 5.0 109* 27 9 [**2117-1-19**] 06:10AM 891 28* 0.8 143 4.4 112* 28 7* [**2117-1-18**] 01:00PM 129*1 29* 0.9 141 4.6 109* 26 11 [**2117-1-17**] 06:00AM 117*1 30* 0.9 140 4.0 110* 27 7* [**2117-1-16**] 05:40AM 117*1 34* 0.8 138 3.6 107 28 7* [**2117-1-15**] 05:55AM 1001 44* 1.1 141 3.9 108 25 12 [**2117-1-14**] 05:20AM 107*1 39* 1.2 139 4.2 106 27 10 ADDED B12 @ 08:08AM ON [**2117-1-14**] [**2117-1-13**] 02:53AM 134*1 36* 1.2 142 4.3 108 27 11 [**2117-1-12**] 02:00PM 145*1 39* 1.5* 139 4.9 106 26 12 ADDED PON CPIS AT 1500 IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES ESTIMATED GFR (MDRD CALCULATION) estGFR [**2117-1-28**] 06:45AM Using this1 Source: Line-left picc line [**2117-1-20**] 10:55AM Using this2 [**2117-1-12**] 02:00PM Using this3 ADDED PON CPIS AT 1500 Using this patient's age, gender, and serum creatinine value of 0.8, Estimated GFR = >75 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure Using this patient's age, gender, and serum creatinine value of 1.2, Estimated GFR = 59 if non African-American (mL/min/1.73 m2) Estimated GFR = 71 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure Using this patient's age, gender, and serum creatinine value of 1.5, Estimated GFR = 45 if non African-American (mL/min/1.73 m2) Estimated GFR = 55 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2117-1-31**] 08:38AM 9 9 51 0.5 Source: Line-PICC [**2117-1-17**] 03:00PM 9*1 [**2117-1-17**] 06:00AM 8*1 [**2117-1-12**] 02:00PM 7 6 54 0.7 ADDED PON CPIS AT 1500 VERIFIED BY REPLICATE ANALYSIS NEW REFERENCE INTERVAL AS OF [**2116-12-28**];UPPER LIMIT (97.5TH %ILE) VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201 BLACKS 801/414 ASIANS 641/313 OTHER ENZYMES & BILIRUBINS Lipase [**2117-1-12**] 02:00PM 12 ADDED PON CPIS AT 1500 CPK ISOENZYMES CK-MB cTropnT [**2117-1-17**] 03:00PM 2 <0.011 [**2117-1-17**] 06:00AM 2 <0.011 [**2117-1-12**] 02:00PM 0.012 ADDED ON TNT AT 1459 [**2117-1-12**] 02:00PM 2 ADDED PON CPIS AT 1500 <0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2117-1-31**] 08:38AM 7.7* 2.3 Source: Line-PICC [**2117-1-29**] 08:00AM 7.6* 3.7 2.1 Source: Line-left picc line [**2117-1-28**] 06:45AM 7.2* 3.5 2.1 Source: Line-left picc line [**2117-1-27**] 04:06AM 7.1* 3.0 2.1 Source: Line-PICC [**2117-1-26**] 05:00AM 7.3* 2.7 2.1 Source: Line-PICC [**2117-1-25**] 08:47AM 7.6* 3.2 2.3 Source: Line-picc line [**2117-1-24**] 08:00AM 7.6* 3.0 2.2 [**2117-1-23**] 05:50AM 2.3* 7.6* 3.9 2.3 [**2117-1-22**] 03:30PM 7.8* 4.7* 2.3 [**2117-1-22**] 06:45AM 7.8* 4.9* 2.3 [**2117-1-21**] 06:45AM 8.1* 4.6* 2.2 [**2117-1-20**] 10:55AM 7.8* 3.4 2.1 [**2117-1-19**] 06:10AM 8.0* 2.6* 2.1 [**2117-1-18**] 01:00PM 8.0* 2.6* 2.1 [**2117-1-16**] 05:40AM 2.5* 7.9* 2.4* 2.1 [**2117-1-15**] 05:55AM 8.1* 3.2 [**2117-1-14**] 05:20AM 8.0* 4.3 2.3 ADDED B12 @ 08:08AM ON [**2117-1-14**] [**2117-1-13**] 02:53AM 2.8* 7.3* 3.7 2.1 HEMATOLOGIC VitB12 [**2117-1-14**] 05:20AM 672 ADDED B12 @ 08:08AM ON [**2117-1-14**] LIPID/CHOLESTEROL Cholest Triglyc [**2117-1-26**] 05:00AM 501 Source: Line-PICC LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE ANTIBIOTICS Vanco [**2117-1-16**] 05:30PM 26.2* Random . . Brief Hospital Course: 78 year old male (retired english professor) with h/o myelofibrosis/anemia (transfusion dependent, dx [**2114**]), longstanding zenker's diverticulum with chronic aspiration and recurrent aspiration pneumonias admitted on [**1-12**] with the same. . 1. Aspiration Pneumonia: Patient was initially admitted to the [**Hospital Unit Name 153**] with significant RLL PNA with pleural effusion and hypotension. Hypotension resolved with IVF and he was transferred to floor. He underwent thoracentesis with resultant exudative fluid, and a chest tube was placed with resultant drainage of 3L of fluid and removal of the catheter on [**2117-1-22**]. He received a ten day course of Levofloxacin/Clindaymycin. At the time of discharge he had normal oxygen saturations on room air. . 2. Chronic aspiration: Patient failed speech and swallow evaluation several times. Dobhoff tube placement was unsuccessful, a PICC was placed on [**2117-1-24**], and TPN was started. The plan is for endoscopic repair of his Zenker's diverticulum by Dr.[**Last Name (STitle) 1837**]. Dr[**Doctor Last Name **] office will call Rehab to schedule a pre-operative visit. . 3. Anemia [**1-26**] Myelofibrosis: Patient received intermittent transfusions to maintain a Hct>22 (is also transfusion dependent as an outpatient). Folate supplementation was continued. He is followed for this issue by his hematologist, Dr.[**Last Name (STitle) 3638**]. . 4. Thrombocytopenia: Platelet count began to trend down during the last week of hospitalization, thought to be [**1-26**] increased splenic congestion in the setting of volume overload while on TPN. There was also concern that his antibiotics were contributing. After completing antibiotics and undergoing diuresis with Lasix 20mg IV as needed, his platelet count began to trend up, and on the day of discharge was 103. . 5.Acute renal failure: Patient noted to have ARF on admission, which improved with IVFs to Cr=0.8. However, he once again developed ARF on [**1-21**] (peak creat 1.7) likely from volume depletion as well, which again improved with hydration. Renal US was within normal limits. . 6. Sacral decubitus ulcer: Patient has a stage II sacral ulcer and was getting wound care and turning frequently. . PCP: [**Last Name (NamePattern4) **].[**Last Name (STitle) 141**] Hematologist: Dr.[**Last Name (STitle) 3638**] ENT: Dr.[**Last Name (STitle) 97218**] Medications on Admission: Combivent Folic Acid Ferrous Sulfate Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Aspiration pneumonia c/b Parapneumonic pleural effusion Zenker's diverticulum with chronic aspiration moderate to severe malnutrition sacral decub stage II Myelodysplastic syndrome and Anemia, transfusion dependent Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted with a recurrent aspiration pneumonia and pleural effusion which required drainage with a chest tube. You were briefly in the ICU. You were treated with antibiotics with improvement in your symptoms and completed these on [**2117-1-26**]. The chest tube had some trouble draining but we were able to fix this with TPA and it drained about 3L of fluid and your breathing improved. The cause of your pneumonia is due to recurrent aspiration, in part due to your large zenker's diverticulum. Dr. [**Name (NI) 97219**] office will contact you to arrange a pre-opertive visit to discuss repair of the diverticulum. A PICC line was placed for TPN, which is IV nutrition. Our hope is that this will make your nutrition status better so you can recover from the surgery. You also required occasional blood transfusions to keep your hematocrit above thirty. Your platelet count dropped to a low of 59, but was increasing at the time of discharge. This was thought to be due to splenic congestion due to volume overload. . Please take all medications as prescribed. It is very important to use your incentive spirometer and work with physical therapy going forward. Followup Instructions: Please follow up closely with your PCP as soon as possible: PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 142**] . You will be contact[**Name (NI) **] by Dr. [**Last Name (STitle) 97218**] to arranged for your endoscopic surgery for Zenker's

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Discharge summary

report

Admission Date: [**2109-12-29**] Discharge Date: [**2110-1-1**] Date of Birth: [**2062-9-18**] Sex: M Service: MEDICINE Allergies: Clindamycin Attending:[**First Name3 (LF) 783**] Chief Complaint: Hypertensive Crisis, Blurry Vision Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 47 yo male with HIV (last CD4 238, viral load 882 in [**11-16**]) on HAART, DM, ESRD on HD, h/o PE on coumadin (dx [**6-16**]), h/o medication noncompliance, h/o malignant hypertension, who awoke this morning with L eye monocular blurry vision and dysequilibrium with standing. When he first awoke, he was seeing double, worse with R gaze. He also felt as though he was losing his balance when standing, but thinks this is due to the double vision in his L eye. He does have some mild pain in his L eye. He deniess vertigo, pre-syncopal symptoms, syncope, lightheadedness, or LE weakness. He had one episode of n/v this AM. He also has had a R temporal HA over the past week which is not throbbing and fairly constant. He rates this HA as [**9-19**], but does not wish to take any pain medications for it. He denies slurred speech, CP, SOB, abd pain, new weakness or numbness in any of his extremities, BRBPR, diarrhea, constipation. He states he has been compliant with taking all of his medications. . In the ED, the pts vitals were: T 99.2, BP 159-204/88-106, HR 80s-90s, R 15-22, sat 93-98% RA. He was noted to have R eye disconjugate gaze and monocular blurry vision. He received lebatolol 5 mg IVx1/10 mg IVx1, valsartan 160 mg po x 1, Nifedipine CR 90mg po x1, Ativan, and heparin gtt. Code stroke was called. CT head and MRI head were negative for acute process. He was started on a labetolol gtt. He was seen by neuro and felt to have L 3rd nerve palsy with pupillary sparing. As soon as the pt arrived to the MICU, his lebatolol gtt was discontinued as his SBP was 140s. Past Medical History: - Type 1 diabetes - HIV (lamivudine, stavudine), dx'd [**2096**] VL 882, CD4 238 in [**11-16**]) - ESRD on HD, attempted on PD on transplant list (clinical study for HIV/solid organ transplant) - PE, on Coumadin, diagnosed [**6-16**] - Malignant Hypertension - hx Serratia bacteremia (presumed AV graft) tx 6 wks meropenem - Hx schistosomiasis - Restless leg syndrome - Peripheral neuropathy on gabapentin - S/p cholecystectomy - s/p R nephrectomy in [**2092**] secondary renal nephrolithiasis Social History: Moved from [**Country 4812**] in [**2091**]. Lives with wife in [**Location (un) 538**]. Works in support services for a law firm. Denies any alcohol or IV drug use. Quit smoking last year; previous 30 pack-year history. Family History: Non-contributory Physical Exam: Physical Exam on MICU admission: VS: Temp: 99.2 BP: 141/61 HR: 95 RR: 20 O2sat: 95% 2LNC GEN: pleasant, laying flat, comfortable, NAD HEENT: patch over R eye, PERRL, L eye unable to adduct or look up/down but able to abduct, anicteric, MMM, op without lesions, no diplopia, clear optic disc margins on left but unable to visualize on R, no hemorrhages on L or R fundoscopic exam NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: faint expiratory wheezing at the bilateral bases but no rales/ronchi CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, 1+dp/pt pulses BL SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact with the exception of the L 3rd CN. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. toes downgoing. Pertinent Results: Admission labs: [**2109-12-29**] 09:55AM WBC-5.9# RBC-4.03*# HGB-14.1# HCT-40.2 MCV-100*# MCH-34.9* MCHC-35.0 RDW-14.0 [**2109-12-29**] 09:55AM PLT COUNT-159 [**2109-12-29**] 09:55AM GLUCOSE-120* UREA N-54* CREAT-9.2* SODIUM-132* POTASSIUM-4.7 CHLORIDE-91* TOTAL CO2-27 ANION GAP-19 [**2109-12-29**] 07:54PM ALT(SGPT)-9 AST(SGOT)-11 CK(CPK)-136 ALK PHOS-71 AMYLASE-116* TOT BILI-0.3 [**2109-12-29**] 07:54PM LIPASE-46 [**2109-12-29**] 09:55AM PT-15.0* PTT-30.3 INR(PT)-1.3* . Pertinent labs: [**2109-12-29**] 09:55AM CK(CPK)-139 [**2109-12-29**] 09:55AM CK-MB-19* MB INDX-13.7* [**2109-12-29**] 09:55AM cTropnT-0.29* [**2109-12-29**] 07:54PM CK-MB-18* MB INDX-13.2* cTropnT-0.43* [**2109-12-30**] 03:56AM BLOOD CK(CPK)-98 [**2109-12-30**] 03:56AM BLOOD CK-MB-NotDone cTropnT-0.56* [**2109-12-31**] 03:35PM BLOOD %HbA1c-4.9 [**2109-12-31**] 06:10AM BLOOD Triglyc-87 HDL-35 CHOL/HD-3.7 LDLcalc-77 . EKG on admission: Sinus rhythm. Left atrial abnormality. Tall T waves in leads V2-V4. Consider acute ischemia or hyperkalemia. Compared to the previous tracing of [**2109-7-18**] T waves are now upright and more acute. . Imaging: CHEST (PORTABLE AP) [**2109-12-29**] IMPRESSION: No acute cardiopulmonary disease. . MRA BRAIN W/O CONTRAST [**2109-12-29**] IMPRESSION: 1. Normal MRA of the head. 2. Ventriculomegaly and low-lying cerebellar tonsils as before. 3. Minimal amount of chronic microangiopathic changes. . CTA HEAD W&W/O C & RECONS [**2109-12-29**] IMPRESSION: 1. Ventriculomegaly and low-lying cerebellar tonsils as before. 2. Normal CTP. 3. Normal CTA of the head and neck. Brief Hospital Course: 47 yo male with HIV (last CD4 238, viral load 882 in [**11-16**]) on HAART, DM, ESRD on HD, h/o PE on coumadin (dx [**6-16**]), h/o medication noncompliance, h/o malignant hypertension, who presents with hypertensive urgency and left 3rd nerve palsy. . # Hypertensive Crisis: Pt was admitted to the MICU. This is likely secondary to medication noncompliance given that pt's BP rapidly normalized after pt received his home BP meds. Pt has possible mild resultant cardiac ischemia from this event (positive MB index). He has prior h/o malignant HTN in the past, treated with nitro gtts and lebatolol gtts. Labetolol gtt was d/c'd once pt came into MICU. He was restarted on home medications with few modificaitons and his BP has been well-controlled. He was continued on his home diovan 160 mg po bid, nifedipine CR 60 mg daily, clonidine TTS 2 patch qSun, Toprol XL 25 mg daily. His lisinopril was increased from 10 mg tid to 20 mg [**Hospital1 **]. . # Transient 3rd nerve palsy: Neurology was consulted and felt his vision changes were likely secondary to 3rd nerve palsy on the L, which is usually caused by DM or HTN. There was no pupillary defect nor papilledema or hemorrhages on fundoscopic exam. Ophthomology also evaluated the pt and reported resolution of the 3rd nerve palsy. His vision changes had resolved by discharge. Pt will follow up with outpatient ophthomology. . # Elevated cardiac enzymes: With his elevated cardiac enzymes, he was initially started on heparin gtt. This was likely due to leakage of enzymes from hypertensive emergency as opposed to ischemic event. His elevated Tpn is likely due to CRF. No had no EKG changes. CK plateaued at 139 and trended down. Heparin gtt was stopped given low suspicion and INR near therapeutic for distant DVT. He was continued on his aspirin. . # Hypoxia: On admission he was hypoxic wtih mild wheezing at lung bases, likely either [**1-11**] to atelectasis vs. volume overload from hypertensive crisis. CXR had no evidence of acute cardiopulmonary process. He was weaned to RA [**12-30**] without desaturation and remained on RA for the remainder of his hospitalization. . # N/V: This was likely related to hypertensive crisis as it resolved with BP control. Amylase/lipase, LFTs were not indicative of an acute processs. His known gastroparesis may have also contributed, and he was continued on his outpatient regimen of Reglan. . # ESRD: Pt cont. to have hemodialysis qMWF. He was continued on lanthanum. . # HIV: He follow ups poorly with both Dr. [**Last Name (STitle) 724**] (ID) and his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Per ID, given his history of medical noncompliance, his HAART medications were held. He will follow up with Dr. [**Last Name (STitle) 724**] as an outpatient regarding reinitiation of HAART. . # h/o PE: Pt was admitted with subtherapeutic INR of 1.3. His coumadin was increased to 5 mg daily and was therapeutic upon discharge. . # ?Depression: Per his nephrologist Dr. [**Last Name (STitle) 1366**] & PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], there has been some concern for worsening depression/coping, which may be possibly contributing to his medical noncompliance. Psychiatry was consulted and felt that he did appear to be somewhat dysthymic but without overt depressive symptoms. Pt denies any medical noncompliance. . # Restless leg syndrome: Pt was continued on neurontin. . # DM: Pt was continued on home NPH and ISS with adqueate control of BS. . # Code Status: Full Medications on Admission: Lamivudine 25 mg QD Zerit 20 mg QD ?Ritonavir 100 mg daily ?Atazanavir 300 mg daily ?Tenofovir 100 mg weekly Diovan 160 mg [**Hospital1 **] NPH 10 U QAM, 7 U QPM Insulin regular 5 U QPM Ativan 1 mg TID PRN Lisinopril 10 mg TID Ambien 10 mg QHS PRN Nifedipine SR 30 mg QD Coumadin 4 mg on non-HD days, 5 mg on HD days Neurontin 100 mg [**Hospital1 **] to TID (depending on how bad restless legs are) Catapress 2 patch weekly Reglan 10 mg qachs fosrenol 1 gm tid Metoprolol Succinate 25 mg daily . Allergies: Clindamycin-rash Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly Transdermal QSUN (every Sunday). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 12. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: [**6-19**] units Subcutaneous twice a day: Please take 10 units in the morning, 7 units in the evening. 16. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 units Injection four times a day: Please take according to attached sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Emergency Cranial nerve palsy . Secondary: HIV Chronic renal failure, stage V Diabetes mellitus type 1 Pulmonary embolus Discharge Condition: Stable Discharge Instructions: You were admitted for dangerously high blood pressure with changes in vision. Your vision changes have resolved. Neurology and Ophthalmology have seen you and Ophthalmology recommends outpatient follow up. Your lisinopril has been changed from 10 mg three times a day to 20 mg twice a day. Your blood pressure has been well-controlled with these medications. . Please continue to take your medications except as above. In addition, please take coumadin (warfarin) 5 mg every evening as your INR was noted to be low. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4026**] to follow your INR and adjust your coumadin dose. In addition, the Infectious Diseases team recommends that you stop taking your HIV medications for now. Please follow up with Dr. [**Last Name (STitle) 724**] of Infectious Diseases regarding when to resume taking these drugs. . If you develop worsening headache, dizziness, lightheadedness, chest discomfort, palpitations, shortness of breath, or any other concerning symptoms, please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4026**] at [**Telephone/Fax (1) 250**] or go to the Emergency Department. Followup Instructions: Please follow up with Ophthalmology (Eye). You have an [**Telephone/Fax (1) 648**] for Tuesday, [**2-25**] at 1PM. Please confirm your [**Month (only) 648**] by calling the clinic at([**Telephone/Fax (1) 5120**]. . Please also follow up with Dr. [**Last Name (STitle) 724**] of Infectious Diseases regarding your medications for HIV. You have an [**Last Name (STitle) 648**] for Tuesday, [**1-7**] at 10AM. Please confirm your [**Month (only) 648**] by calling the clinic at ([**Telephone/Fax (1) 4170**]. . Please keep the following appointments as well: Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2110-1-14**] 9:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2110-2-11**] 9:00 Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2110-2-25**] 1:00 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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Discharge summary

report

Admission Date: [**2167-8-21**] Discharge Date: [**2167-9-1**] Date of Birth: [**2100-11-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Fever, altered mental status Major Surgical or Invasive Procedure: Lumbar Puncture Transesophageal Echocardiagram History of Present Illness: HPI: Patient unable to give good history on his own; hx per daughter. Daughter found pt. when she returned home in evening [**8-20**] lying on the ground, awake; lying there approx. 4 hrs per pt report. Pt states he had "passed out" and couldn't rise. Positive mental status changes at the time and was not able to answer his daughter's questions appropriately. He had not been incontinent of stool or urine. She called her mother and the ambulance and the patient was then brought in to the ED. . The daughter says the patient had not been feeling well the previous day. He was complaining of not feeling well, but could not specify symptoms. Prior to admission, complained of intermittent nausea and insomnia. . At baseline, the patient has L sided weakness, both UE and LE, from a previous stroke. He also has speech difficulties from his most recent strokes in [**12-24**]. He understands some English. He is able to ambulate around their house with a cane. . ED: L IJ catheter placed. Concern for ischemia (EKG ? ST change in V6 -> cards felt LVH not acute MI, received ASA and lopressor IV), meningitis (LP done) or other infection (given tylenol, vanc, ceftriaxone, acyclovir, and gentamicin). He was transferred to [**Hospital Ward Name 121**] 3 and begun on dialysis for a Ca of 12. . On floor, pt. underwent HD; renal eval - AVF site warm and swollen, not tender. [**8-21**] evening, pt had episode hypotension - txf to unit for evaluation - pt tx'd for bacteremia, pt bp stabilized, tx'd with genta/vanco. . ROS: daughter denies any fevers, URI sx, diarrhea, chest pain or SOB; thinks that the patient did have some vomiting yesterday (day PTA). . Past Medical History: 1. Coronary artery disease s/p MI in [**12/2164**], status post 2 stents to the LAD. Cath in [**1-/2165**] revealed re-stenosis of both stents. He is status post 3-vessel CABG on [**2165-2-20**] with LIMA to LAD, saphenous vein to RCA, saphenous vein to OM. 2. ESRD on HD since [**2161**](MWF), felt secondary to HTN 3. Status post CVA in [**2149**] with residual left-sided hemiparesis 4. Hypertension 5. UGIB after cardiac cath on [**12/2164**] 6. Gout 7. Pancreatitis 8. Diverticulosis 9. History of multiple E coli bacteremias 10. Anemia of chronic disease (10.9Hgb [**11-22**]) 11. Hypercholesteremia 12. COPD 13. Afib/Aflutter, not on anticoagulation secondary to history of GI bleed. 14. [**12-24**] TEE: LVEF >55%, small ASD, complex (>4mm non-mobile) atheroma in the descending thoracic aorta, ([**12-21**]+) AR, tr MR. 15. H/O Hepatitis B Social History: The patient lives at home with his wife & daughter in a [**Location (un) 6332**] apartment with an elevator. Family History: Mother with hypertension No history of no strokes, seizures, or heart disease Physical Exam: PE: Tm 99.1, Tc 96.9, HR 90-103, BP 111-142/49-62, RR 18-22, O2 sat 100% NC 2l, 90% ra; CVP 3-5, I: 1400 in, O: none Gen: elderly man appears sleepy, speaks slowly HEENT: PERRL, OP clear, dry MM, neck veins flat CV: RRR, + [**2-22**] early systolic murmur Lungs: b/l basilar crackles, no wheezes Abd: soft, NT, ND Ext: L arm - fistula, no tenderness. No erythema noted, no drainage Pertinent Results: MICRO: [**2167-8-21**] bctx - G+ cocci pairs/clusters ([**3-23**]) [**2167-8-20**]: CSF cx pending, gram stain neg for PMNs/microorg . RADS: [**2167-8-20**]: CXR - No consolidation. L costophrenic angle blunting c/w effusion/chronic thickening. Evidence of CABG/stents . [**2167-8-20**]: CT head - No hemorrhage, no mass effect, no hydrocephalus, chronic L parietal infarct . [**2167-8-21**]: ECHO - no vegetations [**2167-8-21**] 11:15PM CORTISOL-53.7* [**2167-8-21**] 10:34PM CORTISOL-36.0* [**2167-8-21**] 10:02PM TYPE-MIX TEMP-37.3 COMMENTS-MEDIAL POR [**2167-8-21**] 10:02PM LACTATE-2.7* [**2167-8-21**] 10:02PM O2 SAT-90 [**2167-8-21**] 09:59PM GLUCOSE-144* UREA N-31* CREAT-4.9* SODIUM-142 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-29 ANION GAP-14 [**2167-8-21**] 09:59PM CALCIUM-11.9* PHOSPHATE-3.9 MAGNESIUM-2.0 [**2167-8-21**] 09:59PM WBC-11.7* RBC-3.87* HGB-11.3* HCT-33.9* MCV-88 MCH-29.2 MCHC-33.2 RDW-18.8* [**2167-8-21**] 09:59PM NEUTS-78* BANDS-14* LYMPHS-7* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2167-8-21**] 09:59PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2167-8-21**] 09:59PM PLT SMR-VERY LOW PLT COUNT-64* [**2167-8-21**] 09:59PM PT-14.0* PTT-33.2 INR(PT)-1.3 [**2167-8-21**] 06:39PM LACTATE-4.9* [**2167-8-21**] 06:22PM GLUCOSE-175* UREA N-27* CREAT-4.8*# SODIUM-144 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-29 ANION GAP-20 [**2167-8-21**] 06:22PM CK(CPK)-68 [**2167-8-21**] 06:22PM CK-MB-NotDone cTropnT-0.19* [**2167-8-21**] 06:22PM ALBUMIN-4.1 CALCIUM-12.3* PHOSPHATE-4.3 MAGNESIUM-2.0 [**2167-8-21**] 07:15AM GLUCOSE-131* UREA N-58* CREAT-8.7* SODIUM-139 POTASSIUM-3.1* CHLORIDE-92* TOTAL CO2-31 ANION GAP-19 [**2167-8-21**] 07:15AM CK(CPK)-65 [**2167-8-21**] 07:15AM cTropnT-0.20* [**2167-8-21**] 07:15AM CK-MB-NotDone [**2167-8-21**] 02:30AM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-497* POLYS-30 LYMPHS-14 MONOS-26 MACROPHAG-30 Brief Hospital Course: A/P: 1. Bacteremia - Given hypotension, pt. in septic shock. Etiology of bacteremia includes possible AV fistula infxn vs. endocarditis. Pt has hx MSSA bacteremia c possible cardiac emboli involvement (d/c summ [**2-21**]) - at this time, no clinical signs of endocarditis, all ECHOs neg for vegetations. LP results look like viral meningitis (WBC persist to 4th tube, high protein, neg gram stain). Could be UTI but patient is virtually anuric. He was sent to the MICU for a brief period because of hypotension likely secondary to septic shock, adrenal insufficiency was considered but cosyntropin stimulatory test was normal. He also became normotensive with hydration, and did not require pressors. His chest xrays show left sided pleural effusions but no indications of pneumonia. He Received gentamicin and vancomycin while the blood cultures were pending to cover for endocarditis, the vancomycin was changed to oxacillin when cultures grew MSSA. A TTE did no show vegetations and no indications of endocarditis, a followup TEE also indicated no evidence of endocarditis, thus he was treated for bacteremia with a five day course of gentamicin and a ten day course of oxacillin. He remained afebrile for at least the last week of his hospital course, with no evidence of infection. . 2. ESRD - Secondary to hypertenson on hemodialysis. During his hospital course HD was unable to access HD, a LUE ultrasound showed patent brachial artery and vein, but very narrowed flow in AVF, a fistulagram was ordered to followed up. His AVF was ballooned during the fistulagram and was functioning. His electrolytes remained unchanged during the delay in his hemodialysis, although he developed a slight decline of mental status from his baseline, which was attributed to uremia, as the patient was two days past his scheduled dialysis. He was never clinically fluid overloaded on exam. He received HD and his mental status dramatically improved. He continued on sensipar 60 mg po qd dinner and his medications were renally dose meds . 3. Mental status changes were likely due to uremia. He received a lumbar puncture which did not show indications of infection, his viral cultures were negative. His bacteremia may have caused presentation of his prior strokes. Hypercalcemia may have also contributed to his mental status changes. During his hospital course he waxed/waned in mental status, with correlation to his dialysis status. He was noted to have improvements after hemodialysis. . 4. PAF-He was maintained on ASA and rate controlled with a beta blocker, but kept off coumadin secondary to a history of hematochezia. . 4. Elevated troponin/?EKG changes: He had EKG changes and elevated troponins on admission, which trended down. Cardiology was consulted and felt the EKG changes are due to LVH, not acute MI. He was ruled out for a myocardial infarction, and the elevated troponin was likely due leak combined with chronic renal insufficiency. His enzymes were trended and were negative for MI. . 5. Hypercalcemia: This was attributed to ESRD and he was continued on sensipar and hemodialysis during his hospital course . 6. HTN: Well controlled currently. Monitored BP and continued on metoprolol. . 7. Anemia: Etiology unknown, but likely due to ESRD. Will trend Hct over time to make sure anemia is not new finding. He hematocrit remained at a baseline anemia. It slowly trended down his hospital course, with no indications of active bleeding. His epogen received during dialysis was increased and he his hematocrit was followed. . 8. Mental status changes/? syncope: Unclear story. Has prior strokes, so infection could cause reactivation of old deficits. His MS improved with dialysis at the change was attributed to likely uremia. He did receive a lumbar puncture during his hospital course which did not indicate infection, and HSV cultures were negative. . 9. PPX - heparin SC, pantoprazole, bowel regimen . 10. Dispo - The patient agreed to physical therapy, but declined rehabilitation although recommended, in lieu of going home. . 12. Code - presumed FULL . Medications on Admission: Metoprolol 100 mg [**Hospital1 **] Clonidine 0.1mg [**Hospital1 **] po Enalapril 2.5 mg qd Norvasc 5mg qd Renagel 1 po tid (vs ca acetate? -- has both) Ranitidine 150 mg po bid ASA 325g po qd Nephrocaps 1 po qd Cinacalcet ? dose qd Lipitor 10mg po qd Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO QD (). Disp:*60 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Sepsis MSSA bacteremia Discharge Condition: Afebrile, Good Discharge Instructions: You had an infection,sepsis, in your bloodstream and were treated with antibiotics. Please take your medications as instructed You are scheduled to follow up with your Nurse Practioner on [**2167-9-14**] at 9:40am. If you experience, fever, chills, shortness of breath, chest pain, please call your PCP, [**Name10 (NameIs) **] go to the Emergency Room. Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within one week. Followup Instructions: Provider [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 3670**]: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-14**] 9:40 Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-29**] 10:40 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**],MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2167-10-15**] 9:30 Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 3670**]: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-14**] 9:40 Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 3670**]: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-14**] 9:40 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "038.9", "996.62", "996.73", "403.91", "287.5", "995.92", "272.0", "785.52", "V45.81", "274.9", "438.20", "496", "285.21", "427.31", "275.42" ]

icd9cm

[ [ [] ] ]

[ "39.95", "03.31", "39.50", "99.04" ]

icd9pcs

[ [ [] ] ]

11011, 11068

5579, 9676

343, 392

11134, 11150

3605, 5556

11663, 12981

3100, 3179

9977, 10988

11089, 11113

9702, 9954

11174, 11640

3194, 3586

275, 305

420, 2084

2106, 2957

2973, 3084

73,863

142,091

36979

Discharge summary

report

Admission Date: [**2199-6-11**] Discharge Date: [**2199-6-14**] Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Trimethoprim / Penicillins / Celecoxib / Valdecoxib Attending:[**Doctor First Name 5188**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: This is a 87 year old female with a history of chronic atrial fibrillation, hypertension and hypothyroidism who presents to the [**Hospital Unit Name 153**] with cholecystitis. She had been in her usual state of health until 5 days ago when she suddenly began to have abdominal pain. Her abdominal pain was initially intermittent lasting for a few hours at at time. No clear correlation with food. Yesterday, she noticed that her pain was much more severe, [**2200-6-23**] in severity and more localized to the right. This was accompanied by nausea and vomitting. She vomitted twice, with clear liquid emesis and was sent to [**Hospital3 **]. At [**Hospital1 **], she was noted to have elevated amylase/lipase to 538 and 516 with elevated bili to 4.1 and AST/ALT to 198/115 and was given ciprofloxacin, flagyl and 500cc NS and was transferred to the [**Hospital1 18**] emergency department for evaluation for ERCP for presumed gallstone pancreatitis. Past Medical History: hypothyroidism, HTN Social History: lives alone, never smoked, never drank alcohol or used illicit drugs Family History: unknown Physical Exam: GEN: A and O x 1 person, confused at times. NAD CV: RRR no m/r/g RESP: LSCTA bilat ABD soft, nt, nd, + BS EXT: 1+edema in feet/legs with skin discoloration at ankles Pertinent Results: [**2199-6-14**] 06:45AM BLOOD WBC-16.9* RBC-3.43* Hgb-10.3* Hct-31.6* MCV-92 MCH-30.1 MCHC-32.7 RDW-17.7* Plt Ct-225 [**2199-6-11**] 01:45AM BLOOD WBC-16.7* RBC-4.48 Hgb-13.8 Hct-41.4 MCV-93 MCH-30.9 MCHC-33.4 RDW-17.0* Plt Ct-299 [**2199-6-12**] 04:10AM BLOOD Neuts-83.1* Lymphs-6.9* Monos-9.1 Eos-0.5 Baso-0.3 [**2199-6-11**] 01:45AM BLOOD Neuts-92.2* Lymphs-4.7* Monos-2.7 Eos-0.1 Baso-0.3 [**2199-6-14**] 06:45AM BLOOD Plt Ct-225 [**2199-6-11**] 01:07PM BLOOD PT-15.5* PTT-25.0 INR(PT)-1.4* [**2199-6-14**] 06:45AM BLOOD Glucose-77 UreaN-5* Creat-0.5 Na-141 K-3.2* Cl-106 HCO3-26 AnGap-12 [**2199-6-14**] 06:45AM BLOOD ALT-57* AST-31 AlkPhos-128* Amylase-32 TotBili-1.4 [**2199-6-11**] 01:45AM BLOOD ALT-168* AST-271* AlkPhos-171* Amylase-335* TotBili-4.9* [**2199-6-14**] 06:45AM BLOOD Lipase-42 [**2199-6-11**] 01:45AM BLOOD Lipase-537* [**2199-6-14**] 06:45AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.1 [**2199-6-11**] 01:45AM BLOOD Albumin-3.5 Calcium-10.3* Phos-2.7 Mg-1.8 [**2199-6-11**] 01:07PM BLOOD Digoxin-1.4 [**2199-6-11**] 01:53AM BLOOD Lactate-2.4* K-4.1 [**2199-6-11**] 05:40AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.021 [**2199-6-11**] 05:40AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-SM Urobiln-8* pH-6.5 Leuks-MOD [**2199-6-11**] 05:40AM URINE RBC-0-2 WBC-21-50* Bacteri-FEW Yeast-NONE Epi-[**1-17**] TransE-0-2 RenalEp-0-2 . MRSA SCREEN (Final [**2199-6-13**]): No MRSA isolated. . URINE CULTURE (Final [**2199-6-12**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . URINE CULTURE (Final [**2199-6-13**]): NO GROWTH\ . IMAGING: [**6-11**] RUQ US - Cholecystitis - sludge and stones in a distended gallbladder with wall thickening, peri-GB fluid and son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. CBD 5mm. No intrahepatic biliary duct dilation. . [**6-11**]/ERCP: A possible filling defect was seen in the distal [**11-17**] of the common bile duct. A biliary sphincterotomy was successfully performed, sludge extracted. A balloon sweep was performed on the cystic duct with no stone or sludge extraction. A spiral basket was placed in the common bile duct after multiple balloon sweeps and no further stone was extracted. . Brief Hospital Course: At [**Hospital1 18**] EDVS 97.9 HR 83 157/92 RR 18 97% RA. She had a RUQ US that revealed cholecystitis and was given unasyn. Surgery was consulted and recommended admission to [**Hospital Unit Name 153**] for closer monitoring under the surgical service. She was also seen by the ERCP service and ERCP was recommended for today. She was given unasyn and 2 L NS and was admitted to the [**Hospital Unit Name 153**] service. . An ERCP was done showing A possible filling defect was seen in the distal [**11-17**] of the common bile duct. A biliary sphincterotomy was successfully performed, sludge extracted. A balloon sweep was performed on the cystic duct with no stone or sludge extraction. A spiral basket was placed in the common bile duct after multiple balloon sweeps and no further stone was extracted. . On the floor, she reports [**2-22**] abdominal pain, improved from before. She continues to have nausea. No other complaints. With decreased pain and nausea the patient's diet was advanced from sips to regular, tolerated well. She was restarted on PO meds and IVF was d/c'd. The patient will continue on augmentin for 10 days and follow up with Dr. [**Last Name (STitle) 5182**] on [**2199-6-25**] to discuss removing her gallbladder. She will be d/c'd to rehab. . Medications on Admission: Lopressor 25", Furosemide 20', Digoxin 250', Levothyroxine 175', Tramadol 50", Trazadone 12.5, Aricept, Percocet prn, MVI, Xalatan eye drops Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **] Discharge Diagnosis: cholecystitis and gallstone pancreatitis Discharge Condition: Stable. Tolerating regular diet. Pain well controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. SURGICAL SPECIALTIES CC-3 (NHB) Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2199-6-25**] 2:30 [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2199-6-14**]

[ "427.31", "599.0", "577.0", "244.9", "401.9", "574.40" ]

icd9cm

[ [ [] ] ]

[ "51.85" ]

icd9pcs

[ [ [] ] ]

5880, 5982

3914, 5195

308, 315

6067, 6124

1655, 3891

7157, 7478

1443, 1452

5388, 5857

6003, 6046

5221, 5365

6148, 7134

1467, 1636

254, 270

343, 1295

1318, 1340

1356, 1427

29,129

131,352

12956

Discharge summary

report

Admission Date: [**2149-4-27**] Discharge Date: [**2149-4-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5608**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: n/a History of Present Illness: [**Age over 90 **] yo M brought in from [**Hospital3 2558**] today in respiratory distress. In ED, given lasix and broad spectrum abx for ?pneumonia. Blood pressures in 60's-70's systolic, respiratory rate in 40's, sats in 70's. Placed on BiPap when confirmed with patient's PCP and family that the patient was strictly DNR/DNI. Admitted to the MICU. Family recontacted, as patient was not improving with these limited measures and they decided that their wishes were for comfort measures only. Past Medical History: - Congestive heart failure. - Ischemic cardiomyopathy. - CAD - Atrial fibrillation and atrial flutter - Pseudogout. - Hyperlipidemia - Mitral regurgitation - Tricuspid regurgitation. Social History: In [**Hospital3 2558**]. Does not smoke or drink Family History: NC Physical Exam: General: Moderate Respiratory Distress HEENT: EOMI, PERRL Lungs: Diffuse rhonchi and rales Heart: Tachycardic, irregularly irregular Abd: soft NT/ND +BS Ext: cool, scattered ecchymoses. Faint distal pulses, thready. Pertinent Results: [**2149-4-27**] 09:58AM WBC-19.5* RBC-5.18 HGB-15.0 HCT-48.2 MCV-93 MCH-28.9 MCHC-31.1 RDW-16.4* [**2149-4-27**] 09:58AM NEUTS-83.6* BANDS-0 LYMPHS-12.5* MONOS-3.4 EOS-0.2 BASOS-0.3 [**2149-4-27**] 09:58AM GLUCOSE-141* UREA N-63* CREAT-3.0* SODIUM-145 POTASSIUM-7.4* CHLORIDE-107 TOTAL CO2-22 ANION GAP-23* [**2149-4-27**] 10:20AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2149-4-27**] 10:43AM GLUCOSE-129* LACTATE-6.7* NA+-149* K+-5.6* CL--107 TCO2-25 Brief Hospital Course: Admitted to the MICU. Family recontacted, as patient was not improving with these limited measures and they decided that their wishes were for comfort measures only. The patient's antibiotics were stopped and he was transitioned to a morphine drip. The BiPAP was removed. He passed away 1 hour later. PCP, [**Name10 (NameIs) **] and family were notified. Medications on Admission: ceftriaxone vancomycin lasix Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a

[ "272.4", "427.31", "396.3", "414.8", "585.9", "397.0", "712.30", "398.91", "275.49", "486", "427.32", "787.20", "414.01" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

2373, 2382

1910, 2266

283, 289

2430, 2436

1357, 1887

2488, 2495

1102, 1106

2345, 2350

2403, 2409

2292, 2322

2460, 2465

1121, 1338

223, 245

317, 813

835, 1019

1035, 1086

29,339

197,817

34235

Discharge summary

report

Admission Date: [**2152-5-22**] Discharge Date: [**2152-5-27**] Date of Birth: [**2076-3-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2152-5-22**] Three Vessel Coronary Artery Bypass Grafting utilizing a left internal mammary artery to left anterior descending, and saphenous vein grafts to obtuse marginal and PDA. History of Present Illness: This is a 76 year old male who presented to OSH with chest pain. He ruled in for NSTEMI. He was transferrred to the [**Hospital1 18**] for cardiac catheterization which revealed severe three vessel coronary artery disease. He underwent routine preoperative evaluation and was eventually cleared for surgery. Plavix was discontinued as an outpatient in preperation for upcoming surgery. Past Medical History: Type II Diabetes Mellitus Benign Prostatic Hypertrophy Gout MI Social History: Quit tobacco 30 years ago. Denies ETOH. Married, lives with wife. Family History: Two brothers with coronary artery disease. Physical Exam: PREOP EXAM Vitals: 190-202/65-78, 68, 18 General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm, normal ss1s2, no murmur Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2152-5-22**] Intraop TEE: PRE BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve appears structurally normal with trivial mitral regurgitation. POST BYPASS: Normal preserved biventricular systolic function. LVEF 55%. Intact Thoracic aortic contour. Mild AI. Trivial MR. [**2152-5-26**] CXR Moderate cardiomegaly is stable. Patient is post median sternotomy and CABG. There has been improvement in left lower lobe atelectasis. There are small bilateral pleural effusions with associated adjacent atelectasis. There is no CHF or pneumothorax. Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **] on [**5-22**]. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Early postop, he experienced a mild coagulopathy which improved with multiple blood products. Within 24 hours, he awoke neurologically intact and was extubated without incident. His CVICU course was otherwise uneventful and transferred to the SDU on postoperative day one. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He developed atrial fibrillation and was treated with amiodarone and coumadin. His Coumadin will continue to be dosed by Dr. [**Last Name (STitle) 17887**] on discharge, this was confirmed with [**Doctor First Name 4457**] at his office.Target INR is 2.0-2.5. Cleared for discharge to home with services on POD #5. Medications on Admission: Asprin 325 qd, Metoprolol 25 qd, Zocor 40 qd, Glyburide 5 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*1* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*1* 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days. Disp:*20 Capsule(s)* Refills:*0* 9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime: Need to have your INR checked and your Warfarin dose readjusted accordingly by Dr. [**Last Name (STitle) 17887**] . Disp:*100 Tablet(s)* Refills:*0* 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary artery disease - s/p CABG Type II Diabetes Mellitus Gout Benign Prostatic Hypertrophy AF Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Coumadin will be managed by Dr. [**Last Name (STitle) 17887**] ([**Telephone/Fax (1) 18656**]. Please send PT/INR to office for coumadin dosing. First blood draw on Monday [**2152-5-29**]. Goal INR is 2.0-2.5. 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in [**3-25**] weeks, call for appt Dr. [**Last Name (STitle) 17887**] in [**1-23**] weeks, call for appt Completed by:[**2152-5-29**]

[ "427.31", "250.00", "E879.8", "414.01", "682.4", "411.1", "600.00", "999.39", "286.9", "274.9", "458.29", "410.72" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.12", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

5091, 5146

2672, 3707

332, 519

5288, 5295

1582, 2649

6250, 6416

1119, 1163

3818, 5068

5167, 5267

3733, 3795

5319, 6227

1179, 1563

282, 294

547, 934

956, 1020

1036, 1103

64,465

156,135

10824

Discharge summary

report

Admission Date: [**2200-12-29**] Discharge Date: [**2201-1-3**] Date of Birth: [**2129-12-28**] Sex: F Service: SURGERY Allergies: Bactrim / lisinopril / doxazosin Attending:[**First Name3 (LF) 4748**] Chief Complaint: Bilateral renal artery stenosis Major Surgical or Invasive Procedure: [**2200-12-29**]: OPERATION PERFORMED: 1. Ultrasound-guided puncture of right common femoral artery. 2. Ultrasound-guided puncture of right femoral limb of aortobifemoral bypass graft. 3. Abdominal aortogram. 4. Selective catheterization of right renal artery. 5. Selective catheterization of left renal artery. 6. Perclose closure of right graftotomy. [**2200-12-30**]: temporary right internal jugular hemodialysis catheter insertion, with subsequent hemodialysis [**2201-1-1**]: 1. Ultrasound-guided puncture of right brachial artery. 2. Third-order catheterization of abdominal aorta via the brachial artery. 3. Abdominal aortogram. 4. Balloon angioplasty and stenting of the right renal artery. 5. Balloon angioplasty and stenting of the left renal artery. History of Present Illness: 71F followed by a nephrologist over the past year for hypertension difficult to manage despite being on metoprolol, hydralazine, clonidine, and furosemide. She has had two renal artery duplex ultrasounds, most recently in [**2200-11-11**], which showed progressive bilateral renal artery stenosis, with the right particularly worse (90% stenosed) than the left. She presents today for renal artery angiogram and possible stenting. ROS positive for possible sequelae of renal artery stenosis: two episodes of CHF exacerbations in [**2200-11-11**], each managed with hospitalization and diuresis. She was admitted to the Vasular Surgery service and was given intravenous hydration with bicarbonate. She was taken to the endovascular suite for renal angiogram and stenting. Past Medical History: PMH: Diet-controlled type 2 DM, HTN, hyperlipidemia, central tremor of the head, left subclavian stenosis PSH: 2 vessel CABG [**2200-8-11**], open cholecystectomy [**2166**], left subclavian vein stenting [**2195**], aortibifemoral bypass [**2196-1-11**], left carotid endarterectomy [**2190**], left common carotid to subclavian artery bypass, tonsillectomy Social History: Retired from sales, teaching aid. Does not smoke currently, but Hx 1 PPD for 20 years, quit 18 years ago. Drinks one wine per day. No drugs. Family History: Both parents diet of heart disease. Brother s/p CABG. Back problems. Physical Exam: Physical Examination on Admission: Vital Signs: Temp: 97.9 RR: 16 Pulse: 59 BP: 122/78 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: Thyroid normal size, non-tender, no masses or nodules, abnormal: Slight prominence at left CEA site. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm, abnormal: Possible II/VI SEM. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, No hepatosplenomegally, No hernia, No AAA. Rectal: Not Examined. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Ulnar: P. Brachial: P. LUE Radial: P. Ulnar: P. Brachial: P. RLE Femoral: P. Popiteal: P. DP: P. PT: P. LLE Femoral: P. Popiteal: P. DP: P. PT: P. Physical Examination on Discharge: Tmax 98.6, Tc 97.2, HR 76, BP 133/84, RR 20, SaO2 94% RA General: alert, NAD Cardiac: RRR Lungs: CTAB, no respiratory distress Abd: soft, NT, ND, no R/G Wounds: Right groin and antecubital wounds without evidence of bleeding, swelling Extremities: no C/C/E All pulses of bilateral lower and upper extremities palpable. Pertinent Results: [**2200-12-29**] 11:00AM BLOOD WBC-4.4 RBC-3.76*# Hgb-12.0# Hct-35.4*# MCV-94 MCH-32.0 MCHC-34.0 RDW-12.9 Plt Ct-134* [**2201-1-3**] 04:00AM BLOOD WBC-6.0 RBC-2.99* Hgb-9.7* Hct-26.8* MCV-90 MCH-32.3* MCHC-36.0* RDW-15.0 Plt Ct-112* [**2201-1-3**] 04:00AM BLOOD PT-11.2 PTT-33.6 INR(PT)-1.0 [**2200-12-29**] 11:00AM BLOOD Glucose-107* UreaN-39* Creat-1.6* Na-140 K-3.9 Cl-103 HCO3-28 AnGap-13 [**2201-1-3**] 04:00AM BLOOD Glucose-107* UreaN-39* Creat-2.1* Na-134 K-3.3 Cl-102 HCO3-25 AnGap-10 [**2201-1-1**] 01:49AM BLOOD ALT-18 AST-24 AlkPhos-48 Amylase-151* TotBili-0.7 Brief Hospital Course: Ms. [**Known lastname 35307**] was admitted to the Vascular Surgery Service on [**2200-12-29**]. She was given IV hydration with bicarbonate and kept NPO. She was taken to the endovascular suite on [**2200-12-29**] for renal artery angiogram. The surgeon was Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**]. Please see the operative note for greater detail. The renal arteries proved hard to selectively canalize and therefore she was not stented in that session. In addition, she was having progressively difficult to manage hypertension with systolic pressures greater than 200s requiring nitro drip and worsening nausea. The patient was brought to the recovery room in stable condition, where she was monitored overnight. She was hypertensive overnight requiring labetalol drip and occasional hydralazine IV. NGT was placed for vomiting. Urine output dropped so the patient was given several boluses of saline. Serum creatinine increased from 1.6 pre-operatively to 2.4. She also had some agitation and was given haldol and ativan. On [**12-30**], she was transferred to the ICU for additional monitoring. Given oxygen requirement and decreasing urine output, 260 mg of lasix was given without notable increase in urine output, but creatinine continued to rise. Temporary hemodialysis line was placed in the right IJ and the patient received CVVH. In addition to labetalol drip, hydralazine and metoprolol were used for blood pressure control, and clonidine was started at 0.1 mg PO TID. On [**2200-12-31**] the patient received hemodialysis again, before which her creatinine had risen to 4.8. Labetalol drip was switched to nicardipine. NGT was removed. Urine output was minimal throughout the day. On [**2201-1-1**] the patient was taken to the endovascular suite for bilateral renal artery angiogram and stenting. The surgeons were Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**]. Both renal arteries were angioplastied and stents placed. The patient tolerated the procedure well. Urine production resumed immediately after the procedure. She was subsequently taken to the ICU for post-operative monitoring. She received minimal hemodialysis. Her blood pressure control improved, and she was able to be weaned off of a nicardipine drip. Blood pressure was maintained on metoprolol, hydralazine, and clonidine. Home blood pressure regimen was restarted on [**2201-1-2**] and decreased as the patient tolerated, given that her blood pressure remained well-controlled with systolic blood pressure less than 150. The patient produced 2 liters of urine. Hematocrit had trended down to 24.7, and given patient's cardiac history she was transfused with one unit of packed red blood cells. Her hematocrit increased appropriately. On [**2201-1-3**], he patient was ambulating independently. Her foley catheter was discontinued and she was able to void. Her creatinine had trended down to 2.1. Her hemodialysis line was removed from her neck without bleeding or swelling. The arm and groin access sites were clean, dry, intact, without evidence of bleeding or swelling. She was tolerating a regular diet. Pain was well-controlled. The patient was felt to be stable for discharge to home with appropriate followup with her nephrologist and primary care physician, [**Name10 (NameIs) **] outpatient lab measurements of her electrolytes on [**2201-1-5**]. She understood this plan and was in agreement. Medications on Admission: alendronate clonidine ezetimibe [Zetia] furosemide hydralazine lorazepam metoprolol tartrate ranitidine HCl rosuvastatin [Crestor] aspirin calcium carbonate-vitamin D3 [Calcium 600 + D(3)] cetirizine docusate sodium multivitamin Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 5. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 11. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient Lab Work Please measure serum sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, calcium, magnesium, and phosphate. Please have the results communicated to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (call [**Telephone/Fax (1) 1393**]), as well as to the Vascular Surgery residents on call -- please have the lab reports sent to [**Hospital Ward Name 121**] 5 at fax # [**Telephone/Fax (1) 35308**] (attn: Vascular Surgery team) and call [**Telephone/Fax (1) 35309**] to notify that this has been sent. Discharge Disposition: Home Discharge Diagnosis: Bilateral renal artery stenosis. Acute renal failure, resolving. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Renal Artery Angioplasty and Stenting Discharge Instructions Medications: ?????? Continue to take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed. However, please do not take your furosemide (Lasix) at this time as your kidneys are recovering from not making urine. ** Please consult your primary care physician or nephrologist for resumption of Lasix, if they feel this medication is necessary. In the interim, seek medical attention immediately if you start to notice shortness of breath. Call your primary care physician if you start to notice increased swelling of your legs. ?????? You make take Tylenol for any post procedure pain or discomfort. ** Extremely Important Re: Blood Pressure Management ** Regarding your blood pressure medications, your metoprolol dose has been halved as your blood pressure is expected to reduce after the renal artery stenting. Since your blood pressure will likely decrease further in the coming days and weeks, you must followup with your primary care physician as soon as possible for management of your blood pressure. If you start to experience symptoms of decreased blood pressure, including dizziness, weakness, confusion, tiredness, or fainting, seek medical attention immediately. Please measure your blood pressure daily. If the systolic blood pressure (the higher number) is 100 mm Hg or less, please contact your physician as this is too low, and your medications may need to be modified. Regarding your kidney function: - You must have your blood electrolytes checked on Monday [**2201-1-5**]. - If you start to urinate excessively (more than about 8 times per day), please contact the office as your may become dehydrated or your electrolytes may become imbalanced. Relatedly, if you start to notice signs of electrolyte imbalance, including headache, dry mouth, lack of urination, chest pain, dizziness, weakness, confusion, tiredness, fainting, palpitations, numbness, tingling, nausea, vomiting, or abdominal pain, please seek medical attention immediately. What to expect when you go home: ?????? Pursue activity as you tolerate. ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry), however do not get the neck wound where your hemodialysis catheter was formerly get wet. ?????? The site on your right neck where your hemodialysis catheter was placed should be kept covered for 48 hours to allow it to seal, at which time you can remove the dressing. ?????? Your groin and arm incisions are healing well and may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin and arm puncture sites to heal) ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications SUDDEN, SEVERE BLEEDING OR SWELLING (Arm, groin or neck puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. ?????? If you notice swelling of your neck at the former site of the hemodialysis catheter or if you have difficulty breathing, please seek medical attention immediately. Followup Instructions: Please followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] in two weeks. Please call [**Telephone/Fax (1) 1393**] to make this appointment. Please followup with your primary care physician or nurse practitioner within the next week in order to evaluate control of your blood pressure. Please followup with your outpatient nephrologist in the next two weeks, given that you have had angioplasty and stenting of your renal arteries, and given that you had acute renal failure which is resolving. Please get outpatient blood labs drawn on Monday [**2201-1-5**]. Please have the results sent to Dr.[**Name (NI) 1392**] office. Completed by:[**2201-1-3**]

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icd9cm

[ [ [] ] ]

[ "88.45", "39.95", "00.46", "00.41", "39.50", "39.90", "88.42" ]

icd9pcs

[ [ [] ] ]

9610, 9616

4399, 7961

325, 1099

9725, 9725

3803, 4376

14000, 14694

2463, 2534

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3464, 3784

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1127, 1904

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2304, 2447

25,725

179,209

43005

Discharge summary

report

Admission Date: [**2120-12-11**] Discharge Date: [**2120-12-18**] Service: MICU HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old woman with a history of bronchogenic adenocarcinoma, status post left lower lobe resection in [**2120-7-7**] complicated by pneumonia and failure to wean from the ventilator. She is transferred from [**Hospital1 **] Rehabilitation Center at The patient's course status post her left lower lobe adenocarcinoma resection was notable for multiple episodes of respiratory failure which required re-intubation. She also had multiple episodes of pneumonia. She had a tracheostomy and jejunostomy tube placed in [**2120-7-7**]. From that point, the patient has had a prolonged course in which she Her course at [**Hospital1 **] Rehabilitation Center is notable for decreased hematocrit and guaiac positive stools. Her Coumadin had been stopped, an esophagogastroduodenoscopy was unsuccessful and the barium swallow was deferred secondary to high aspiration risk. The patient was on Coumadin for atrial fibrillation which had developed postoperatively but resolved after initiation of Amiodarone. The patient also had a right sided thoracentesis for a large (greater than 2 liters) pleural effusion. She had rapid re- accumulation of this effusion which was by report a transudate. The patient did have sputum which grew Methicillin resistant Staphylococcus aureus. The patient also had stool that was positive for C. difficile. The patient also had recurrent urinary tract infection most recently with Klebsiella which was treated with a 5 day course of Zosyn just prior to admission here. Family reports that at baseline the patient is deaf but is able to communicate through writing and lip [**Location (un) 1131**]. They have noted no recent changes in her mental status. They have become frustrated that she has not been able to progress off the ventilator and are requesting further evaluation at [**Hospital1 1444**]. PAST MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation complicated by hypotension during recent hospitalization to [**Hospital1 69328**]. 2. Left lower lobe adenocarcinoma of the lung, status post resection surgically by Dr. [**Last Name (STitle) 175**] at [**Hospital1 29402**] in [**2120-7-7**]. 3. Triple A repair in [**2110**]. 4. Hypertension. 5. Osteoporosis. 6. Open reduction and internal fixation of the right hip. 7. C. difficile stool infection. 8. Methicillin resistant Staphylococcus aureus in sputum. 9. Recurrent urinary tract infections. 10. Right sided pleural effusions. MEDICATIONS ON TRANSFER: 1. Combivent MDI two puffs q.i.d. 2. Albuterol nebs q two hours p.r.n. 3. Premarin 0.625 mg p.o. G-tube q day. 4. Multivitamin one q day. 5. Omeprazole 40 mg per G-tube q day. 6. Flovent 225 mg two puffs b.i.d. 7. Neurontin 100 mg per G-tube q 8 hours. 8. Celexa 40 mg per G-tube q day. 9. Potassium 20 mEq q day. 10. Iron Sulfate 5 cc's per G-tube q day. 11. Lasix 40 mg per G-tube q day. 12. Zosyn 3.375 mg intravenous q 6 hours, completed on [**2120-12-10**]. PHYSICAL EXAMINATION: Heart rate 60, normal sinus rhythm, blood pressure 110/60. Afebrile. Vent settings IMV with a rate of 14, tidal volume 450, pressure support 10, PEEP 5, FIO2 0.45. General: The patient closes eyes tightly in response to tactile fremitus. Chest: Coarse breath sounds anteriorly without rales or signs of consolidation. Tracheostomy is in place. Cardiovascular: JVP obscured by trach collar, regular S1 and S2. Coarse 2/6 systolic murmur at the left lower sternal border towards the apex. Abdomen: Rare bowel sounds, soft, nontender, nondistended. G-tube is in place. Well healed midline surgical scar. Pulses: 2+ radial, femoral, dorsalis pedis, posterior tibial pulses bilaterally. Lower extremities: No edema, bruising distal to the knee. No skin breakdown obvious. Neurologic: In response to tactile stimulation the patient closes her eyes tightly. There is a tremor with intention of the extremities and head. She has diffuse rigidity with sustained ankle clonus bilaterally. She is diffusely hyperreflexic. LABORATORY FINDINGS: White blood count 8.6, hematocrit 28.6, platelets 276, sodium 135, potassium 3.3, chloride 94, bicarbonate 35, BUN 30, creatinine 0.5. Glucose 105, ALT 20, AST 22, alk phos 135. Total bilirubin 0.3, albumin 2.5, calcium 8.6, phosphate 2.1. Urinalysis 1.014 specific gravity, trace protein, 2 white cells, occasional bacteria, no yeast, one epithelial. Sputum with greater than 25 polys and less than 10 epithelial cells with 1+ gram negative rods, 4+ gram positive rods. Chest x-ray: Shows slight cardiomegaly, bilateral pleural effusions, mild to moderate pulmonary edema. HOSPITAL COURSE: 1. Pulmonary: The patient was initially diuresed with an extra dose of Lasix the day of her admission. She was then sent for a CT scan of her chest on [**2120-12-13**] and this showed the following. Question of a left lingular bronchus partially obstructing lesion. Ground glass opacity changes mostly in the upper lobes, predominantly the right upper lobe. Generally aside from the right upper lobe findings, the parenchyma is much improved compared to a CT scan from [**2120-8-7**]. There is question of overinflation of the cuff of her tracheostomy. There is interval increase in the right sided pleural effusion with interval decrease in her left sided pleural effusion. The patient underwent bronchoscopy on [**2120-12-16**], which revealed a somewhat concerning appearance to a heaped up type lesion at the left lower lobe stump. This lesion was biopsied times three given its somewhat concerning appearance. The tissue at this lesion was not friable nor did it bleed in an abnormal way. The biopsies are pending at the time of dictation. The patient was put on trials of trach mask. The patient surprisingly tolerated these trials on trach mask quite well. She was generally rested over night on SIMV, however, during the day she was able to tolerate trach mask for several hours during the day. We will continue to put her on trials of trach mask off the ventilator as tolerated while she is still at [**Hospital1 69**]. On the day of discharge from the [**Hospital1 18**], she tolerated trach collar >24 hours (including overnight). It is possible that some component of pulmonary edema from congestive heart failure may be impeding her ability to wean. Bronchoscopy otherwise revealed areas of thick mucous plugs which were clear in appearance and not purulent. Also, the Pulmonary Interventional Service will evaluate the patient on [**2120-12-17**] to change her trach collar to a different size so that there is no leak as a leak had been noted around the trach collar, however, the CT scan suggested her cuff is overinflated. They suggested the size of the trach is actually somewhat small for her airway. 2. Cardiovascular: There were no acute cardiovascular issues during this admission. As noted we did try some mild extra diuresis and changed her Lasix to twice a day dose while here. She generally maintained a negative fluid balance over 24 hour period. There was no recurrence of atrial fibrillation during this admission. The patient had a transthoracic echo, which otherwise unchanged from previous echocardiograms at this institution as well as [**Hospital1 **], revealed question of a left atrial mass. It was not entirely clear from the views on the TTE as to the nature of this mass, however, upon review with cardiology attending, the mass did not appear to be displaying paradoxical motion within the atrium. A transesophageal echocardiogram was scheduled, however, the patient did not tolerate sedation required for the procedure as she dropped her blood pressure precipitously. This blood pressure drop responded to a brief bolus of pressors. She had no further hemodynamic instability following the procedure. The procedure was aborted and is not being rescheduled at this time. It is felt that the mass that was seen on the TTE is likely within the wall of the atrium rather than an attached thrombus or myxoma. This will not e further pursued during this admission. 3. Infectious Disease: The patient was still spiking temperatures above 101.0. She was cultured multiple times, with sputum showing greater than 25 polys and 1+ gram negative rods. At the time of this dictation those gram negative rods are being speciated and sensitivities to the antibiotics are pending. We suspect the 4+ gram positive rods are likely colonizer, especially upon review of prior sputum samples this has turned out to be corynebacterium. The CT scan did raise some question of whether there is an atypical pneumonia with deep ground glass opacity findings in her right upper lobe. Given the spike temperature and her multiple courses of antibiotics, we elected to start Ceftazidime. This was started empirically to cover gram negative rods in her sputum as well as apparently gram negative rods in her urine which were growing. There is some concern whether a five day course of Zosyn may have been somewhat short for the purulent strain that she had grown. Other data at the time of this dictation is pending with regards to her cultures. She will be discharged on Ceftazidime 1 gram q 12 hours intravenous, started on [**2120-12-16**]. 4. Renal. The patient maintained a good urine output during this admission with a good response to Lasix and Hemodynamic stability. There were no active issues otherwise. 5. Gastrointestinal. The patient tolerated tube feeds throughout this admission. They were changed to a different tube feed formulation in an effort to reduce CO2. This is changed to Respalor. The patient tolerated tube feeds well and no further changes were necessary. 6. Access. The patient was had a peripheral intravenous during this admission, no central access was necessary. 7. Prophylaxis: The patient was on Protonics, pneumoboots, and subcutaneously Heparin. 8. Code Status: "Do Not Resuscitate", confirmed with the patient's proxy, [**Name (NI) **] [**Name (NI) 36924**]. DISCHARGE MEDICATIONS: 1. Ceftazidime 1 gram intravenous q 12 times 10 days. Started on [**2120-12-16**]. 2. Albuterol nebs q 2 hours p.r.n. 3. Prevacid suspension 30 mg nasogastric tube q day. 4. Lasix 40 mg nasogastric tube b.i.d. 5. Heparin 5000 units subcutaneously b.i.d. 6. Premarin .625 mg per G-tube q day. 7. Multivitamins one per G-tube q day. 8. Potassium chloride 20 mEq per G-tube q day. 9. Celexa 40 mg per G-tube q day. 10. Neurontin 100 mg per G-tube three times a day. 11. Flovent MDI 220 mcs b.i.d. 12. Combivent MDI two puffs b.i.d. 13. Iron sulfate 5 cc's per G-tube q day. DISCHARGE DIAGNOSIS: 1. Prolonged mechanical ventilation dependence. 2. Mild pulmonary edema. 3. Question lesion at left lower lobe stump site. Status post biopsy, biopsy results pending. 4. Question gram negative rods in sputum and urine. 5. Question left atrial mass, however, further identification aborted due to inability to tolerate TTE. 6. History of paroxysmal atrial fibrillation. 7. Left lower lobe adenocarcinoma, status post resection [**2120-7-7**]. 8. Status post tracheostomy, mechanical ventilation dependent. 9. Hypertension. 10. Osteoporosis. 11. Open reduction and internal fixation right hip. 12. C. diff colitis. 13. History of Methicillin resistant Staphylococcus aureus in sputum. 14. Recurrent urinary tract infection. 15. Right sided pleural effusion, transudate. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**] Dictated By:[**Name8 (MD) 16017**] MEDQUIST36 D: [**2120-12-16**] 18:12 T: [**2120-12-16**] 18:13 JOB#: [**Job Number 92814**]

[ "518.83", "799.4", "427.31", "599.0", "519.02", "V46.1", "428.0", "511.9", "E878.3" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.05", "33.27", "97.23", "96.6", "33.21" ]

icd9pcs

[ [ [] ] ]

10173, 10758

10779, 11850

4776, 10150

3125, 4759

120, 1983

2625, 3102

2005, 2600

12,798

159,669

644

Discharge summary

report

Admission Date: [**2191-7-18**] Discharge Date: [**2191-7-24**] Service: CCU THIS REPORT WILL BE CONCLUDED IN AN ADDENDUM. HISTORY OF PRESENT ILLNESS: The patient is an 86 year old gentleman with a history of coronary artery disease status post three vessel coronary artery bypass graft in [**2181**] with the following anatomy: Left internal mammary artery to left anterior descending; saphenous vein graft to patent ductus arteriosus; saphenous vein graft to obtuse marginal 3; ischemic cardiomyopathy with an ejection fraction of 20; three plus mitral regurgitation; atrial fibrillation status post pacemaker placement in [**2189**], on Coumadin; diabetes mellitus type 2; hypertension; history of colon cancer status post sigmoid colectomy in [**2167**]; history of herpes zoster with post herpetic neuralgia; chronic renal insufficiency with baseline creatinine of 1.9 to 2.2; history of anemia. He was initially admitted to the General Medicine Service after being found confused by his wife. Emergency Medical Services was called to his house and found a glucose of 40. The patient was given a glass of [**Location (un) 2452**] juice and was transferred to the Emergency Room and subsequently was transferred to he General Medicine Floor. As per patient's wife, the patient has had diarrheal illness for three days with a decreased p.o. intake; no fevers or chills. No weight loss. The patient was admitted to Medicine on [**7-18**]. It was decided that the patient was dehydrated secondary to diarrheal illness and hypoglycemia resolved secondary to taking regular dose of oral hypoglycemics. The patient was admitted for overnight gentle intravenous fluid hydration. In the a.m., the patient was found with worsening mental status; his blood sugar was 20. The patient had a persistent right lower quadrant pain and was subsequently transferred to the Coronary Care Unit for close monitoring with Swan-Ganz catheter and hydration, and with the suspicion for ischemic bowel in the setting of hyperperfusion. PAST MEDICAL HISTORY: 1. Coronary artery disease status post three vessel coronary artery bypass graft with anatomy mentioned in the History of Present Illness. 2. Ischemic cardiomyopathy with ejection fraction of 20%. 3. Three plus mitral regurgitation. 4. Baseline weight 150 pounds. 5. Atrial fibrillation status post permanent pacemaker placement in [**2189**], on Coumadin. 6. Diabetes mellitus type 2. 7. Hypertension. 8. Status post sigmoid colectomy in [**2167**] for colon cancer. 9. History of herpes zoster with post herpetic neuralgia. 10. Chronic renal insufficiency with baseline creatinine of 1.9 to 2.2. 11. Anemia with hematocrit of 33 to 36. MEDICATIONS ON TRANSFER: 1. Aspirin. 2. Coreg 12.5 twice a day. 3. Lisinopril 30 q. day, on hold. 4. Lasix 60 mg p.o. twice a day on hold. 5. Digoxin 0.125 mg q. day. 6. Coumadin 5 mg p.o. q. day on hold. 7. Protonix. 8. Sliding scale insulin. 9. Multivitamin. 10. Trazodone p.r.n. 11. Tylenol p.r.n. ALLERGIES: Penicillin with rash; amiodarone. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Very active elderly gentleman. Exercises on treadmill every day. ASSESSMENT: The patient was admitted to the Intensive Care Unit for hemodynamic monitoring and hydration with a concern for high suspicion of ischemic bowel. PHYSICAL EXAMINATION: On transfer, the patient's temperature was 98.5 F.; blood pressure 100/50; pulse 70 and paced; O2 saturation of 97% on three liters nasal cannula. General examination: The patient was uncomfortable in bed, lying still. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Oropharynx was moist with no lesions. Neck: There were no carotid bruits. There was no jugular venous distention. Pulmonary: Good inspiratory movement; was clear to auscultation bilaterally. Cardiovascular system with regular rate and rhythm, normal S1 and S2. There were no rubs. There was a three plus holosystolic ejection murmur at the right sternal border radiating into apex, consistent with the patient's mitral regurgitation. Abdomen: There were positive bowel sounds. The patient's abdomen was extremely tender to even light palpation; there was positive rebound in all quadrants, but specifically in the right lower quadrant. The patient has shown clear peritoneal signs. There was extreme tenderness upon right lower extremity elevation above 30 degrees. The patient also has demonstrated increased tenderness in the right lower quadrant and right flank. Extremities with no cyanosis, clubbing or edema. HOSPITAL COURSE: Upon transfer to the Coronary Care Unit: [**Unit Number **]. CARDIOVASCULAR SYSTEM: It was decided to optimize the patient's management to place a Swan-Ganz catheter to monitor the patient's hemodynamics, which was agreeable with the patient and his family. Initial Swan-Ganz catheter numbers showed central venous pressure of 24, PA pressure of 70/90; and pulmonary capillary wedge pressure of 24. Cardiac output of 5.2, cardiac index of 2.84 and SVR of 508. Gentle hydration was continued. Initial low SVR was thought to be attributed to patient being on a good medical regimen for his coronary artery disease and cardiomyopathy. The patient has done well from the cardiac standpoint, however, over the course of the night, he had persistent low SVR and we were concerned about a questionable septic picture, especially in the context of questionable ischemic bowel. Therefore, the next morning, Vancomycin intravenously was added to the patient's regimen. This was in addition to Levofloxacin and Flagyl that were started empirically in the Coronary Care Unit for likely ischemic colitis, in order to prevent peritonitis due to the transit of the bowel flora through the bowel wall. The following morning, the patient has done extremely well. The patient's abdominal examination was improved and over the course of the next day, the patient has maintained stable Swan-Ganz catheter numbers showing good hemodynamics. The patient's central venous pressure was between 6 and 10. Pulmonary artery diastolic pressure was between 18 and 22; cardiac index between 2 and 2.4. SVR around 800 and mixed venous O2 saturations of 50s to 60s. Subsequently, the patient's Swan-Ganz catheter was taken out and the patient has continued to be doing well. The patient was restarted on his home regimen of Coreg and Lisinopril. The patient has not been receiving Lasix and instead required several fluid boluses in order to maintain his urinary output. The patient was restarting on digoxin home dose and he has tolerated the above regimens well. The patient has been in sinus rhythm with a ventricular paced rate around 70. On Telemetry, the patient has shown few runs of non-sustained ventricular tachycardia, three to four beats, and has remained asymptomatic. 2. GASTROINTESTINAL: The patient was admitted to the Coronary Care Unit with suspected ischemic colitis versus diverticulitis with subsequent micro-perforation versus appendicitis, all of the above could give him localized peritonitis picture. Surgical Consultation team was consulted to participate in his care and per their recommendations, empiric antibiotic coverage was started with Levofloxacin and Flagyl. The next day, Vancomycin was added to include enterococcus. The patient's options of care were explained to the patient on the night of transfer to the Coronary Care Unit including abdominal scan with or without contrast to exclude diverticulitis or appendicitis as well as to rule out ischemic colitis versus taking patient to the Operating Room without prior imaging if the patient's condition deteriorates. After a long discussion with the patient and his family, it was the patient's wishes to continue antibiotic treatment and overnight hydration without abdominal imaging or urgent surgery and to hope for clinical improvement. This was done and the patient has improved greatly overnight and over the next few days the patient's physical examination and today's was significant only for mild right lower quadrant tenderness. The patient has been kept n.p.o. and on the day three of Coronary Care Unit stay had bowel movements with Dulcolax suppositories with streaks of blood that were consistent with fissure versus hemorrhoids, since the patient's previous guaiac examinations were negative. The patient's abdominal x-rays were unremarkable. It was decided to slowly advance the patient's diet to clear liquids as tolerated which was in agreement with the Surgical consultation service. 3. RENAL: Acute on chronic renal failure. The patient demonstrated a component of prerenal azotemia on top of chronic renal insufficiency. With gentle hydration and occasional fluid boluses, the patient's creatinine returned to his baseline and was ranging between 1.3 and 1.6. The patient maintained good urinary output throughout the hospitalization. 4. ENDOCRINE: Hypoglycemia was improved with hydration with D5 [**1-13**] normal saline. It was likely due to the lasting effect of oral hypoglycemics superimposed on acute on chronic renal failure. 5. GENITOURINARY: The patient has had an episode of gross hematuria that was attributed secondary to Foley trauma. The hematuria cleared subsequently. The patient was also found to have a mild urinary tract infection which was already treated with triple antibiotic coverage for probable ischemia colitis. The patient's antibiotic regimen was not changed awaiting sensitivities. This dictation is to be followed by an Addendum. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 4937**] MEDQUIST36 D: [**2191-7-24**] 18:42 T: [**2191-7-24**] 18:54 JOB#: [**Job Number 4938**]

[ "427.31", "V45.01", "584.9", "V45.81", "276.5", "557.0", "V58.61", "424.0", "414.00" ]

icd9cm

[ [ [] ] ]

[ "89.64", "89.68", "38.93" ]

icd9pcs

[ [ [] ] ]

3088, 3106

4648, 9895

3375, 4630

166, 2041

2736, 3070

2063, 2711

3124, 3351

52,875

168,988

16434

Discharge summary

report

Admission Date: [**2183-2-26**] Discharge Date: [**2183-3-4**] Date of Birth: [**2122-10-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7299**] Chief Complaint: Aspirin and Tylenol ingestion Major Surgical or Invasive Procedure: Femoral dialysis line placement PICC line placement History of Present Illness: 60 year old female with PMH of depression followed by a psychiatrist with h/o suicide attempt 15 years ago and past psychiatric hospitalizations (last 1 year ago), bipolar disorder, HTN, and hypothyroidism who initially presented to [**Location (un) 620**] at 4:30PM on [**2-25**] s/p an overdose of reportedly 300 tablets of aspirin and 10 tablets of Tylenol Extra Strength at 3:30PM this afternoon. She said that this was a suicide attempt but reported no other co-ingestions. She denied CP/SOB, abdominal pain, and diarrhea at [**Location (un) 620**]. She vomited twice at [**Location (un) 620**], both times were non-bloody. Initially when she presented to [**Location (un) 620**]: 4:21 pm - ETOH neg, tylenol 87, aspirin 9.7 6:45 pm - LFTs neg, tylenol 40.3, aspirin 63.2 bicarb=24.5 Cr 1, K 4.6 EKG: QRS 102 She was started on a bicarb drip at [**Location (un) 620**], given activated charcoal, and transferred to [**Hospital1 18**] for toxicology. . In the [**Hospital1 18**] ED, initial VS were: 97.8, 88, 130/80, 18, 96% RA. An EKG showed sinus rhythm at 90, NA/NI, TWI in III. CXR shows bilateral increased vascular markings but no acute infiltrate. Initial tox screen showed ASA=42 and Tylenol=44. Toxicology was consulted and recommended q2 hour aspirin levels and alkalinization of the urine with a goal pH of 7.5-8.0. She was started on bicarb drip at 150cc/hr titrated to 1-2cc/kg/hour urine output. Toxicology recommended no intubation. If ASA levels increase or acidosis is refractory, toxicology wanted renal consultation for dialysis. No indication for NAC. Bicarb was to be stopped when aspirin level is 30 or less. Patient received another dose of activated charcoal. Transfer vitals: 148/83, 98, 16, 97% RA . On arrival to the MICU, patient was uncomfortable and obtunded on admission, but still redirectable. Around 5AM she became completely obtunded and generally unreponsive in correlation with her ASA level rising to above 90. Past Medical History: -Hypothyroidism -Depression -Bipolar disorder -Hypertension Social History: She is not working. She drinks alcohol socially. She does not smoke. She is married. Her activity level is quite low at baseline because of pain. Family History: Non-contributory Physical Exam: On admission: Vitals: T: 98.3, BP: 132/64, P: 110, R: 23 O2: 96% General: Obtunded, tachypneic, uncomfortable appearing, diffusely erythematous HEENT: Sclera anicteric, dry MM Neck: supple CV: Tachycardic Lungs: Tachypneic, clear to auscultation bilaterally with some rales bilaterally at bases Abdomen: soft, non-tender, non-distended, bowel sounds present GU: Foley Ext: warm, no clubbing or edema Neuro: obtunded . At discharge: 98.9, 139/94, 75, 18, 94% RA General: AAOX3, anxious but well appearing female in NAD HEENT: Sclera anicteric, MMM, EOMI, PERRLA Neck: supple, no JVD, no lymphadenopathy CV: RRR, no M/R/G Lungs: CTABL, reduced air entry bibasally. Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, no clubbing or edema Neuro: CNII-XII grossly intact. Moving all four extremities. Pertinent Results: Admission labs: [**2183-2-25**] 10:45PM WBC-7.7 RBC-3.64* HGB-11.6* HCT-33.5* MCV-92 MCH-31.8 MCHC-34.5 RDW-13.2 [**2183-2-25**] 10:45PM NEUTS-72.4* LYMPHS-19.5 MONOS-4.1 EOS-3.7 BASOS-0.4 [**2183-2-25**] 10:45PM PLT COUNT-378 [**2183-2-25**] 10:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004 [**2183-2-25**] 10:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [**2183-2-25**] 10:45PM URINE RBC-2 WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [**2183-2-25**] 10:45PM ASA-42.0* ETHANOL-NEG ACETMNPHN-44* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2183-2-25**] 10:45PM ALT(SGPT)-11 AST(SGOT)-46* LD(LDH)-759* ALK PHOS-85 TOT BILI-0.2 [**2183-2-25**] 10:45PM GLUCOSE-89 UREA N-23* CREAT-1.2* SODIUM-142 POTASSIUM-8.0* CHLORIDE-108 TOTAL CO2-23 ANION GAP-19 [**2183-2-25**] 10:56PM TYPE-[**Last Name (un) **] PO2-52* PCO2-37 PH-7.48* TOTAL CO2-28 BASE XS-3 . Discharge Labs: [**2183-3-4**] 10:22AM BLOOD WBC-8.2 RBC-3.42* Hgb-10.7* Hct-32.9* MCV-96 MCH-31.2 MCHC-32.3 RDW-13.8 Plt Ct-221 [**2183-3-4**] 10:22AM BLOOD Glucose-128* UreaN-11 Creat-1.2* Na-144 K-4.2 Cl-113* HCO3-22 AnGap-13 [**2183-3-3**] 06:22AM BLOOD ALT-71* AST-68* LD(LDH)-420* AlkPhos-76 TotBili-0.3 [**2183-3-4**] 10:22AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9 . Salicylate levels: [**2183-2-26**] 03:52AM BLOOD ASA-93.8* Acetmnp-26 [**2183-2-26**] 07:06AM BLOOD ASA-128* [**2183-2-26**] 09:14AM BLOOD ASA-136.5* [**2183-2-26**] 11:23AM BLOOD ASA-92.0* [**2183-2-26**] 02:41PM BLOOD ASA-27.8* [**2183-2-26**] 05:30PM BLOOD ASA-31.1* [**2183-2-26**] 11:37PM BLOOD ASA-32.1* [**2183-2-27**] 04:59AM BLOOD ASA-31.0* [**2183-2-27**] 09:43AM BLOOD ASA-31.6* Acetmnp-NEG [**2183-2-27**] 05:55PM BLOOD ASA-34.0* [**2183-2-27**] 08:58PM BLOOD ASA-30.5* [**2183-2-27**] 11:43PM BLOOD ASA-28.4* [**2183-2-28**] 04:01AM BLOOD ASA-25.0 [**2183-2-28**] 02:47PM BLOOD ASA-15.1 [**2183-3-1**] 04:37AM BLOOD ASA-6.8 [**2183-3-2**] 05:08AM BLOOD ASA-NEG [**2183-3-3**] 06:22AM BLOOD ASA-NEG . ABG/VBGs: [**2183-2-25**] 10:56PM BLOOD Type-[**Last Name (un) **] pO2-52* pCO2-37 pH-7.48* calTCO2-28 B03/07/12 11:52AM BLOOD Type-ART pO2-109* pCO2-14* pH-7.71* calTCO2-18* [**2183-2-26**] 02:04PM BLOOD Type-ART O2 Flow-2 pO2-110* pCO2-21* pH-7.67* [**2183-2-27**] 05:09AM BLOOD Type-ART Temp-37.3 pO2-109* pCO2-37 pH-7.51* [**2183-2-27**] 09:22PM BLOOD Type-[**Last Name (un) **] pO2-201* pCO2-34* pH-7.51* calTCO2-28 [**2183-2-28**] 03:12PM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-43 pH-7.47* calTCO2-32* ECG: Sinus rhythm. Baseline artifact. Low amplitude P wave. No previous tracing available for comparison Imaging: AP CXR on admission: IMPRESSION: No radiographic evidence for pulmonary edema. CXR [**2183-2-27**] The heart size is top normal. The hilar and mediastinal contours are within normal limits and unchanged. The aorta is slightly tortuous. The lung volumes are low, resulting in bibasilar atelectasis. However, there is a superimposed right basilar opacity which could represent aspiration or early pneumonia. Linear left basilar opacities reflect atelectasis versus focal scarring, unchanged since the [**2183-2-25**] examination, but new neighboring opacities are also concerning for mild aspiration/consolidation. There is no pneumothorax. Blunting of the left costophrenic angle is suggestive of a tiny pleural effusion. IMPRESSION: 1. Right basilar aspiration or consolidation. 2. Possible left basilar consolidation or aspiration. 3. Bibasilar atelectasis in the setting of low lung volumes. 4. Tiny left pleural effusion. RUQ U/S: IMPRESSION: 1. Prominence of the portal triads, correlate with LFTs or right heart failure. 2. Evidence of lithium nephropathy with bilateral innumerable tiny cysts. Echogenic kidneys could also relate to medical renal disease. Brief Hospital Course: 60 year old female with PMH of depression followed by a psychiatrist with h/o suicide attempt 15 years ago and past psychiatric hospitalizations (last 1 year ago), bipolar disorder, HTN, and hypothyroidism who initially presented to [**Location (un) 620**] at 4:30PM on [**2-25**] s/p an overdose of reportedly 300 tablets of aspirin and 10 tablets of Tylenol Extra Strength at 3:30PM this afternoon. #. Toxic ingestion: The patient reported taking 10 tablets of Extra Strength Tylenol and 300 tablets of Aspirin. It was thought that she likely had an aspirin bezoar in her stomach that was slowly leeching out variable doses of aspirin. She received 2 doses of activated charcoal and was started on a bicarb drip with a goal pH 7.5 to 7.6. ASA levels have trended from 9.7->63.2->42->93.8->128. This increase was associated with decreased consciousness but did not have any evidence of seizure. She was initially treated with N-acetylcysteine for the Tylenol ingestion, but her serum levels trended down and NAC was stopped as she was below the nomogram. She was extremely tachypneic during the first few days in the MICU. Her Aspirin levels and ABG were trended every 2 hours. As her PCO2 remained low with the CNS mediated tachypnea and she did not require intubation at any point. The morning of [**2-26**] a femoral dialysis line was placed. She required three pressors (phenylephrine, neosynephrine, and vasopressin) to get her blood pressures high enough for dialysis. With 6 hours of dialysis, her Aspirin level went from a peak level of 128 to 30. Her mental status and tachypnea improved. Her Aspirin remained at 30 for 24 hours, raising the possibility of a continued bezoar. She was given 3 more doses of activated charcoal. Her Aspirin levels continued to trended down, and she did not require further dialysis, or EGD to look for bezoar. Her mental status slowly improved and respiratory rate trended back to normal. #. Suicide attempt: patient has long history of bipolar disease and past suicide attempts. She apparently was decompensating prior to this ingestion. After her mental status improved, she was kept with a 1:1 sitter. She denied further plans to harm herself. Her home Lithium, citalopram, glycopyrrolate, clonoazepam were held. Psychiatry was consulted. She will require inpatient treatment on discharge. . #. Aspiration pneumonia: Patient had one fever, suspected aspiration while getting activated charcoal. She was also hypotensive and difficult to wean off pressors, perhaps in part due to sepsis. She was started on antibiotics, and due to rapid clinical improvement, transitioned to PO levofloxacin. She will need to complete a 14 day course of levofloxacin by [**2183-3-13**]. #. Hypernatremia: She was hypernatremic on presentation, but blood sodium levels dropped to low 130s on the bicarbonate drip. Following discontinuation of the bicarb drip, her sodium came up to 148. The patient had large urine output, dilute urine with urine osmolality 133 with serum osmolality 304. Review of outpatient labs at [**Hospital1 **] [**Location (un) 620**] revealed that hyponatremia has been chronic since at least 07/[**2181**]. The picture is consistent with nephrogenic diabetes insipidus as a consequence of chronic lithium use. Her abdominal ultrasound also showed microcystic changes in the kidneys, consistent with lithium toxicity. Her lithium levels were in the therapeutic range, and lithium was stopped during this hospitalization as above. Per nephrology, the patient was given access to free water and encouraged to drink water. Her hypernatremia remained stable. She will require outpatient followup with nephrology following discharge from inpatient psychiatry, and should be continued to be encouraged to drink plenty of water. #. Hypotension: She had been persistently hypotensive after her toxic ingestion of ASA, likely due to vasodilation from direct aspirin toxicity, possibly complicated by an aspirin bezoar or sepsis from aspiration pneumonia. She was maintained on three pressors to facilitate dialysis as above, but was successfully weaned off pressors on [**2183-3-1**]. Following transfer to the floor, her blood pressure stabilised and trended up to SBP in the 150s. We restarted her home lisinopril and her blood pressures were stable and well-controlled at the time of discharge. # Elevated LFTs: Likely secondary to tylenol toxicity combined with aspirin toxicity. LFTs were trending down at the time of discharge, but she will require followup to ensure that LFTs have normalized. #. Hypothyroidism. Continued home levothyroxine 88mcg daily. TRANSITIONAL ISSUES: 1. She will require inpatient psychiatric treatment following discharge from the medical floor. Psychoactive medications were held during this hospitalisation and may need to be reinstated as appropriate. 2. She was noted to have acute renal failure in the setting of toxic ingestions, but also chronic kidney disease of unclear etiology, likely secondary to lithium toxicity with nephrogenic diabetes insipidus. She will need to followup with nephrology as an outpatient. 3. Please encourage drinking of water and ensure constant access to free water, to allow the patient to self-correct hyprnatremia secondary to nephrogenic diabetes insipidus. 4. Please repeat LFTs at follow up with primary care. 5. She will complete a course of levofloxacin for pneumonia on [**2183-3-13**] Medications on Admission: -Levothyroxine 88mcg daily -Lithium 300mg [**Hospital1 **] -Citalopram 20mg daily -Dulcolax daily -MVI daily -Glycopyrrolate 1mg TID -Clonazepam 0.5mg daily -Lisinopril 2.5mg daily Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 9 days: last day [**2183-3-13**]. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 7. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Salicylate and Tylenol Overdose. Secondary: Depression, Bipolar Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname **], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted following an overdose on aspirin and tylenol, following which you became obtunded and developed severe metabolic abnormalities. You were cared for in our intensive care unit, where you required aggressive treatments and dialysis to remove aspirin from your body. . You also had some liver damage from the tylenol, for which we treated you with N-acetylcysteine to remove tylenol from your body. . While your mental status was poor, you likely inhaled some secretions into your lung and developed an aspiration pneumonia. You were started on antibiotics for this, and will need to complete a course of levofloxacin following discharge. . Once we stopped fluid treatments for your overdose, we noticed that the sodium level in your blood was high. Blood and urine tests suggested that this is probably a condition called "nephrogenic diabetes insipidus" a condition in which the body makes excess amounts of dilute urine and causes the sodium level in the blood to rise. This is a consequence of your long-term lithium use. An ultrasound scan of your kidneys showed some cysts in your kidney, which may also be related to lithium. It is important that you keep yourself well-hydrated by drinking plenty of water. You will need to followup with nephrology as an outpatient. . Now that you have medically recovered from aspirin and tylenol poisoning, you will need further treatment in a psychiatric facility. . We made the following changes to your medications: STOPPED Lithium STOPPED Citalopram STOPPED Clonazepam STOPPED Glycopyrrolate . STARTED Levofloxacin Last date [**2183-3-13**] STARTED Pantoprazole STARTED Miconazole powder Followup Instructions: At the time of dicharge from inpatient psychiatry, please arrange followup with the patient's primary care practitioner, nephrology (Dr. [**Last Name (STitle) 15369**], [**Hospital1 18**]), and psychiatry (Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 46739**] at [**Telephone/Fax (1) 46740**]).

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icd9cm

[ [ [] ] ]

[ "38.97", "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

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41822

Discharge summary

report

Admission Date: [**2135-7-16**] Discharge Date: [**2135-7-19**] Date of Birth: [**2051-12-15**] Sex: M Service: SURGERY Allergies: morphine Attending:[**First Name3 (LF) 3200**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [**2135-7-19**] Colonoscopy History of Present Illness: 83M s/p right hemicolectomy for colon cancer on [**2135-6-22**] by Dr. [**Last Name (STitle) 43078**] at [**Hospital3 90829**] transferred from [**Hospital1 **] for lower GI bleed. He presented to [**Hospital3 **] on [**2135-7-14**] after having a bloody bowel movement at home. Colonoscopy was performed, but they were unable to identify a source of bleeding due to the amount of blood in his colon. He was hypotensive during the procedure, but responded to volume resuscitation. He is on coumadin for afib, and his INR was 3.5 upon admission. He was given 4 units FFP and may have received vitamin K, though cannot be confirmed. He was transfused a total of 6u PRBC's but continued to have BRBPR, and was transferred. At the time of admission to the SICU, he states he feels well. His last bloody bm was prior to transfer from [**Hospital3 **]. Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] for transfer, as IR and angio are not available at [**Hospital3 **]. Past Medical History: Past Medical History: right colon cancer, a-fib, hypertension, hyperlipidemia Past Surgical History: tonsillectomy, knee arthroscopy, R hemicolectomy Social History: Lives with wife. Social EtOH. No tobacco. Family History: Non-contributory Physical Exam: Vitals: 99.3, 86, 131/76, 17, 96RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: tachycardic but regular, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, red blood mixed with stool in rectal vault Ext: No LE edema, LE warm and well perfused Pertinent Results: Hct: 29.4->27.0-24.4-(2u PRBC)-26.0-26.6-27.0-28.1-26.1-26.4 INR: 3.5 at OSH, given ffp and vitamin K -> 1.2 here Bleeding study [**7-17**]: Normal study, specifically with no evidence of gastrointestinal, or other source of bleeding. [**2135-7-19**] Colonoscopy : Diverticulosis of the descending colon and sigmoid colon Previous colorectal anastomosis of the proximal transverse colon Normal mucosa in the colon Otherwise normal colonoscopy to cecum [**2135-7-19**] HCT 29.3 Brief Hospital Course: Mr. [**Known lastname 3646**] was transferred to the TICU on [**2135-7-16**] for management of his lower GI bleed. He was hemodynamically stable upon transfer and remained so throughout his ICU stay. He had 3 small bloody bowel movements the evening of [**7-16**] and the early morning of [**7-17**], as well as a Hct drop from 29.4 to 24.4. He received 2u PRBC's and his Hct improved to 28.1. He had a bleeding scan on [**2135-7-17**], which was negative, and he had a normal bm the morning of [**7-18**]. Neuro: He received intermittent narcotics for pain control. His mental status remained intact throughout his stay. CV: He was reportedly hypotensive during his colonoscopy at the OSH, but remained hemodynamically stable here. He was in NSR and his Coumadin was not resumed. Dr. [**Last Name (STitle) 10543**] was notified and he will follow up with him in a few weeks. Resp: No issues. FEN/GI: He was initially NPO with IV fluids while watching for active bleeding. His electrolytes were monitored and repleted when necessary. Once his bleeding stopped, he was allowed a clear liquid diet. GI was consulted and recommended a colonoscopy which was done on [**2135-7-19**]. There was no active bleeding noted, simply diverticulosis of the descending and sigmoid colon. A regular diet was resumed and he tolerated it well. GU: His urine output was monitored and remained adequate throughout his stay. Heme: He was transferred with a Hct of 29.4, which was after receiving 6u PRBC at the OSH over 48 hours. He received an additional 2u at [**Hospital1 18**] for Hct 24.4, after which it stabilized at 28. On the day of discharge his hematocrit was 29.3. ID: No issues. After an uneventful stay he was discharged to home on [**2135-7-19**] and will follow up with Dr. [**Last Name (STitle) 43078**] his surgeon at [**Hospital1 **]. Medications on Admission: Coreg 3.125mg po bid, zocor 10mg po daily, warfarin 2.5mg po alternating w/5mg po daily, amiodarone 200mg po MWF, percocet prn Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 2. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital with a lower GI bleed and required 2 units of blood in addition to the blood that you received at [**Hospital3 **]. Your hematocrit has been stable along with your vital signs. The tagged red cell scan did not show any abnormalities and the Gi service then did a colonoscopy which showed diverticulosis of the lower colon. There was no active bleeding. * You should continue to eat a regular diet and stay well hydrated. * Do NOT resume your Coumadin. You can discuss that with Dr. [**Last Name (STitle) 10543**] at your next appointment. * If you develop any more rectal bleeding, lightheadedness, dizziness or any other symptoms that concern you please call your doctor or return to the Emergency Room. * If you have any questions about this hospitalization please call the Acute Care Clinic at [**Telephone/Fax (1) 600**]. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 43078**] at [**Hospital3 **] for post operative evaluation. Call Dr. [**Last Name (STitle) 10543**] at [**Telephone/Fax (1) 4475**] for a follow up appointment in [**1-13**] weeks. Completed by:[**2135-7-19**]

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icd9cm

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41207

Discharge summary

report

Admission Date: [**2162-2-20**] Discharge Date: [**2162-3-4**] Date of Birth: [**2100-8-10**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8388**] Chief Complaint: Altered mental status, vomiting, falls, abdominal pain Major Surgical or Invasive Procedure: EGd, Intubation History of Present Illness: (obtained from records): 61 y/o M with hx of CVA, hep C cirrhosis, GIB, was reportedly found slightly altered and covered in vomit at home, by his sister. She reported concern that he had not been taking his medications. The patient reportedly told her that he had had several falls earlier in the day. He was assisted to the bathroom, but fell there with a head strike but no LOC. He subsequently had an acute change in his mental status, manifested by confusion and repetitive questioning. His baseline mental status is reportedly normal; he was last seen at this baseline this past Wednesday. . In the [**Hospital1 18**] ED, initial VS were 97.5, 161/104, 120, 18, 98% 4L NC. Exam was notable for soft abdomen, reactive pupils, and melenotic, guaiac positive stool. He was reportedly A+Ox1. He vomited once, with bilious, non-bloody emesis, no coffee grounds. Labs revealed elevated anion gap with lactate of 9. Hct was 32 and WBC count was 18 with left shift. Lactate trended down with IVF and fluids. LFTs were generally normal, with DBili 1.8. BUN was mildly elevated but creatinine was normal. . He had a negative FAST survey. He was given lorazepam 1 mg, lactulose 30 mg, pantoprazole 40 mg IV, rifaximin 550 mg, levaquin 750 IV, metronidazole 500 mg IV, cefepime 2g, and an unspecified amount of IVF. Hepatology was consulted, and felt that the patient is having an episode of hepatic encephalopathy, triggered by a UTI. They recommended treating encephalopathy with lactulose and rifaximin, as well as treatment of his presumed UTI. It was felt that the patient had too little ascites to tap. Hepatology also recommended monitoring hct and performing emergent endoscopy if becomes unstable, in the setting of known varices. Past Medical History: - hepatitis C - DM - S/p stroke - Htn - COPD - hemachromatosis Social History: Stopped smoking 3 weeks ago. Stopped drugs 1 year ago. Denies etoh. Family History: Unable to obtain Physical Exam: VS: Temp:99.3 BP: 142/92 HR:101 RR:22 O2sat:94% RA GEN: awake, alert, but not participating in interview. Appears generally encephalopathic, but in NAD HEENT: Mild conjunctival icterus. PERRL, EOMI. MM dry, OP clear. No cervical lymphadenopathy, no jvd, no carotid bruits RESP: Poor inspiratory effort, mild wheeze bilaterally. No rhonchi or crackles CV: Tachycardic, regular, normal S1/S2, no S3/S4/M/R ABD: Softly protruberant, nontender to palpation. +NABSx4. No masses or hepatosplenomegaly. No rebound tenderness or guarding EXT: No C/C/E. Symmetric 2+ dp/pt/radial pulses bilaterally. +Mild asterixis SKIN: Bilaterall LE tattoos. No rashes or ecchymoses NEURO: Awake, alert, but not responding appropriately to questioning. Speech is unintelligible. Moving all extremities freely. Not participating in sensory or coordination testing. Gait assessment deferred. Pertinent Results: Admission Labs: [**2162-2-20**] 11:39PM LACTATE-5.5* [**2162-2-20**] 11:35PM GLUCOSE-150* UREA N-36* CREAT-0.7 SODIUM-142 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-26 ANION GAP-13 [**2162-2-20**] 09:05PM AMMONIA-129* [**2162-2-20**] 08:43PM GLUCOSE-156* UREA N-39* CREAT-0.8 SODIUM-143 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-23* [**2162-2-20**] 08:43PM ALT(SGPT)-27 AST(SGOT)-51* ALK PHOS-81 TOT BILI-1.8* [**2162-2-20**] 08:43PM LIPASE-34 [**2162-2-20**] 08:43PM cTropnT-<0.01 [**2162-2-20**] 08:43PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2162-2-20**] 08:43PM URINE HOURS-RANDOM [**2162-2-20**] 08:43PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2162-2-20**] 08:43PM WBC-18.1* RBC-3.56* HGB-10.6* HCT-32.1* MCV-90 MCH-29.8 MCHC-33.0 RDW-18.8* [**2162-2-20**] 08:43PM NEUTS-77.1* LYMPHS-15.0* MONOS-6.1 EOS-0.9 BASOS-0.9 [**2162-2-20**] 08:43PM PLT COUNT-304 [**2162-2-20**] 08:43PM PT-19.4* PTT-31.0 INR(PT)-1.8* [**2162-2-20**] 08:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2162-2-20**] 08:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2162-2-20**] 08:43PM URINE RBC-[**7-16**]* WBC-[**12-26**]* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2162-2-20**] 08:43PM URINE HYALINE-0-2 [**2162-2-20**] 08:42PM LACTATE-9.1* Discharge Labs: [**2162-3-4**] 05:16AM BLOOD WBC-6.4 RBC-2.82* Hgb-8.3* Hct-25.4* MCV-90 MCH-29.4 MCHC-32.7 RDW-18.1* Plt Ct-137* [**2162-3-4**] 05:16AM BLOOD PT-17.6* INR(PT)-1.6* [**2162-3-4**] 05:16AM BLOOD Glucose-138* UreaN-10 Creat-0.5 Na-137 K-3.5 Cl-108 HCO3-24 AnGap-9 [**2162-3-4**] 05:16AM BLOOD ALT-24 AST-38 AlkPhos-93 TotBili-0.8 [**2162-3-4**] 05:16AM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.5* Mg-1.8 EKG: Sinus tachycardia @ 117 bpm. Leftward axis. Normal intervals. Atypical R wave progression suggests suboptimal lead placement. +TWF in V1. . Imaging: -CXR: Low inspiratory lung volumes. No acute cardiopulmonary abnormality otherwise identified. -CT C-spine (prelim): 1. no fx or malalignment 2. prominent posterior osteophytes @ C3-C4 with neural foramina narrowing and moderate spinal canal narrowing, placing pt @ increased risk for cord injury - if clinical concern for such exists, MR would be recommended -CT head (prelim): 1. no ich. 2. old L PCA infarct -CT abd/pelvis (prelim): 1. cirrhotic liver w/ gastroesophageal varices, patent umbilical vein, and perihepatic/splenic ascites 2. no colitis, obstruction, or abscess EGD --> nonbleeding varices (grade I- III), 3 duodenal ulcers with one visible vessel in the ulcer. Cauterized the biggest ulcer and injected epinephrine into the visible vessel Ultrasound-guided paracentesis: IMPRESSION: Uncomplicated paracentesis with removal of 1.1 liters of fluid. MRI HEAD without contrast - IMPRESSION: 1. No evidence of acute hemorrhage, acute infarct, or mass effect. 2. Extensive FLAIR/T2 hyperintensity within the cerebral white matter. This most likely represents advanced microvascular disease. Sparing of the central [**Doctor Last Name 352**] matter makes metabolic processes less likely. 3. Large, chronic left PCA infarct, similar to prior. Other details as above. RUQ Ultrasound - Limited imaging of four quadrants was performed to evaluate for ascites. There is a small amount of free fluid seen in the right upper quadrant, without significant fluid seen in the remaining quadrants. EEG - Results pending. Brief Hospital Course: # Altered mental status: Likely chronic advanced microvascular disease as demonstrated on MRI with superimposed hepatic encephalopathy due to acute GI bleed. Patient was treated with lactulose and rifaximin and his asterixis resolved. His mental status however, has not returned to his baseline, likely due to microvasculature insults to his brain. Final EEG results pending at time of discharge although suspicion for seizure activity overall is low. Seroquel, opiates, benzodiazepines and his home trazodone were held/avoided to prevent further confusion. # Abdominal discomfort: He was initially treated with ceftriaxone 1g daily for SBP prophylaxis, but due to persistent abdominal discomfort, he received a diagnostic paracentesis on [**2162-2-25**]. Peritoneal fluid cultures were negative, but he was empirically treated with ceftriaxone 2g daily for 8 days due to high suspicion for SBP and potentially negative cultures while on prophylactic antibiotic dosing. RUQ ultrasound [**2162-3-3**] revealed a small amount of ascites and with mildly increased LE edema, his diuretics were increased to furosemide 40mg [**Hospital1 **] and spironolactone 100mg daily. These diuretics can be increased should his weight continue to increase at the skilled nursing facility. # Upper GIB: Patient presented with melena and had known varices. Hct was initially stable but in setting of NGT placement he was noted to have bright red bloody emesis. Started on PPI gtt and octreotide gtt. Transfused 2 unit PRBC, GI called and decision to intubate for EGD was made. Intubated successfully and EGD revealed nonbleeding varices (grade I- III), 3 duodenal ulcers with one visible vessel in the ulcer. GI cauterized the largest ulcer and injected epinephrine into the visible vessel. Required another 2 units PRBCs for emesis following EGD. Hct has remained stable since. Octreotide gtt was stopped after 72 hours, PPI switched to [**Hospital1 **], he was continued on sucralafate, and treated for 9 of 10 days of H.pylori eradication. Nadolol was increased from 10mg to 20mg daily for varices. Plavix and aspirin were held (previously taking for stroke prevention) due to GI bleed. These can be resumed as determined by his new hepatologist, Dr. [**Last Name (STitle) **] and his PCP. # Hep C cirrhosis: LFTs initially mildly elevated, but trended down. HCV viral load 6,300 IU/mL. Elevated INR suggests impaired synthetic function. Liver appears cirrhotic on CT. Patient has been seeing a hepatologist at an outside hospital, but we have set up follow up with Dr. [**Last Name (STitle) **]. He will need follow up EGD in 2 weeks as scheduled for varices screening. He will need ferritin checked as an outpatient by Dr. [**Last Name (STitle) **] and potential genetic testing for hemochromatosis if suspected. # Hematuria: Patient had recent ureteral stent removal [**2162-2-16**] and prior cystoscopy [**2162-2-10**] per family report. He received Ceftriaxone during his admission, all other admission antibiotics were discontinued. He needs urology follow up within 1-2 weeks with his outside urologist. His sister is working on scheduling a follow up appointment and the skilled nursing facility will help facilitate this follow up appointment. # Diabetes mellitus: Good glucose control on ISS. Home oral glycemics held. # Hypertension: Clonidine held. Nadolol uptitrated to 20mg daily. Continued on diuretics. Comm: [**Name (NI) **] [**Name (NI) **] [**Name (NI) 89773**] (sister) [**Telephone/Fax (1) 89774**] Medications on Admission: confirmed from PCP's list - diazepam 5mg TID and Q4-6H PRN - Oxycontin 20mg QAM and 10mg QPM plus 10mg PRN Q4-6H - Nadolol 10mg daily - Citalopram 20mg daily - Proair INH 1-2 puffs Q4-6H - Aspirin 325mg daily - Seroquel 25mg QHS - Lasix 40mg QAM - Clonidine 0.1mg [**Hospital1 **] - Trazadone 100mg QHS - PLavix 75mg daily - Motrin 600mg TID - Bactrim DS [**Hospital1 **] - Percocet 1-2tabs Q4H PRN - Phenazopyridine 200mg [**Hospital1 **] plus 200mg [**Hospital1 **] PRN - NItrofurantoin 100mg [**Hospital1 **] - Ciprofloxacin 500mg [**Hospital1 **] - Metformin 1000mg [**Hospital1 **] - Nicotine 21mg/hr patch - Glipizide ER 10mg daily Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q8H PRN () as needed for pain: Max dose 2g daily. 6. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours) for 2 days: Last dose evening of [**2162-3-5**]. 7. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 days: Last dose evening of [**2162-3-5**]. Tablet(s) 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): Please titrate to [**4-9**] bowel movements daily to prevent hepatic encephalopathy. 11. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. potassium chloride 20 mEq Packet Sig: One (1) PO once a day. 16. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): Please continue until erythema in mouth resolves. 18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed for itching. 19. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 20. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): Please see attached sliding scale which may be adjusted as needed. . Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: Duodenal ulcer bleed with acute blood loss anemia H. pylori Hepatic encephalopathy Advanced intracerebral microvascular disease Cirrhosis - secondary to chronic Hepatitis C virus and previous alcohol use Diabetes Mellitus Type 2 Hypertension Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. At high risk for falls. Discharge Instructions: Dear Mr. [**Known lastname 805**], You came to the hospital because of bleeding from an ulcer in your small intestine. The bleeding was stopped during an urgent endoscopy. You were noted to have esophageal varices during your endoscopy, which will need to be monitored periodically by your liver doctor. You will need a repeat endoscopy in 2 weeks to ensure the ulcer has healed and monitoring of your esophageal varices. You were treated with antibiotics for H.pylori. You had an MRI of your brain which showed that you have "advanced microvascular disease" which likely explains your residual confusion. Please continue taking rifaximin and lactulose to prevent worsening confusion due to your liver disease. We made the following changes to your medications: INCREASE Furosemide to twice a day and START Spironolactone to decrease fluid retention and ascities. INCREASE Nadolol to 20 mg daily. START Amoxicillin and Clarithromycin to treat H. pylori infection. Last dose should be the evening of [**2162-3-5**]. START Pantoprazole and sucralfate to heal your duodenal lining. START Lactulose and Rifaximin to prevent hepatic encephalopathy. START folate, thiamine, and multivitamin START humalog insulin sliding scale (see attached scale) START nystatin swish and swallow until thrush in mouth disappears. START sarna lotion to help with itching skin. START zofran as needed for nausea. START potassium supplementation. The dose of this medication may need to be adjusted based on your blood levels which should be checked in 1 week. STOP taking Plavix, Percocet, Pyridium, Macrobid, Trazodone, Clonidine, Seroquel, Ciprofloxacin, Aspirin, Ibuprofen, Bactrim, Glipizide, Metformin, and Nicoderm patches. We wish you a speedy recovery. Followup Instructions: Department: ENDO SUITES When: TUESDAY [**2162-3-16**] at 2:30 PM Department: DIGESTIVE DISEASE CENTER When: TUESDAY [**2162-3-16**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: LIVER CENTER When: FRIDAY [**2162-4-2**] at 10:50 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Please follow-up with your urologist within the next week. Completed by:[**2162-3-5**]

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Discharge summary

report

Admission Date: [**2199-11-25**] Discharge Date: [**2199-12-9**] Date of Birth: [**2131-12-4**] Sex: M Service: Medical Intensive Care Unit HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old male with known alcoholic cirrhosis and Grade III esophageal varices that were recently banded in [**2199-10-20**]. He presented to the Emergency Department [**2199-11-25**] for sudden onset of bright red hematemesis. Patient denied chest pain and shortness of breath as well as abdominal pain, however, did complain of nausea. In the Emergency Department, the patient had a nasogastric tube placed, however, bright red blood did not clear with lavage. The patient was transfused 2 units of packed red blood cells and given intravenous fluids and remained hemodynamically stable. An esophagogastroduodenoscopy was attempted in the Emergency Department, however, the airway was compromised by hemorrhage, and patient was emergently intubated for airway protection. The patient received Ativan, Demerol, vecuronium for intubation in esophagogastroduodenoscopy. PAST MEDICAL HISTORY: 1. Alcoholic cirrhosis with Grade III esophageal varices status post banding in [**10-21**]. 2. Portal gastropathy. 3. Hypertension. 4. Seizure disorder. 5. Type 2 diabetes. 6. History of prostate cancer status post prostatectomy. 7. History of chronic renal insufficiency with a baseline creatinine of 2.1-2.3. MEDICATIONS ON ADMISSION: 1. Propanolol 20 [**Hospital1 **]. 2. Dilantin 500 once a day. 3. Univasc 30 once a day. 4. Aldactone 25 once a day. 5. Insulin. 6. Protonix 40 once a day. ALLERGIES: IV contrast as well as to sulfa and codeine. SOCIAL HISTORY: Notable for longstanding history of alcohol abuse. Patient was actively drinking until his last admission in [**10-21**]. No history of tobacco use. The patient has a very close-knit and involved family including daughter, [**Name (NI) 1404**] and son, [**Name (NI) 122**]. On admission, the patient had a heart rate of 100, blood pressure of 117/60, saturation of 98% on FIO2 of 0.4. The patient was ventilated with settings assist control tidal volume of 600, rate of 12, PEEP of 10, FIO2 of 0.4. Patient was in no apparent distress, sedated. Had no evidence of jaundice. HEENT showed no scleral icterus. Cardiovascular examination was tachycardic, but regular. Chest examination was clear to auscultation bilaterally, anteriorly and laterally. Abdomen was soft, slightly distended, nontender. Extremities had no edema. LABORATORIES ON ADMISSION: The patient had a white count of 9.6, hematocrit of 24 which was down from 31.6 on discharge several days prior. Platelets of 231. Sodium of 136, potassium 4.5, chloride 101, bicarb 22, BUN 21, creatinine 2.5 up from a baseline of 2.1. Glucose of 235. Liver function tests: ALT was 15, AST 27, alkaline phosphatase 86, T bilirubin 0.2, amylase 172, lipase 140, INR was 1.7, and PTT 28. This is up from an INR baseline of 1.4. Chest x-ray showed cardiomegaly and no evidence of pneumonia. Electrocardiogram was notable for normal sinus at 94 with normal axis, normal intervals, no Q waves, and no ST changes, however, T-wave inversions in III and V that were unchanged from [**2199-11-14**]. In short, this is a 57-year-old male with alcoholic cirrhosis admitted for upper GI bleed, emergently intubated for airway protection. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient underwent emergent esophagogastroduodenoscopy, which showed a [**1-21**] bands had fallen off with typical banding ulcers and Grade IV varices in his esophagus extending proximally. There was no acute bleeding, however, there was stigmata of bleeding from the banding ulcers. The patient had small cardiac and fundal varices, a lot amount of clot in his fundus. No gastric or duodenal ulcers were present. The patient was started on intravenous Protonix as well as octreotide transfused as necessary. The initial plan was to take the patient for TIPS done by Interventional Radiology, however, TIPS was attempted unsuccessfully. Surgery was consulted regarding surgical intervention and question of a portocaval shunt, however, the patient's anatomy was inappropriate for a portocaval shunt using the splenic vein. Patient also was not felt to have been maximally medically managed at that time, thus plan changed. The patient was eventually weaned off octreotide, however, after rebled after being weaned off octreotide. The patient was rescoped by the Hepatology Service, who found no evidence of rebleeding, no stigmata of bleeding, and his banding ulcers, just large clot in his fundus. No obvious varices with stigmata of bleeding were noted, and his varices were noted to be Grade II at the time of re-EGD on [**2199-12-3**]. The patient was restarted on octreotide, and continued on Protonix as well as Carafate, however, the patient continued to require large volumes of packed red blood cells. Patient's bleeding had not fully resolved at the time of his death. Multiple surgical options were rediscussed as well as consideration of repeat TIPS, however, it was felt that patient would be unlikely to benefit from any of these procedures given his poor mental status, and the increase risk of encephalopathy. Also of great consideration, was the patient's mortality from surgery, which was felt to be astronomically elevated, thus making surgical intervention not an option for this patient. 2. Pancreatitis: Patient was noted to have elevated amylase and lipase. He underwent CT scan without contrast, however, this did not adequately visualize the pancreas. Was started on TPN and continued on TPN throughout the course of his hospital stay. The patient's enzymes had started trending downward, however, they never fully normalized. 3. Abdominal distention: Patient's abdominal distention initially thought to be due to decreased portal hypertension and ascites. It was tapped successfully on [**2199-12-3**], a liter and a half of clear fluid was removed without complications. This was not consistent by cell count or chemistry with being notable for spontaneous bacterial peritonitis. Gram stain and cultures of fluids remain negative. Patient's belly continued to increase in size, and it was again attempted to use paracentesis on [**2199-12-6**], however, it was difficult to localize the pocket of fluid. Ultrasound guided tap was attempted, which revealed only small to moderate ascites, just large dilated loops of bowel. Flat film showed some air within the bowel, however, film was largely unremarkable and showed no evidence of obstruction. The patient continued to have melena and output from his nasogastric tube both suggesting that he was not obstructed. Patient unfortunately continued to become more distended, and his bladder pressures were in the high 20s. Surgery was consulted regarding the question of surgical decompression as his bladder pressures were not. Patient's creatinine worsened as did his liver function tests, however, it is felt that the patient's surgical mortality would be enormous and surgical intervention was unlikely to be helpful to this patient. 3. Mental status: Patient initially had been intubated for airway protection only, and was sedated on Ativan as well as propofol. The patient's sedating medications were stopped on [**2199-12-1**], and it was thought that he would regain consciousness as his system slowly metabolized the Ativan, however, patient never regained consciousness or purposeful movement. Unclear whether this is due to worsening encephalopathy or whether patient had an acute cerebral event. 4. Respiratory: Patient was maintained on mechanical ventilation throughout the course of his hospital stay. He was initially, when heavily sedated, maintained on assist control, however, after his sedation was stopped, the patient tolerated pressure support fine. The patient became increasingly difficult to ventilate as his abdominal pressures increased and required higher and higher levels of PEEP. The patient, however, was electively extubated on [**2199-12-9**] at the request of his family, who wished to make him comfort measures only. 5. Code status: The patient's family was actively involved with his care and supportive, however, they were concerned that their father would not want aggressive surgical intervention and prolonged hospitalization if at all possible. They were willing to entertain TIPS as a possibility, however, as the patient's situation became worse, and it became clear that TIPS was not likely to be helpful to their father, patient's family remained ambivalent about surgery especially after hearing the high mortality that would be associated with surgical options. Family discussed what their father would want, and decided to stop medications and medical intervention, and make the patient comfortable. The patient was started on a Morphine drip, and remained intubated for two days further at which point patient's family decided to withdraw ventilatory support. Patient expired later the same day with his family present at the bedside. The patient's official time of death was 8:55 pm on [**2199-12-9**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2199-12-26**] 09:22 T: [**2199-12-29**] 09:19 JOB#: [**Job Number **]

[ "572.2", "584.9", "780.39", "276.7", "276.2", "518.81", "789.5", "456.20", "571.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "39.1", "45.13", "96.72", "99.15", "42.33" ]

icd9pcs

[ [ [] ] ]

1441, 1656

3387, 7163

186, 1080

2534, 3370

7179, 9424

1102, 1415

1673, 2519

58,163

147,486

38295

Discharge summary

report

Admission Date: [**2186-12-11**] Discharge Date: [**2186-12-15**] Date of Birth: [**2151-1-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4891**] Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 35 yo M w/ IDDM (c/b retinopathy, DKA, gastroparesis), ESRD on HD (MWF), HTN who was recently admitted with gastroparesis from 12/12-14/11 and now presents with nausea and vomiting x 2 days similar to his previous episodes of gastroparesis. His abdominal pain is mostly in the lower quadrants. He has been unable to tolerate po intake for the last 2 days. He has been taking in water but no food. He has been vomiting >10x/ day. He did have a small amount of blood in his vomit this morning. He denies fevers, but does endorse some chills. He has not checked his blood sugar for the last two mornings. He did not take his medications this morning. . In the ED, initial VS were: 97.7 109 200/100 18 100%. His labs were notable for FSBG 350. He was given zofran 8 mg iv, morphine 10 mg iv, 10 of insulin given and repeat FSBS was over 300. He was given 2 L IVF and was started on an insulin drip at 7units/hr. NG tube was placed and showed clotted coffee grounds. His HCT was 29 (at baseline). VS on transfer were: FS 307 (12:41), P: 97, BP: 173/103, on 100% on RA. Past Medical History: - Type I diabetes: since age 19, complicated by gastroparesis, retinopathy (laser treatment), DKA, chronic kidney disease - ESRD, on HD MWF, started [**9-3**] - [**Doctor Last Name 9376**] syndrome - Hypertension - Asthma - HLD - chronic multifactorial anemia, on Epo, h/o pRBC transfusion x 2 in [**2186-7-24**] related to renal failure Social History: Lives with his girlfriend and two children ages 14 and [**Location (un) 85328**]. Denies tobacco use, alcohol use, or illicit drug use. Family History: Father with CAD/MI, HLD, type II DM. Mother with thyroid cancer. Physical Exam: ADMISSION PHYSICAL: Vitals: T: 96.3 BP: 183/111 P: 100 R: 15 O2: 99% on RA General: young man, Alert, oriented, appears slightly uncomfortable HEENT: Sclera anicteric, sl dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, minimally tender in bilateral lower quadrants, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE PHYSICAL: Physical Exam: Tc 97.3 Tm 98.6 BP 107-179/64-90 HR 70s RR 18 O2 sat 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, decreased breath sounds R lung base CV: Regular rate and rhythm, normal S1 + S2, II/VI holosystolic murmur best heard at RUSB (in sync with AVF, so may be radiation from AVF) Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well-perfused, 2+ pulses, no edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: Labs On Admission: [**2186-12-11**] 11:00AM BLOOD WBC-6.4 RBC-3.30* Hgb-9.8* Hct-29.8* MCV-90 MCH-29.8 MCHC-33.1 RDW-14.7 Plt Ct-216 [**2186-12-11**] 11:00AM BLOOD Glucose-366* UreaN-72* Creat-9.4*# Na-137 K-5.8* Cl-97 HCO3-16* AnGap-30* [**2186-12-11**] 11:00AM BLOOD CK(CPK)-71 [**2186-12-11**] 02:47PM BLOOD Lipase-23 [**2186-12-11**] 02:47PM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 Cardiac Enzymes: [**2186-12-11**] 11:00AM BLOOD CK-MB-3 [**2186-12-11**] 11:00AM BLOOD CK(CPK)-71 [**2186-12-11**] 11:00AM BLOOD cTropnT-0.16* [**2186-12-11**] 02:47PM BLOOD CK(CPK)-48 [**2186-12-11**] 02:47PM BLOOD CK-MB-3 cTropnT-0.15* [**2186-12-11**] 11:18PM BLOOD CK(CPK)-37* [**2186-12-11**] 11:18PM BLOOD CK-MB-3 cTropnT-0.14* Micro: Blood culture x 2 [**12-11**]: NGTD at the time of discharge Imaging: CXR [**12-11**]: IMPRESSION: No acute cardiopulmonary process; possible ascites. ABG: [**2186-12-11**] 11:07AM BLOOD pO2-116* pCO2-25* pH-7.47* calTCO2-19* Base XS--2 Comment-GREEN TOP Labs on Discharge: [**2186-12-15**] 07:09AM BLOOD WBC-4.6 RBC-2.72* Hgb-8.0* Hct-24.3* MCV-89 MCH-29.5 MCHC-33.1 RDW-14.4 Plt Ct-150 [**2186-12-15**] 07:09AM BLOOD Glucose-112* UreaN-40* Creat-6.3*# Na-137 K-4.1 Cl-98 HCO3-27 AnGap-16 [**2186-12-15**] 07:09AM BLOOD Calcium-7.9* Phos-4.8* Mg-2.0 Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Mr. [**Known lastname 14782**] is a 35M with h/o DM type I (h/o retinopathy, DKA, gastroparesis), ESRD on HD (MWF), HTN admitted to ICU with nausea, vomiting (10 episodes per day for 2 days, reportedly with some small amounts of blood), abdominal pain, and inability to take PO (water but no food), now transferred to floor after AG closed. ACTIVE DIAGNOSES: #Type I DM: Upon presentation to ICU, patient had FSG >300 and AG 16. Serum ketones were not assessed, so it is uncertain if he had AG from ketoacidosis or from renal failure. He had poor PO intake the morning of presentation secondary to gastroparesis, and missed his AM Lantus, which is the likely etiology of his ketoacidosis, if present. He has no infectious signs or symptoms. He was started on an insulin gtt and his AG closed in the ICU. Patient was restart on home insulin regimen and transferred to the floor. He was maintained on a diabetic, consistent carbohydate diet. [**Last Name (un) **] consult recommended carb counting and 1:15 humalog sliding scale, as well as 5U Lantus in the morning and 4U Lantus in the PM. He will follow-up with [**Last Name (un) **] as an outpatient. #Hypertension: Patient was hypertensive in the ED to SBP to 200s. Patient's blood pressure normally runs 160s/80s, secondary to DMI and ESRD. Current elevation in bp likely secondary to distress from nausea and vomiting and improved somewhat with anti-emetic and analgesic therapy. Patient's dose of lisinopril was increased from 20 to 40 daily and started on clonidine patch 0.1mg weekly. In the two days it takes the clonidine patch to work, he was bridge 0.1mg PO qhs. He was also provided HD per home schedule, which provided volume control. On discharge his bp was 140s/80s. # Nausea/vomiting/gastroparesis: Patient has had multiple admissions for nausea and vomiting secondary to gastroparesis, most recently discharged on [**12-6**]. It is likely that this presentation is due to a flare of his gastroparesis, leading to nausea/vomiting and not taking his insulin. He has no signs or symptoms of an infectious etiology. Metabolic alkalosis also seen on ABG likely secondary to vomiting. He was continued on compazine and zofran for nausea, and he was started on erythromycin and reglan for GI motility. In discussions with his internist, outpatient visits have been challenging in the recent past, given the escalation of his condition and inpatient needs. He was referred for outpatient follow-up with GI motility specialist, and the internist was aware to prepare a referral for the patient, in conjunction with discussions with the patient once the appointment was scheduled. # Anemia. Hct trended down from 29.8 on admission to 24 by the time of transfer to the floor from the ICU. Anemia is likely secondary to hemodilution, as all cell lines trended down and patient received IVF in ICU for DKA. Patient is chronically anemic secondary to ESRD and epo deficiency. He had no active source of bleeding. In [**2186-7-24**], iron studies were normal. Hct as monitored during hospitalization. # ESRD on HD. Patient normally gets HD on MWF and was maintained on this regimen while in house. He was also continued on Sevelamer, NephroCaps, and Epo. His medications were renally dosed. # Hematemesis: He had small volume hematemesis on admission, which was likely caused by retching in the setting of gastroparesis. His NG lavage showed small amount of red clots. Patient's hematocrit was now 29.8 (baseline 28-30). On [**2186-12-5**], patient vomited bright red blood and had an EGD which showed no blood in stomach or duodonum and no active source of bleeding. A small but healed [**Doctor First Name 329**] [**Doctor Last Name **] tear was visualized. Small amount coffee grounds this admission were thought to be likely secondary to another small [**Doctor First Name 329**] [**Doctor Last Name **] tear. Patient's hct continued to trend down in the ICU, but no active source of bleeding was seen. He was continued on PPI [**Hospital1 **] and his hct was trended. Transitional Issues: Patient was discharged with follow up at [**Last Name (un) **] and with planned referral to GI motility sub-specialist. PCP was updated on his clinical course and was happy to provide [**Last Name (un) **] and GI referrals. Emergency Contact: Mother [**Name2 (NI) **] [**Telephone/Fax (1) 85319**] Code Status: Full Medications on Admission: Medications: (per d/c [**12-6**]) 1. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day. 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q8H (every 8 hours). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. insulin glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous twice a day. 9. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day: <150: 0 units 151-220: 1 unit [**Unit Number **]- 290: 2 units 291- 360: 3 units > 361: 4 units. 10. epoetin alfa 2,000 unit/mL Solution Injection 11. prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea. Disp:*20 Suppository(s)* Refills:*0* 12. Ocean Nasal Mist 0.65 % Aerosol, Spray Sig: One (1) spray Nasal every four (4) hours as needed for nasal congestion. Discharge Medications: 1. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q8H (every 8 hours). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Lantus 100 unit/mL Solution Sig: [**3-28**] units Subcutaneous twice a day: Please take 5U in AM, 4U in PM. 6. Humalog 100 unit/mL Solution Sig: sliding scale units Subcutaneous qachs: <150: 0 units 151-220: 1 unit [**Unit Number **]- 290: 2 units 291- 360: 3 units > 361: 4 units. 7. epoetin alfa 2,000 unit/mL Solution Sig: One (1) injection Injection once a week. 8. Ocean Nasal Mist 0.65 % Aerosol, Spray Sig: One (1) spray Nasal every four (4) hours as needed for cold symptoms. 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*5* 10. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). Disp:*4 Patch Weekly(s)* Refills:*0* 11. metoclopramide 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Hypertension End Stage Renal Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 14782**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with nausea, vomiting, and found to have diabetic ketoacidosis. You were initially admitted to the ICU for an insulin drip, but eventually transferred to the floor when we felt your blood sugars were under control. You were also found to have high blood pressure and started on a new blood pressure medication. Please note that the following changes have been made to your medications: - Please START Clonidine patches, one new patch every Tuesday - Please INCREASE your dose of Lisinopril to 40mg daily - Please START nephrocaps, one capsule daily - Please START Reglan, as needed for gastroparesis symptoms of nausea/vomiting, up to 3 times/day - Please CHANGE your Lantus to 5U in AM, 4U at night, and keep carb counting the same 1:15 Followup Instructions: Please follow-up with the following appointments: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital1 641**] Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**] Phone: [**Telephone/Fax (1) 644**] Appointment: THURSDAY [**12-21**] AT 8:00AM **At this appointment, please speak with your physician about the need for follow up care with an Endocrinologist for your diabetes.** Name: [**Last Name (LF) 10088**], [**First Name3 (LF) **] Location: [**Last Name (un) **] Diabetes Center Phone: ([**Telephone/Fax (1) 3258**]. Appointment: Tuesday, [**12-26**] at 1:30pm Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 682**] Appointment: Tuesday [**2186-12-26**] 3:30pm Completed by:[**2186-12-16**]

[ "277.4", "403.91", "250.13", "536.3", "V58.67", "493.90", "250.53", "285.21", "276.3", "250.63", "585.6", "530.7", "V45.11", "250.43", "362.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11798, 11804

4745, 5123

340, 346

11906, 11906

3443, 3448

12937, 13823

1987, 2053

10501, 11775

11825, 11885

9203, 10478

12056, 12914

2830, 3424

8858, 9177

3841, 4424

267, 302

4443, 4722

374, 1455

3462, 3824

11921, 12032

5141, 8837

1477, 1817

1833, 1971

23,637

166,493

551

Discharge summary

report

Admission Date: [**2194-7-24**] Discharge Date: [**2194-8-3**] Service: [**Hospital1 139**] - Medicine and MICU HISTORY OF PRESENT ILLNESS: This 84-year-old female with a history of diverticula, CREST and irritable bowel syndrome presented to the Emergency Room with a chief complaint of epigastric pain, lightheadedness, nausea without emesis and dark stools. She denied chest pain, shortness of breath, cough, fevers, chills and night sweats. In the Emergency Room she was found to have a blood pressure of 130/palp with a heart rate of 72. One hour later this was 119/39 with a pulse of 100. She had heme positive stool and hematocrit was found to be 16.6. The patient therefore had an emergent EGD in the GI unit. No nasogastric lavage was performed. PAST MEDICAL HISTORY: The patient has Sjogren's with sicca syndrome and presumed CREST with a history of dysphagia and dyspepsia. The patient's primary gastroenterologist is Dr. [**Last Name (STitle) 1940**]. Patient has a history of hypertension, hypothyroidism, irritable bowel syndrome with chronic diarrhea, Raynaud's, history of TAH, cholecystectomy and pericholecystectomy hernia repair, COPD and bronchiectasis, right bronchial sclerosis and Sjogren's, history of bladder stretchings, negative MRCP [**6-18**] except for some liver cysts, diverticula on colonoscopy [**7-/2193**] with possibility of Crohn's noted. SOCIAL HISTORY: The patient smoked some tobacco in the past but it was a small amount. She drinks no alcohol. FAMILY HISTORY: Crohn's disease. ALLERGIES: Penicillin, Bactrim and Sulfa. MEDICATIONS: Norvasc 10 mg q d, Atenolol 50 mg q d, Levoxyl 1.25 mg q d, Dyazide 37.5/25 q d, Serax prn, occasional NSAIDs, Premarin .625 mg q d and Aspirin. PHYSICAL EXAMINATION: Temperature 97, blood pressure 95/69, respiratory rate 14, satting 100% on two liters. The patient was alert and oriented times three, she was fully conversant and awake, interactive and appropriate. She was in no acute distress. Conjunctiva were pale. She had dry mucus membranes. She was normocephalic, atraumatic, extraocular movements intact, pupils were equal, round and reactive to light. There was no JVD. Neck was supple. TMs were normal. There was no lymphadenopathy of the neck, faint bibasilar crackles were heard on lung exam. The patient was tachycardic with a normal S1 and S2 with 2/6 systolic ejection murmur radiating to the axilla. Abdomen was soft and non distended with normal bowel sounds, was mildly tender to deep palpation. Extremities without clubbing, cyanosis or edema. Fingers were cool as were the toes but she had 1+ pulses times four. Cranial nerves II through XII were intact. Motor was 5/5 strength globally, symmetric. Deep tendon reflexes were 2+ globally and were symmetric. LABORATORY DATA: White count 12.8, hematocrit 16.6, platelet count 282,000, MCV 89. Chem 7, sodium 140, potassium 4.8, chloride 105, CO2 21, BUN 53 with a baseline of 10, creatinine .9, glucose 98, anion gap 14, ESR 60, ALT 52, AST 84, alkaline phosphatase 313, thyroid peroxidase antibody and endomesial antibodies were positive. Note was made of prior alkaline phosphatase elevations as well as a GGT of 469 and a lipase of 199. TSH was 6.4. [**Doctor First Name **] was positive at greater than 1:1280. Gastrin was normal in 9-00 at 92. EKG showed normal sinus rhythm at 100, left axis deviation, intervals were 184/74/422. There was a small T wave inversion in 1 and AVL, question of left anterior fascicular block, small ST deviation similar to prior on [**2193-7-21**]. CT done [**7-/2193**] for abdominal pain showed emphysema, no acute cardiopulmonary disease, hypoattenuation of liver and fibrotic lung changes. HOSPITAL COURSE: 1. GI and Cardiovascular: On [**7-24**] the patient presented with malaise, epigastric pain, nausea for three days, lightheadedness, black stools and was found to have a hematocrit of 15.6 from a baseline of 43 and BUN of 53. The patient was admitted to the MICU. Two peripheral IVs were placed, fluids and blood was applied, Protonix was begun IV. Emergent EGD was performed that showed a stomach full of blood, a probable AVM which was treated with electrocautery. The patient ruled out for MI because she had inferolateral EKG changes with ST depression which later resolved after a blood transfusion. She had relative hypotension given her history of hypertension. On the 7th she was evaluated by surgery and told that operation for her bleed would be high risk and high morbidity and would involve partial gastrectomy so she declined the operation. A groin line was placed. On the 8th a repeat EGD was similar to the first with large amounts of blood and the patient was taken to interventional radiology where she had her left gastric artery embolized. No further IR options were available after this procedure. In total the patient received 11 units of blood, ending on the 8th and hematocrits through the 10th were approximately 40 and stable. Vascular access was initiated during the stay and on transfer to the floor [**7-28**], the patient had only one PID. Groin line was removed on the 8th because of fever and stool contamination and on the 9th the triple lumen was removed because the patient felt she had no definitive options if she did have a massive bleed. The patient was made DNR, DNI at her request and plans were to make her comfort care if she had a large recurrent bleed, although she later indicated that short-term central line would be acceptable. On transfer to the floor her issues were mild sinus tachycardia thought to be due to beta blocker withdrawal since it persisted through blood and volume repletion. A repeat EGD was performed [**7-29**] since the patient's lesion was never well visualized with all the blood in her stomach. This showed only gastritis with friability and the same findings in the duodenum. Beta blocker was increased to treat her hypertension and tachycardia but with caution since she was at risk for rebleed. Diarrhea was noted and C. diff and fecal leukocytes were checked and were negative. This was then attributed to melena and it trailed off when she had stable hematocrit. On the 12th the patient was noted to have a decreased hematocrit which declined from 42 to 32.8 with an apparent rebleed with increased melena post EGD. It remained stable thereafter through the 15th at 33.5. Simethicone was given for gassy distension and ambulation was encouraged to decrease this as well. 2. Fluids, Electrolytes & Nutrition: Lytes especially potassium and phosphorus were repleted. 3. Endocrine: Synthroid was continued for hypothyroidism and it increased to 150 since her TSH was high. This needs to be followed up with a repeat TSH. 4. Pulmonary: With her persistent tachycardia on BVL replacement, concern for PE rose and a chest x-ray which showed a right upper lobe process thought to be early pneumonia was performed. CT angio was then done on the 12th which showed no PE but a large right upper lobe consolidation and left upper lobe and left lower lobe consolidations adjacent to an effusion as well. She was therefore treated for multifocal PNA thought to be related to possible aspiration at the time of her EGD with Levofloxacin and Flagyl with resultant decrease in white blood count. Nebs were provided for wheezing, most likely related to COPD. 5. The patient was seen for question of aspiration and it was felt her meds should be crushed and administered in apple sauce and that soft moist solids and liquids would serve her best but she was not a major aspiration risk. 6. ID: As per pulmonary, patient also had a positive urinalysis and a culture showing 1,000 to 100,000 proteus and pseudomonas but since transferring to the floor, the patient complained of no urinary discomfort so this was not treated. Repeat urinalysis [**7-31**] showed no UTI. The patient was followed by physical therapy and assisted with ambulation. 7. Patient's CREST and Sjogren's were treated with solutions to mouth and eyes as per her routine. Calcium channel blocker for question esophageal spasm was held given the risk of re-bleed and hypotension. 8. Renal: Patient's creatinine clearance was estimated at slightly more than 50 cc per minute and was stable throughout. DISCHARGE MEDICATIONS: Protonix 40 mg [**Hospital1 **], Simethicone 80-125 mg qid prn, Serax 10 mg po prn, Trazodone 25 mg po prn insomnia, Metoprolol 50 mg po tid, Synthroid 150 mcg q d, Colace 100 mg po bid, Milk of Magnesia prn. Patient's own mouth rinses and eyedrops were sicca syndrome. Levofloxacin 500 mg po q d through [**2194-8-10**], Flagyl 500 mg po tid through [**2194-8-10**]. DISCHARGE CONDITION: Stable. FOLLOW-UP: To arrange with Dr. [**Last Name (STitle) 1940**] of gastroenterology and the patient's primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4427**]. DISCHARGE DIAGNOSIS: As per HPI plus: 1. GI bleed secondary to gastritis and AVM (arteriovenous malformation). DR.[**Last Name (STitle) **],[**First Name3 (LF) 4514**] J. 12-424 Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2194-8-4**] 08:20 T: [**2194-8-7**] 20:35 JOB#: [**Job Number 4515**]

[ "496", "494.0", "535.51", "244.9", "710.1", "799.4", "710.2", "537.83", "401.9" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.29", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

8739, 8937

1529, 1751

8346, 8717

8959, 9286

3749, 8322

1774, 3732

151, 773

796, 1399

1416, 1512

25,068

110,151

30207+57686

Discharge summary

report+addendum

Admission Date: [**2136-5-3**] Discharge Date: [**2136-5-12**] Date of Birth: [**2101-1-25**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: thoracic tumor Major Surgical or Invasive Procedure: T8-12 Lami for tumor and Fusion T8-L2 History of Present Illness: Pt is a pleasant 35-year-old gentleman who had developed lower back pain. An MRI was obtained, which demonstrated a spinal and paraspinal mass. This is worked up with a biopsy, which was diagnostic for a low-grade spindle cell tumor. He continues to be asymptomatic,in particular, he denies any difficulty with bowel, bladder, or gait. His back pain is mild. Past Medical History: His past medical history is significant for asthma and cluster headaches. Social History: He does not smoke. He continues to work. Family History: NC Physical Exam: On examination, his motor strength is [**3-31**] in the upper and lower extremities. His sensory examination was intact with respect to the modality of light touch. His reflexes were normal and symmetric. There was no point tenderness in the thoracolumbar spine. There was no clonus and toes were downgoing bilaterally. Pertinent Results: An MRI of the thoracic spine obtained on [**2135-12-26**] was available for review. It demonstrates a left-sided paraspinal mass that proceeds from roughly T8-L1. It seems to originate from paraspinal location and expands to neuroforamina at T9-10, T10-11, T11-12, and T12-L1. There is significant extension within the spinal canal, which displaces the spinal cord from left to right. The majority of the mass is in the paraspinal region. The bone appears to be scalloped rather than invaded. Brief Hospital Course: Pt was admitted electively to the hospital and brought to the OR where under general anesthesia a thoracic laminectomy, excision of paraspinal mass, thoracic instrumented fusion and iliac crest bone graft was performed. He tolerated this procedure well and post-op was transferred intubabted to the SICU. His motor and sensation post op were intact. Pt developed anemia post-operatively and was transfused 2 units of autologus blood. Post transfusion hct remained at 26. he was extubated on first post op morning. He was begun on PCA. Drainage from 2 drains placed intra-op was monitored. His activity and diet were advanced. he was transferred to the floor. While on the floor, patient had both drains removed. A PT consult was obtained and patient began transferring and ambulating with assisstance. Pt was started on a bowel regimen and pain medications were changed to provide improved relief. On post op day #5 the pt's temperature was elevated to 102.7. CXR and UA were negative. LFT's were not elevated and he did not have any signs or symptoms of PE (no calf tenderness or cord noted on exam). Blood cultures were sent and the results no growth . His incision remains clean and dry without erythema. He has been ambulating quite frequently as well as utilizing his incentive spirometry. Chest/abdomen/pelvis CT done [**2136-5-10**] showed: 1. Status post thoracotomy at T8 through T10 with laminectomy extending from T9 through L1 and posterior fusion of T8 through L2. There is a collection of fluid and gas within the left paraspinal region extending from T8 through T12 as described above, which may represent post-surgical changes; however, infection cannot be excluded 2. Bilateral symmetric ill-defined low density involving the subscapularis muscles bilaterally, new since prior exam. Differentail includes muscular edema from positioning during surgery vs synovial fluid. 3. Layering left pleural effusion and adjacent compressive atelectasis. 4. Sigmoid diverticulosis without evidence of diverticulitis. IV Vancomycin 1g IV BID is started on [**2136-5-11**] for a 10-day course. The patient has remained afebrile for > 24 hours. His staples and drain sutures were removed [**2136-5-12**]. He is ambulating well, taking in food PO, and his pain is under control. Arrangements have been made for him to receive his vanco at the ER at [**Hospital 71976**] [**Hospital 107**] Hospital [**Telephone/Fax (1) 71977**]. Medications on Admission: albuterol, nexium, advair, zafirlukast Discharge Medications: 1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed: do not drive while you are on narcotics for pain. Disp:*60 Tablet(s)* Refills:*1* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*20 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily): this medication can be constipating as well as the narcotics. Make sure to compliment your diet with fluids and fiber. . Disp:*120 Tablet(s)* Refills:*1* 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO bid (). 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Bed [**Hospital 485**] hospital bed disp:1 10. raised toilet seat raised toilet seat with arms disp:1 11. equipment please provide a [**Hospital **] hospital bed and raised toilet seat with rails 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 10 days: 10 days total, started [**5-11**]. Disp:*18 * Refills:*0* 13. PICC management per protocol PICC management per protocol 14. Outpatient Lab Work Please have a vancomycin trough drawn before your dose on [**2136-5-14**]. Please fax the results to our office [**Telephone/Fax (1) 87**]. 15. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0* 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Medlink Discharge Diagnosis: Thoracic Tumor fever urinary retention Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? [**Month (only) 116**] take daily showers. No tub baths or pools until seen in follow up. ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation - You need to have Vancomycin through your PICC line for a total of 10 days and you need a trough drawn on [**2136-5-14**]. Arrangements have been made at the ER at [**Hospital 71976**] [**Hospital 107**] Hospital [**Telephone/Fax (1) 71977**]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: Follow up with Dr [**Last Name (STitle) 548**] in 6 weeks with xrays. Call [**Telephone/Fax (1) 2992**] for appt. You should also follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] [**Telephone/Fax (1) 1844**] from neuro-oncology on the same day as Dr [**Last Name (STitle) 548**] try to coordinate your appointments Completed by:[**2136-5-12**] Name: [**Known lastname 12049**],[**Known firstname **] Unit No: [**Numeric Identifier 12050**] Admission Date: [**2136-5-3**] Discharge Date: [**2136-5-12**] Date of Birth: [**2101-1-25**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2427**] Addendum: The patient's PICC line appeared to be pulled out slightly on [**2136-5-12**]. He had a CXR and the radiologist confirmed that it had good placement in the SVC and is safe to be used for antibiotics. He will be discharged home. Discharge Disposition: Home With Service Facility: Medlink [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**] Completed by:[**2136-5-12**]

[ "780.6", "493.90", "336.3", "285.1", "562.10", "788.20", "192.2", "998.89" ]

icd9cm

[ [ [] ] ]

[ "81.05", "81.63", "41.31", "80.99", "03.4", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9036, 9231

1824, 4261

333, 373

6548, 6572

1302, 1801

8010, 9013

938, 942

4350, 6404

6486, 6527

4287, 4327

6596, 7987

957, 1283

279, 295

401, 765

787, 863

879, 922

61,636

115,504

20313

Discharge summary

report

Admission Date: [**2195-10-29**] Discharge Date: [**2195-11-2**] Date of Birth: [**2117-5-4**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 800**] Chief Complaint: chest pain, dyspnea, syncope Major Surgical or Invasive Procedure: none History of Present Illness: This is a 78 year old male with past medical history notable for prostate cancer, temporal arteritis, hyperlipidemia, and gout who presents today ont transfer with "massive bilateral PE's." Per the patient he had been in his regular state of health until several weeks ago he developed a severe flare of his gout that he is finally getting over. More recently (approximately [**3-3**] wks ago) he developed intermittent chest pain that would occasionally radiate to his back or shoulder. This was about a [**6-7**] severity and each bout of pain would last perhaps a few minutes. This pain was nonexertional. In addition to this he developed some dyspnea on exertion, which was not temporally associated with the chest pain. This had perhaps been getting a bit worse with episodes most days over the past week. This morning while getting his pills he passed out and awoke on the floor. He denies any prodrome, but after coming back to consciousness he felt sweaty and unwell. He then was brought into the [**Location (un) 620**] ED where he was diagnosed with massive, bilateral pulmonary emboli. He was started on heparin drip after bolus and transferred to [**Hospital1 18**]. In the ED, initial vs were: T 97.7P 91 BP 120/66 R 18 O2 sat 97 % on 2L. Patient was admitted to the medical intensive care unit. Past Medical History: -Prostate Ca s/p external beam radiotherapy 4 years ago -Temporal Arteritis, diagnosed [**4-/2195**] -Gout, first attack 3 weeks ago -Hyperlipidemia -Hx umbilical hernia repair 3 years ago -Hx appendectomy at age 11 Social History: Lives alone. Attorney. Never a regular smoker and no tobacco during past 3 months. Approximately 1 EtOH beverage/night. No illicits. Family History: Dad w/ CVA. Colon cancer and glaucoma on maternal side. "Heart Problems" on father's side. Father with history of blood clots, was on Coumadin. Physical Exam: On transfer to medical floor: . Vitals: T: 97.4 BP:103/56 P:66 R: 18 O2: 96% on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP 7 cm Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender. Ext: WWP. Bilateral ankle edema. Pertinent Results: Laboratory: . [**2195-10-29**] 07:05PM BLOOD WBC-12.8* RBC-4.56* Hgb-13.4* Hct-39.3* MCV-86 MCH-29.3 MCHC-34.1 RDW-14.8 Plt Ct-326 [**2195-10-29**] 07:05PM BLOOD Neuts-88* Bands-1 Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* [**2195-11-2**] 07:30AM BLOOD PT-14.2* PTT-25.9 INR(PT)-1.2* [**2195-10-29**] 07:05PM BLOOD PT-13.5* PTT-64.4* INR(PT)-1.2* [**2195-10-29**] 07:05PM BLOOD Glucose-112* UreaN-22* Creat-1.0 Na-141 K-3.1* Cl-100 HCO3-29 AnGap-15 [**2195-10-30**] 04:16AM BLOOD CK(CPK)-51 CK-MB-NotDone cTropnT-0.03* [**2195-10-29**] 07:05PM BLOOD CK(CPK)-73 CK-MB-NotDone cTropnT-0.07* proBNP-1746* [**2195-11-2**] 11:20AM BLOOD TotProt-6.6 [**2195-10-30**] 04:16AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0 [**2195-11-2**] 11:20AM BLOOD PEP-NO SPECIFI IgG-713 IgA-153 IgM-52 IFE-NO MONOCLO . Microbiology: . MRSA screen [**2195-10-30**]: positive . EKG [**2195-10-29**]: Sinus arrhythmia. Right bundle-branch block. Possible inferior myocardial infarction, age indeterminate. There is an S1-Q3-T3 pattern. Possible pulmonary embolus. Non-specific T wave changes. No previous tracing available for comparison. . Imaging: . [**2195-11-2**] Thyroid ultrasound: Multinodular thyroid gland with small nodules, which do not demonstrate any son[**Name (NI) 5326**] worrisome features. Routine followup is recommended. . [**2195-11-1**] Bilateral lower extremity ultrasound: Bilateral deep venous thrombus definitively involving but not completely occluding the right popliteal vein and also involving the left posterior tibial vein in the calf. . [**2195-10-30**] Transthoracic echocardiogram - The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no ventricular septal defect. The right ventricular cavity is markedly dilated with depressed free wall contractility. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2195-10-29**] CTA ([**Hospital1 **] [**Location (un) 620**]) - [**2195-10-29**]. There is extensive bilateral pulmonary embolism. There is a saddle embolus involving the main and right and left pulmonary arteries, with emboli extending into all lobar branches. The right ventricle appears enlarged, but the chronicity of this finding is unknown. There is no pericardial or pleural effusion. The aorta is tortuous. Scattered linear opacities in the dependent basal portions of the lower lobes are most consistent with atelectasis. The tracheobronchial tree is patent to segmental levels. There is no mediastinal, hilar or axillary lymphadenopathy. There is a 1.5 cm solid-appearing nodule with a coarse calcification arising exophytically from the posterior inferior aspect of the right thyroid lobe. There is a 3.5 cm cyst in the imaged portion of the right kidney and a 3.5 cm cyst in the imaged portion of the left kidney. Other imaged other abdominal organs are grossly unremarkable in the early phase of contrast enhancement. Multilevel degenerative changes are present in the spine. IMPRESSION: 1. MASSIVE BILATERAL PULMONARY EMBOLISM AS DESCRIBED ABOVE. 2. RIGHT VENTRICULAR ENLARGEMENT OF UNKNOWN CHRONICITY. GIVEN THE PRESENCE OF MASSIVE PULMONARY EMBOLISM, THIS FINDINGS IS CONCERNING FOR ACUTE RIGHT HEART STRAIN. 3. SOLID-APPEARING 1.5 CM RIGHT THYROID NODULE. FURTHER EVALUATION BY ULTRASOUND IS RECOMMENDED WHEN THE PATIENT IS STABLE, IF NOT PERFORMED PREVIOUSLY. Brief Hospital Course: 1. Pulmonary Embolism/Deep venous thrombosis: The patient was admitted to the medical intensive care unit with extensive pulmonary embolism and evidence of right heart strain. He was later found to have bilateral deep venous thrombosis (right greater than left). Anticoagulation was initiated with IV heparin. The patient remained stable and was transferred to the medical floor. On the medical floor, warfarin was started, and IV heparin was changed to Lovenox. The patient was taught how to self-administer Lovenox and how to manage his diet while on Coumadin. The patient will self-administer Lovenox until he has had a therapeutic INR for 2 days. The patient will follow up with his primary care physician for management of anticoagulation, with the first two [**Month/Day/Year **] draws occurring on [**2195-11-4**] and [**2195-11-6**]. The patient's INR was 1.2 at the of discharge. The patient was advised to stop his daily aspirin until his next appointment with his primary care physician and discuss resuming aspirin at that time. The etiology of the patient's PE/DVT was unclear. There was no recent surgical history. The patient has a family history of venous thrombosis (father). He has been less mobile than usual in the setting of gouty flair. The patient has a possible inflammatory risk factor (temporal arteritis). He also has history of prostate cancer. The patient is due for colonoscopy. SPEP/UPEP was ordered while the patient was in the hospital, and the patient's primary care doctor should follow up on this. The hypercoagulability work-up will be completed in the outpatient setting. . 2. Thyroid nodule: A thyroid nodule was identified incidentally on the patient's CT angiogram. The patient underwent thyroid ultrasound, which showed multiple nodules with no son[**Name (NI) 5326**] suspicious features. He should undergo further follow-up for this as an outpatient. . 3. Hyperlipidemia: Continued home statin. . 4. Temporal Arteritis: Continued home prednisone. . 5. Lower extremity edema: The patient has been taking Lasix for lower extremity edema. The edema is likely related to his DVTs. The patient was instructed to stop taking Lasix as this could cause a dangerous drop in his blood pressure in the setting of extensive PE. . 6. Glaucoma: Continue brimonidine/timolol drops. The patient will need to contact his ophthalmologist for a prescription refill. . 7. Gout: The patient was without symptoms of gout and continued his home colchicine. . 8. MRSA: A routine MRSA swab in the medical intensive care unit was positive. The patient was put on contact precautions. Medications on Admission: simvastatin 40 mg PO daily Combigan 1 drop each eye [**Hospital1 **] colchicine 0.6 mg PO daily prednisone 20 mg PO daily clonazepam 0.5 mg PO BID PRN multivitamin 1 tab PO daily ASA 81 mg PO daily Caltrate 600/D 1 tab PO TID Lasix 20 mg PO daily Discharge Medications: 1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Combigan 0.2-0.5 % Drops Sig: One (1) drop each eye Ophthalmic twice a day. 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Dose will need adjustment based on monitoring. Use as directed by your primary care doctor. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 6. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours) for 6 doses. [**Last Name (Titles) **]:*6 doses* Refills:*0* 7. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One (1) Tablet PO three times a day. 8. Outpatient [**Name (NI) **] Work PT/PTT/INR check on [**2195-11-4**] and [**2195-11-6**], to be followed up on by patient's primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**]. Fax number is [**Telephone/Fax (1) 41861**]. Discharge Disposition: Home Discharge Diagnosis: Primary: Saddle Pulmonary Embolism Secondary: Temporal Arteritis Hyperlipidemia Glaucoma Discharge Condition: Hemodynamically stable, maintains good oxygen saturation on room air, tolerating oral diet, alert and oriented Discharge Instructions: You came to [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Last Name (Titles) 620**] with symptoms of chest pain, shortness of breath, lightheadedness, and an episode of passing out. You were found to have a large blood clot in your lungs, and you were transferred to [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Location (un) **] for further treatment. You were intially admitted to the medical intensive care unit, but as your condition improved, you were transferred to the medical floor. You were treated with anti-clotting medications. You will go home on two anti-clotting medications, (1) Coumadin (also called warfarin), and (2) Lovenox (also called enoxaparin). Coumadin is an oral medication that you will need to take at the same time every day. Coumadin requires frequent monitoring with blood tests in order to maintain the appropriate level of anticoagulation. There are some foods that can alter the effects of Coumadin, and you met with a nutritionist to go over this. Many medications can alter the effects of Coumadin, so you will need more frequent monitoring whenever you start a new medication or change the dose of an old medication. You will also need more frequent monitoring right now, while you are first starting Coumadin. This week, you will need to have a blood test called an INR checked on [**2195-11-4**] and [**2195-11-6**] in order to ensure an appropriate Coumadin level. It is very important that you follow up as advised because elevated levels of Coumadin can put you at risk for serious bleeding, and low levels of Coumadin can put you at risk for further blood clots. Until your Coumadin level is appropriate, which will likely take about a week, you will need to take a second anti-clot medication called Lovenox. Lovenox is a medicine that you will inject subcutaneously twice daily. You have been taught how to use Lovenox during your stay at the hospital. We stopped your Lasix. You should not restart your Lasix until instructed to do so as these could cause a dangerous drop in your blood pressure in the setting of the blot clots in your lungs. You should stop your aspirin for now, but you should discuss with you primary care physician whether this should be continued when you see him later this week. You had ultrasounds of your legs, which showed venous blood clots on both sides, with more significant involvement on the right. These blood clots are likely the source of the blood clots in your lungs. Your CT angiogram showed a thyroid nodule. You had an ultrasound of your thyroid gland to follow up on this. The ultrasound showed two benign-appearing nodules. You should follow up with your primary care physician for further evaluation of these nodules. You should to the hospital if you develop lightheadedness, chest pain, difficulty breathing, fever, worsening cough, or any other symptom that is concerning to you. It is important for you to follow up closely with your physicians. We have arranged a follow-up appointment with your primary care physician for this Thursday, [**2195-11-5**], as explained below. Followup Instructions: You have an appointment to follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**], on Thursday [**2195-11-5**] at 1:30 p.m. You should talk to your primary care physician about colonoscopy. You will need to have blood drawn on [**2195-11-4**] and [**2195-11-6**] to monitor your Coumadin therapy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

[ "415.19", "446.5", "274.02", "V02.54", "365.9", "241.1", "453.42", "V10.46" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10525, 10531

6597, 9203

309, 316

10665, 10778

2636, 6574

13935, 14416

2060, 2205

9500, 10502

10552, 10644

9229, 9477

10802, 13912

2220, 2617

241, 271

344, 1655

1677, 1894

1910, 2044

79,236

141,314

41455

Discharge summary

report

Admission Date: [**2140-4-12**] Discharge Date: [**2140-4-24**] Date of Birth: [**2054-9-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / cefazolin Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Coronary artery bypass grafting times four (left internal mammary artery to left, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) [**4-18**] History of Present Illness: [**Known firstname 122**] [**Known lastname 90187**] is an 85 year old male with a past medical history significant for diabetes, coronary artery disease, peptic ulcer disease with gastrointestinal bleed and ventricular tachycardia status post AICD who presented to an outside hospital emergency department with shortness of breath. His shortness of breath was of sudden onset with no associated symptoms. He was admitted to [**Hospital1 **] with an NSTEMI, troponin of 1.17 on [**4-9**]. He [**Month/Year (2) 1834**] a cardiac catheterization at [**Hospital6 1109**] today which revealed severe left main and three vessel coronary artery disease and he was transferred to [**Hospital1 18**] for a coronary artery bypass grafting. Past Medical History: CAD s/p stent placment, VT s/p AICD, cervical radiculopathy, NIDDM only on Metformin, BPH, PUD, GI bleeding, esophagitis, hyperlipidemia, Cardiomyopathy EF 35-40%, s/p AICD Social History: Mr. [**Known lastname 90187**] lives in an [**Hospital3 **] facility with his wife. Family History: non-contributory Physical Exam: Pulse:80S Resp:20 O2 sat: 96% RA B/P Right: 110/74 Left: Height: 5'6" Weight: 61.6 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: cath site, 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 90188**]Portable TTE (Complete) Done [**2140-4-13**] at 9:40:00 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2054-9-22**] Age (years): 85 M Hgt (in): 65 BP (mm Hg): 152/80 Wgt (lb): 132 HR (bpm): 72 BSA (m2): 1.66 m2 Indication: Left ventricular function. Preoperative assessment CABG, Valvular heart disease. ICD-9 Codes: 414.8, 424.0, 424.2 Test Information Date/Time: [**2140-4-13**] at 09:40 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Adequate Tape #: 2011W013-0:00 Machine: Vivid [**8-3**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.5 m/s Left Atrium - Peak Pulm Vein D: 0.5 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 35% >= 55% Left Ventricle - Stroke Volume: 66 ml/beat Left Ventricle - Cardiac Output: 4.75 L/min Left Ventricle - Cardiac Index: 2.86 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 8 < 15 Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 21 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 0.71 Mitral Valve - E Wave deceleration time: 243 ms 140-250 ms Pulmonic Valve - Peak Velocity: 0.8 m/sec <= 1.5 m/sec Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+] TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with basal to mid lateral akinesis (including the basal inferior wall) and anterior/antero-septal and apical hypokinesis (suggestive of multivessel CAD). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: On [**4-18**] Mr. [**Known lastname 90187**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting times four (LIMA to LAD, SVG to Dx, SVG to OM, SVG to PDA). Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the intensive care unit. His AICD was interrogated by the electrophysiology service. He was weaned from pressors and extubated by post-operative day one. Epicardial wires and chest tubes were removed and he was transferred to the step down floor by the following day. He was seen in consultation by the physical therapy service for strength and consitioning and an interim rehab stay was recommended. He was started on betablockers and diuresed toward his preoperative weight. His stain therpay was also resumed. He experienced post-op confusion which cleared when narcotics were discontinued. By post-operative day six he was cleared for discharge to [**Hospital 3548**] [**Hospital 3549**] Rehab in [**Location (un) 1110**] [**Telephone/Fax (1) 90189**]. All follow-up appointments were advised. Medications on Admission: Trazadone 100 q HS Ambien 5 mg HS PRN Flomax 0.4 mg [**Hospital1 **] Lasix 10 mg daily Protonix 40 daily Lipitor 10 daily Lisinopril 10 daily Metfromin 1 gm [**Hospital1 **] Avodart 0.5 daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for to chest. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: when edema resolved decrease to home dose of 10mg. 12. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily (). 16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3549**] Discharge Diagnosis: coronary artery disease Non indulin dependent diabetes, BPH, Peptic ulcer disease, esophagitis, hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2140-5-12**] 2:00 Cardiologist: Please all your cardiologist and schedule an appointment for 2 weeks. [**Last Name (LF) 31888**], [**Name8 (MD) **] MD Please call to schedule appointments with your in [**5-3**] weeks Primary Care Name: [**Doctor Last Name 9529**],HARVEEN Address: [**Apartment Address(1) 90190**], [**Location (un) **],[**Numeric Identifier 66490**] Phone: [**Telephone/Fax (1) 82564**] Fax: [**Telephone/Fax (1) 90191**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2140-4-24**]

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icd9cm

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42444

Discharge summary

report

Admission Date: [**2189-1-7**] Discharge Date: [**2189-1-27**] Date of Birth: [**2139-8-14**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 896**] Chief Complaint: Overdose Major Surgical or Invasive Procedure: Mechanical ventilation and intubation Central venous line placement Tunneled line placement Hemodialysis Fasciotomies x 2 History of Present Illness: 49M with past medical history significant for asthma, GERD, multiple psychiatric problems, heavy alcoholism and new lung nodule presents from outside hospital in rhabdomyolysis, renal failure, shock requiring 2 pressors of unknown etiology, as well as depressed mental status. . Interval history reveals that apparently the wife found him this morning lying in the bathtub, where he apparently slept overnight after being involved in a domestic dispute. She found that he had taken more doses of his prescription meds than should, including all of his fluoxetine, ativan, ambien, and Neurontin, and naproxen, and doxepin [**1-3**] pills and he was again not responsive. He was taken to outside hospital where he was unresponsive and so was intubated for airway protection. Trauma CXR pelv there negative, as were head and C-spine CT (unknown whether trauma was involved initially). His labs there showed an anion gap acidosis, with rhabdomyolysis (CK of about 10,000), potassium of 7.1 EKG changes for which he was given calcium, insulin, bicarbonate. . Arrived to our emergency department on dopamine and we have fed, with a wide complex EKG (QRS 170) and potassium of 6.5. He required 2 amps of calcium, bicarbonate, and after bicarbonate his QRS narrowed dramatically. . Bedside echocardiogram and shock ultrasound revealed hyperdynamic ventricular function, normal caliber aorta, IVC which appeared very compressible with respiratory variability indicating under resuscitation. He was aggressively fluid resuscitated and subsequently weaned off the dopamine during his ED stay. . Prior to transfer he dropped his pressures and was restarted on dopamine and levophed. . . On arrival to the MICU, he is intubated and sedated. . Wife says he has had no access to over the counter medications specifically denying benadryl. Past Medical History: asthma GERD multiple psychiatric problems heavy alcoholism recently discovered lung nodule undergoing work up lung abcess Social History: - Tobacco: 40 pack year history - Alcohol: Heavy at times unknown daily quantitiy - Illicits: Not to his wife knowledge [**Name2 (NI) 91896**] he has been hanging out with people his wife feels to be unsavory Family History: Lung cancer on his mothers side Physical Exam: Admission Vitals: P107 Bp 137/75 98% Intubated General: Intuabted and sedated HEENT: Sclera anicteric, ETT in place, NGT in place pupils round and reactive. Neck: supple, JVP not elevated, no LAD CV:Tachycardia RRR no MRG Lungs: Bilateral breathsounds CTA Abdomen: soft, non-tender, non-distended, absent bowel sounds GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge: General: patient alert and oriented in no acute distress HEENT: sclera anicterica, PEARLA, EOMI CV: No MRG lungs: CTAB Abdomen: soft, non-tender, non-distended Neuro: CN 2-12 intact, strength 5/5 in the left upper ext, strength 4/5 in the right upper ext with proximal muscles weaker than distal, right lower ext [**3-5**] with proximal weaker than distal Pertinent Results: Pertinent Labs: [**2189-1-7**] 01:48PM BLOOD WBC-15.9* RBC-4.27* Hgb-11.6* Hct-36.5* MCV-86 MCH-27.3 MCHC-31.9 RDW-15.5 Plt Ct-285 [**2189-1-7**] 06:04PM BLOOD Neuts-82* Bands-0 Lymphs-12* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2189-1-7**] 01:48PM BLOOD PT-12.6* PTT-32.9 INR(PT)-1.2* [**2189-1-7**] 06:04PM BLOOD Glucose-249* UreaN-35* Creat-3.5* Na-139 K-6.0* Cl-99 HCO3-20* AnGap-26* [**2189-1-7**] 09:04PM BLOOD ALT-214* AST-751* CK(CPK)-[**Numeric Identifier 91897**]* TotBili-0.5 [**2189-1-7**] 06:04PM BLOOD Calcium-7.1* Phos-6.7* Mg-2.1 [**2189-1-16**] 01:03AM BLOOD Hapto-403* [**2189-1-19**] 04:31AM BLOOD calTIBC-224* Ferritn-240 TRF-172* [**2189-1-17**] 03:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE [**2189-1-7**] 01:48PM BLOOD ASA-NEG Ethanol-26* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2189-1-17**] 03:45PM BLOOD HCV Ab-POSITIVE* [**2189-1-7**] 02:58PM BLOOD Type-ART pO2-122* pCO2-36 pH-7.25* calTCO2-17* Base XS--10 [**2189-1-7**] 01:49PM BLOOD Glucose-182* Lactate-6.4* Na-140 K-6.5* Cl-108 calHCO3-13* [**2189-1-9**] 11:24PM BLOOD Glucose-170* Lactate-2.0 K-6.4* [**2189-1-7**] 06:58PM BLOOD freeCa-0.97* [**2189-1-7**] 02:11PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2189-1-23**] 05:27AM BLOOD HIV Ab-NEGATIVE. . **FINAL REPORT [**2189-1-22**]** WOUND CULTURE (Final [**2189-1-22**]): ENTEROCOCCUS SP.. >15 colonies. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R . ECG [**1-7**]: Wide complex tachycardia with left bundle-branch block morphology and left superior axis suggestive of supraventricular tachycardia with intraventricular conduction delay. However, cannot exclude ventricular tachycardia or accelerated idioventricular rhythm. No previous tracing available for comparison. . ECG [**1-12**]: Sinus tachycardia with atrial premature beats. Low QRS voltage in the limb leads. Compared to tracing #1 atrial ectopy is new. QRS voltage in the precordial leads is increased. . LENI [**1-9**]: No evidence of deep vein thrombosis seen in either leg. Note is made of some fluid tracking in the region of the left popliteal fossa. Note is also made of prior left lower leg amputation. . Head CT [**1-11**]: 1. New hypodensity in the genu of the left internal capsule is suggestive of an acute infarction. A dedicated brain MRI is recommended for further evaluation. 2. Ethmoidal and sphenoidal mucosal thickening with air-fluid levels and aerosolized secretions is suggestive of acute sinusitis. . TTE [**1-12**]: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at restx2 (late bubbles are seen at 5 beats c/w transpulmonic passage). Global left ventricular systolic function is normal. There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No discrete vegetations are seen. Trace aortic regurgitation is seen. The anterior mitral valve leaflet is mildly thickened, but without discrete vegetation. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis seen. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest. Normal biventricular function. . Carotid U/S [**1-13**]: Duplex was performed of bilateral carotid arteries. No significant plaque is seen bilaterally. . CT Abdomen [**1-15**] 1. Small bowel obstruction with a transition point in the right lower quadrant. No evidence for free air or bowel ischemia. 2. Nodular consolidative opacities seen at the right lung base are likely representative of developing pneumonia. 3. Distended gallbaldder with enhancing wall and surrounding fluid may be related to volume status. However, if there is clinical concern for cholecystitis a HIDA scan should be obtained. 4. Small trace bilateral pleural effusions with adjacent compressive atelectasis. . CT Chest/Abdomen/Pelvis [**1-18**] 1. Widespread multifocal pneumonia involving primarily right lung but also left upper lobe. 2. Small bilateral pleural effusions. 3. Segment [**Doctor First Name 690**] liver hypodensity too small to fully characterize. 4. Interval improvement of small-bowel obstruction. 5. Right lung base pleural calcifications. Brief Hospital Course: 49M with past medical history significant for asthma, GERD, multiple psychiatric problems, heavy alcoholism and new lung nodule (being worked up for malignancy, +PET, no bx yet) presents from outside hospital with TCA overdose who initially presented with rhabdomyolysis, renal failure and shock initially requiring 2 pressors now weaned off pressors. ICU course has been complicated by oliguric/anuric renal failure requiring continued CVVH/HD, compartment syndrome s/p fasciotomies x 2, new finding of stroke, SBO (now resolved), and persistent leukocytosis and fever. 1. Ingestion/Overdose with resulting respiratory failure requiring mechanical ventilation: Patient found down with empty pill bottles by his side. Tox screen was positive for TCAs and EtOH and otherwise negative. Initially presented with AMS, metabolic acidosis, hypotension and QRS >100 suggestive of TCA overdose. He was started on intravenous bicarbonate infusion and his QRS narrowed appropriately. He was started on neosynephrine and levophed for his hypotension (presumed to be more likely drug effect than sepsis) which was successfully weaned on [**1-10**]. Serial ECGs showed no signs of widening. Patient was initially intubated for airway protection. Extubation was attempted on [**1-15**] but failed due to massive bilious emesis and concurrent aspiration. He was successfully extubated on [**1-18**]. Circumstances of ingestion are unclear. Appears to have occurred after night of drinking in the context of domestic dispute. Per family, patient had been under increased stress for the past several months as he was in the process of being worked up for potential lung cancer. When patient had regained his speech capabilities, psychiatry was reconsulted and they felt that he should be started on anti-depressant monotherapy after the course of linezolid is completed. 2. Sepsis secondary to pneumonia and CVL: Though patient intially presented with leukocytosis, he showed no signs of infection on first presentation. Then from [**1-13**] onwards, patient's temperature was noted to be gradually increasing in tandem with his white count until he finally became febrile to 102 on [**1-15**]. Patient was empirically started on vanc, zosyn, and flagyl. His lines were discontinued and foley was changed. The patient??????s gallbladder was visualized and no cholecystitis was seen. There was concern for C.diff given patient's concurrent abdominal distention so he was empirically started on treatment for C.diff with concurrent PO vanc, which was discontinued after negative C. diff PCR. CT Chest indicated multifocal pneumonia likely from aspiration event during first attempted extubation (see below). Plan for antibiotics was to continue vanc and zosyn for PNA for an eight day course until [**1-22**] and azithromycin for a five day course (added for atypical coverage of PNA) until [**1-23**]. On [**1-22**], culture tip from catheter was positive for VRE. Patient was switched to linezolid on [**1-22**] for 14 day course and vancomycin was discontinued. Blood cultures showed no growth after. HIV serologies negative. On discharge patient had completed the antibiotic course for his pneumonia and is on linezolid for the VRE+ central line culture. 3. Acute renal failure / acute tubular necrosis - Renal failure secondary to rhabdomyolysis, with peak CK in the 60,000 range. Patient initially with elevated potassium and phosphate and low calcium requiring agressive correction. Pt was started on CVVH then transitioned to HD for Monday, Wednesday, Friday sessions after tunneled line was placed by IR. Per renal, chance of renal recovery remains slim. Per renal, recommendations on discharge include measure interdialytic CR and obtain a 24 hour urine collection for a urea and creatinine clearance once urine outpute is > 400. On the day of his discharge patient had a urine output of around 200cc and will continue HD at his [**Hospital1 1501**]. 4. Small Bowel Obstruction: On [**1-15**], the day of his first extubation attempt, patient experienced copious bilious vomiting with likely aspiration of bilious material. Patient had been having some stool output prior but worsening abdominal distention was noted. Subsequent CT scan showed small bowel obstruction with transition point in the RLQ. Cause felt to be likely ileus but infection was a concern as well so Cdiff treatment was initiated. ACS was consulted who felt there was no need for acute surgical intervention so patient was kept NPO with an NG tube in place. Repeat imaging showed improvement of the obstruction so patient's diet was slowly advanced as tolerated. 5. Compartment Syndrome due to rhabdomyolysis: Patient had been found down in a bathtub. On presentation, noted to have tense right upper arm and right upper thigh. Evaluated by orthopedics who noted that pressures in both compartments were elevated necessitating urgent fasciotomies the night of admission. Wounds were closed on [**1-12**] and wound vacs were placed until drainage ceased. Ortho recommended starting ancef for prophylaxis for one weeks but this was discontinued once broad-spectrum antibiotics were initiated. Sutures were removed on [**1-24**]. Ortho will follow-up with patient 2-4 weeks after discharge. 6. Acute stroke: Though patient presented with a negative Head CT on admission, patient was noted to have decreased movement of his right side and repeat Head CT showed a hypodensity in the internal capsule in the geniculate on the left side. LENIs were negative for clot and TEE was without vegetation or PFO. Neurology was consulted who recommended ASA and carotid ultrasounds which were negative. The patient did have a single episode of afib on [**1-11**] which may be related to etiology of stroke. MRI showed evidence of acute left subcortical infarct in the posterior frontal and anterior parietal lobes. MRA head and neck showed no evidence of occlusion or aneurysm. Neurology recommended anticoagulation with coumadin. Patient was bridged with heparin and had therapuetic INR on discharge 7. Atrial fibrillation with RVR: One episode in the AM of [**1-11**]. The patient had a non-sustained interval of afib with RVR with accompanying hypotension. It responded well to diltiazem bolus and patient remained in sinus rhythm for the remainder of his stay. Started on anticoagulation per neurology recommendations as above. TRANSITIONAL ISSUES - Patient will need further work-up of his underlying lung nodules which are PET positive. - Patient was found to be HCV positive on bloodwork here. Will require liver follow-up as outpatient - Renal recommendations as above: interdialytic CR and obtain a 24 hour urine collection for a urea and creatinine clearance once urine outpute is > 400 Medications on Admission: Gabapentin 900mg QHS Fluoxeptine 60mg QD Doxepin 150mg QHS Omeprazole Ambien 10mg QHS Ativan 1mg [**Hospital1 **] Flomax Naproxen Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): give after hemodialysis. 8. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. linezolid 600 mg/300 mL Parenteral Solution Sig: Three Hundred (300) mL Intravenous twice a day. 13. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. 14. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Primary Diagnoses: Tricyclic antidepressant overdose Acute respiratory failure requiring mechanical ventilation Rhabdomyolysis Acute kidney failure requiring hemodialysis Compartment syndrome s/p fasciotomies x 2 Embolic Stroke wirh right sided hemiparesis and aphasia Multifocal pneumonia Small bowel obstruction Atrial Fibrillation Secondary diagnoses: Depression Alcohol abuse Lung nodules Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Last Name (Titles) 91898**], You were admitted to the [**Hospital1 69**] after you overdosed on prescription medications. You needed to be admitted to the intensive care unit and were initially dependent on a mechanical ventilator. You developed severe kidney failure requiring hemodialysis which you will continue after discharge. You also required surgeries on your right arm and right leg to help relieve the pressure that had built up there while you were unconscious. Unfortunately, you also developed a stroke during your stay and will require continued rehab and anticoagulation as you regain your strength and speech. . We have made the following changes to your medications: # START coumadin 2mg daily by mouth with goal INR [**1-2**] # START linezolid 600mg every 12 hours IV for 9 more days # START nephrocaps 1 daily # START sevelamer 1600mg three times daily # START thiamine 100mg daily # START senna 8.6mg twice daily as needed for constipation # START bisacodyl 10mg daily as needed for constipation # START nicotine patch to be tapered over 2 weeks # START advair twice daily # DECREASE gabapentin to 300mg daily after hemodialysis # STOP fluoxetine # STOP doxepin You will need ongoing psychiatric care and once the antibiotics stop, you may be able to start a low dose antidepressant. Followup Instructions: Orthopedics: please follow up in 2-4wks with Dr. [**Last Name (STitle) **]. Please call [**Numeric Identifier 18919**] to make an appointment. Department: INFECTIOUS DISEASE When: TUESDAY [**2189-2-10**] at 10:00 AM With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: NEUROLOGY When: TUESDAY [**2189-3-24**] at 8:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *You have also been placed on a cancellation list for this appointment. The office will contact you at home when a sooner appointment becomes available. Name: [**Last Name (LF) **],[**First Name3 (LF) **] Z. Address: [**Doctor Last Name 90140**], [**Hospital1 **],[**Numeric Identifier 26407**] Phone: [**Telephone/Fax (1) 78940**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.

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icd9cm

[ [ [] ] ]

[ "96.6", "39.95", "86.59", "83.45", "96.72", "83.09", "33.24", "38.91", "88.72", "96.71", "38.95", "96.04" ]

icd9pcs

[ [ [] ] ]

16707, 16781

8384, 15145

275, 399

17219, 17219

3483, 3483

18737, 19930

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227, 237

427, 2252

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3499, 8361

2274, 2398

2414, 2625

805

182,868

9985

Discharge summary

report

Admission Date: [**2159-9-3**] Discharge Date: [**2159-9-13**] Date of Birth: [**2110-12-5**] Sex: M Service: MEDICINE Allergies: Lisinopril / Morphine Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: epigastric pain Major Surgical or Invasive Procedure: femoral central line placement History of Present Illness: Mr. [**Known lastname 33419**] is a 48 year-old Cuban gentleman with a history of idiopathic dilated cardiomyopathy (EF 15-20%) s/p AICD [**2159-8-7**] who presented to the Emergency Department with intermittant, epigastric pain that is similar to his presentation at his last admission on [**8-25**]. Also admits to bilious emesis. Denies any f/chills. He reports pain worsened over the past 3 days with N/V as well as abdominal distension and firmness. He reports some increased dysuria intermittently for the past 2 days. . In the [**Name (NI) **], pt temp was 97.7, Hr 112, BP 110/69, 100%RA. He received 1L NS, D5W + bicarb and mucomyst prior to receiving IV contrast during his CT torso. Past Medical History: 1. CHF: Idiopathic dilated cardiomyopathy. Echo [**6-2**] with LVEF 15-20%, mild-mod MR. [**Name14 (STitle) 33421**] [**4-30**] with global hypokinesis, moderate dilation, no perfusion defects and normal EKG. Cath [**8-2**] with no flow limiting coronary disease, elevated right and left sided filling pressures consistent with biventricular diastolic dysfunction (RVEDP = 16 mmHg, LVEDP = 31 mmHg), moderate pulmonary arterial hypertension, markedly reduced cardiac index, and markedly elevated SVR and PVR. Dry weight is 144lbs (65.5kg). 2. NSVT: Pt with several episodes during hospitalization in [**8-2**] and underwent AICD placement. 3. h/o STDs: MSM. +gonorrhea [**2153**]. HBV core Ab+, sAb+. HIV neg [**7-3**], HCV neg [**7-3**]. 4. RUE DVT - on coumadin 5. ? Protein C and S deficient last admit Social History: The patient immigrated from [**Country 5976**] in [**2149**]. He currently lives alone in [**Location (un) 686**]. He denies any use of alcohol, tobacco or illicit drugs. He is a man who has sex with men (see above). Family History: CAD - Mother died of MI in her 50s. Brothers and sisters also have "problems with their hearts." No known history of blood clots. Physical Exam: Admission PE: VS: T97.2 BP96/52 P116 R20 O2 95%RA GEN: NAD, comfortable, Spanish-speaking gentleman, breathing comfortably. HEENT: PERRL. MMM. OP clear. No JVD. HEART: RRR no m/r/g. Defibrillator site c/d/i without erythema or swelling. LUNGS: CTA B/L ABD: soft, nondistended. Hyperactive BS. Diffuse TTP throughout abd, but no rebound/guarding. Mild CVAT on R, none on L. EXT: No edema bilat. NEURO: AO x 3. No focal deficits Pertinent Results: Admission Labs: . [**2159-9-2**] 08:20PM BLOOD WBC-7.1 RBC-4.65 Hgb-13.1* Hct-38.5* MCV-83 MCH-28.2 MCHC-34.0 RDW-15.7* Plt Ct-351 [**2159-9-2**] 08:20PM BLOOD Neuts-65.7 Lymphs-27.6 Monos-5.0 Eos-1.2 Baso-0.4 [**2159-9-2**] 08:20PM BLOOD Hypochr-1+ Microcy-1+ [**2159-9-2**] 08:20PM BLOOD PT-36.2* PTT-30.3 INR(PT)-4.0* [**2159-9-2**] 08:20PM BLOOD Glucose-112* UreaN-20 Creat-1.3* Na-135 K-6.2* Cl-100 HCO3-21* AnGap-20 [**2159-9-2**] 08:20PM BLOOD ALT-54* AST-77* CK(CPK)-140 AlkPhos-157* Amylase-30 TotBili-1.0 [**2159-9-2**] 08:20PM BLOOD Lipase-30 [**2159-9-2**] 08:20PM BLOOD CK-MB-2 [**2159-9-2**] 08:20PM BLOOD Calcium-8.8 Phos-4.6* Mg-2.2 . Other labs: [**2159-9-2**] troponin <0.01, CK 140 [**2159-9-5**] homocystein level 10 [**2159-9-5**] ACA IgM 8.0 and ACA IgG 5.2 [**2159-9-5**] prothrombin mutation not detected [**2159-9-5**] Factor V leiden mutation not detected . CXR ([**2159-9-2**]): 1. Marked cardiomegaly, stable. 2. Interval improvement in the degree of congestive heart failure with a tiny right pleural effusion. 3. Stable appearance of the transvenous pacemaker and leads. . CT Torso ([**2159-9-2**]): 1. Likely small subsegmental nonocclusive lingular pulmonary embolus. 2. Heterogeneous right nephrogram, new from [**2159-7-31**], is pyelonephritis versus renal infarcts. 3. A moderate right pleural effusion. (enlarged from [**2159-7-31**]), and small ascites (relatively unchanged). . Echo [**2159-9-3**]: The left and right atrium are moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2159-6-12**],the findings are similar. . Echo [**2159-9-4**]: The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed. No definite thrombus identified (cannot definitively exclude). Spontaneous echo contrast is noted in the left heart consistent with slow flow. The right ventricular cavity is dilated. There is moderate to severe global right ventricular free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . RLE U/S [**2159-9-6**]: no DVT . Discharge Labs: . [**2159-9-13**] 06:40AM BLOOD WBC-6.1 RBC-4.68 Hgb-12.7* Hct-38.4* MCV-82 MCH-27.0 MCHC-33.0 RDW-16.4* Plt Ct-459* [**2159-9-13**] 06:40AM BLOOD Plt Ct-459* [**2159-9-13**] 06:40AM BLOOD PT-19.6* PTT-33.2 INR(PT)-1.9* [**2159-9-13**] 06:40AM BLOOD Glucose-93 UreaN-23* Creat-1.1 Na-133 K-4.8 Cl-98 HCO3-24 AnGap-16 [**2159-9-13**] 06:40AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 Brief Hospital Course: 48 year-old M with nonischemic dilated CMP with EF<20%, multiple VTE (DVT/PE) who presents with persistent epigastric pain initially admitted to medicine, transfered to the MICU due to hypotension on the same day, then CCU the next day for further management of CHF (tailored therapy). His hospital course for this admission is as follows: . 1 CHF: Severe systolic CHF with EF <20% with moderate MR, hypotension likely secondary to poor cardiac output. We continued his digoxin at home dose. Central line was placed, and he was started on dobutamine drip tailored therapy at 15/kg/min on [**2159-9-4**] which was gradually weaned to 12mcg/kg/min on [**2159-9-6**], and weaned completely on [**2159-9-7**] and his central line was pulled on the same day. We monitored him closely for arrythmias on the tele while he was on the dobutamine drip. Lasix, [**Last Name (un) **], and spironolactone was held initially given increased Cr, while he was at the CCU, [**Last Name (un) **] (valsartan 40''), lasix 40', aldactone 25' was restarted once his Cr function was back to his baseline. He was held on most of his heart failure meds given BP parameter setting (SBP<95), but we adjusted the parameter to hold meds for SBP<85, and the decision was made not to take him for right heart cath at the time since he was able to tolerate his heart failure meds with changing parameters. He was discharged home with valsartan 40mg PO qhs, lasix 80mg PO qday, aldactone 25mg PO qday, digoxin 0.125mg PO qday. . 2 Ischmia. No CP, no h/o CAD. initial troponin and CK negative. . 3 Rhythm. pt had sinus tach, likely [**3-1**] to low cardiac output, anticipate improvement. . 4 Abdominal Pain. Leading diagnosis is congestion from CHF causing pain from liver capsule expansion. Somewhat responsive to PPI. He continued to complained abdominal pain while in the hopsital, and seemed to improved with pain management. CT torso initially was unrevealing. We followed his daily LFTs, which continued to be mildly elevated but stable c/w with liver congestion from his heart failure. . 5 DVT/PE. Unclear etiology. RUE VTE developed at home, not in setting of line placement. Patient now developed a small PE while supratherapeutic on coumadin. Concerning for hypercoagulable state. Hem/Onc was consulted, but was difficult to send hypercoagulable stuides given patient already anticoagulated; we sent antiphospholipid Ab which was WNL, pt didn't carry the more common factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5244**] mutation and Prothrombin mutations, homocysteine levels was WNL; His initially INR was supratherapeutic 4.0->3.5, coumadin was held initially; coumadin was restarted at 3mg PO qhs when INR came down to 2.5. Given Echo showed questionable LV thrombus and given ? hx of hypercoagulable state, he was also started on Lovenox 60mg SC q12h when INR became undertherapeutic (INR<2.0) while on Coumadin. He also finished a 7 day course for Kefelx for superifical thrombophlebitis. . 6 R renal infarct. Noted on CT torso, new finding which was concerning for thromboembolic disease, possibly LV thrombus give dilated CMP predisposing to intracardiac stasis. Echo aslo suggestive of poor flow. No clots seen on echo however. No evidence of endocarditis given no fevers, bl cx negative to date from ED. We continued anticoagulation with coumadin and lovenox (when INR<2.0), and monitored renal function closely where Cr trending down to baseline. . 7 Cr elevation. Baseline 1.0, initially slightly elevated secondary to poor cardiac output +/- renal infarct. anticipate improvement with improved cardiac output on pressors. We held lasix and [**Last Name (un) **] initially given slightly elevated BUN/Cr; once Cr back to his baseline, [**Last Name (un) **] and lasix was restarted. . 8 Pain syndrome. Multifactorial, mainly around his ICD site (no signs of infection and remained afebrile thorughout the hospital course) and abdomen (most likely related to congestive hepatopathy). Chronic pain service was consulted, which recommended oxycodone 5-15mg PO q4h prn, tradmadol 50mg PO q4-6h prn, and gabapentin 600mg PO tid, and lidocaine 5% patch 12 hours on and 12 hours off. Patient's pain slightly improved on this regimen. . 9 Congestive hepatopathy. LFTs mildly elevated initally, we followed closely his daily LFTs, which remained slightly elevated but stable. . 10 FEN: cardiac diet, fluid restriction 1500ml/day, lyte repletion prn . 11 PPx: INR elevated initially, once therapeutic, started coumadin (and lovenox and INR<2.0), bowel reg prn, po diet, PPI . 12 Full Code Medications on Admission: Medications at Home: Pantoprazole 40 mg Q24H Digoxin 125 mcg PO DAILY Spironolactone 25 mg PO DAILY Valsartan 40 mg PO BID Carvedilol 12.5 mg PO BID Tramadol 50 mg PO Q4-6H as needed Furosemide 20 mg PO qOD Warfarin 2mg qhs Oxycodone 10mg q4, prn Keflex 500 [**Hospital1 **] x2 more days . Meds Upon Transfer to CCU: - Digoxin 0.125 mg PO DAILY - OxycodONE (Immediate Release) 10 mg PO Q4H - OxycodONE (Immediate Release) 5 mg PO Q6H:PRN - Pantoprazole 40 mg PO Q24H - traMADOL 50 mg PO Q4-6H:PRN - Dolasetron Mesylate 12.5 mg IV Q8H:PRN - Cephalexin 500 mg PO Q6H Duration: 2 Days Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP<85. Disp:*15 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:*45 Tablet(s)* Refills:*0* 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP<85. Disp:*15 Tablet(s)* Refills:*0* 7. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous twice a day for 3 days. Disp:*6 syringes* Refills:*0* 8. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): hold for BP<85. Disp:*15 Tablet(s)* Refills:*0* 9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times a day: hold for oversedation. Disp:*90 Capsule(s)* Refills:*0* 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily): hold for SBP<85. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*0* 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*15 Tablet(s)* Refills:*0* 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical once a day: apply for 12 hours, and remove for 12 hours. Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0* 15. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO every six (6) hours as needed: hold for oversedation and RR<12. Disp:*180 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Idiopathic dilated cardiomyopathy chronic pain . Secondary diagnosis: NSVT s/p AICD placement [**8-2**]. h/o STDs: MSM. +gonorrhea [**2153**]. HBV core Ab+, sAb+. HIV neg [**7-3**], HCV neg [**7-3**]. RUE DVT/small subsegmental PE - on coumadin as outpatient Chronic pain - [**3-1**] AICD placement, DVT, superficial thrombophlebitis, abdominal pain Discharge Condition: Patient is in stable condition, afebrile, no chest pain, shortness of breath, Blood pressure stable, ambulating, O2 sat in the upper 90%. Discharge Instructions: If you experience any chest pain, SOB, heart palpitations, fever, abdominal pain different than your baseline or any other serious medical conditions, please go to the emergency room immediately. . You heart is dilated and not pumping well. Please restrict fluid intake to less than 1500ml per day. Please weigh yourself everyday, if your weight increased by more than 5-10lbs, please contact your PCP or your cardiologist immediately. Please make sure you take all your heart failure medications which may help your abodominal pain, including: digoxin 0.125mg po qday lasix 80mg PO qday toprol XL 50mg PO qday aldactone 25mg PO qday valsatan 40mg PO every night . You are on coumadin (indefinitely) and lovenox( for three days only), blood thinners. It is very important that you take coumadin everynight, please have your INR checked regularly by your PCP to keep it within the therapeutic range (goal INR [**3-2**]) to prevent clots development in your heart which can cause stroke and other serious problems. Please make sure you get lovenox shot 60mg SC bid for three days in addition to take coumadin 3mg PO every night indefinitely to allow INR be in the therapeutic range. . You have chronic pains, and we consulted chronic pain management team, they recommended you taking oxycodone 5-15mg PO every [**5-3**] hours as needed for pain control, tramodal 50mg PO every [**5-3**] hours as needed for pain control, lidocaine 5% patch 12 hours on and 12 hours off, and gabapentin 600mg by mouth three times a day for pain control. If you experience pain different than your baseline, please seek medical attention immediately. . Please take your medication as prescribed. . Please follow up with your appointments see below. Followup Instructions: Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33426**] [**Name (STitle) **] ([**Telephone/Fax (1) 250**]) on [**2159-9-24**] 9:50am and follow up with Dr. [**First Name (STitle) 437**] on [**2159-9-17**] at 10:30am for INR check and appointments . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2159-9-24**] 9:50 Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2159-9-17**] 10:30am Completed by:[**2159-9-14**]

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icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

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6243, 10847

305, 337

13867, 14007

2741, 2741

15791, 16400

2145, 2278

11482, 13425

13475, 13475

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365, 1061

13564, 13846

2757, 3392

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1083, 1891

1907, 2129

3404, 5828

24,285

155,638

44078

Discharge summary

report

Admission Date: [**2155-11-21**] Discharge Date: [**2155-11-24**] Date of Birth: [**2072-5-20**] Sex: M Service: SURGERY Allergies: Ticlid / Lipitor Attending:[**First Name3 (LF) 598**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: IR embolization of two splenic artery pseudoaneurysms History of Present Illness: 83M s/p [**2072**]4 hours ago. He was ambulating with his walker when he lost his balance and fell hitting the left side of his chest on the edge of a table. No LOC, he remembers the event. He felt well until today when he felt very lethargic and tired. He called his PCP who told him to go to the ED to be evaluated. He does report left sided chest pain similar to his angina symptoms and shortness of breath. He does have a history of recent falls so he has stopped taking his coumadin. Past Medical History: PMH: OA, CAD, CHF (EF 35-40%), pulmonary HTN, a-fib, HTN, hyperlipidemia, anemia, prostate cancer s/p XRT, h/o C.diff in [**2152**] . PSH: CABG '[**35**] with multiple stents (last in [**2151**]), Left hip surgery, s/p TURP Social History: Denies tobacco and ETOH use. Family History: Noncontributory Physical Exam: ON discharge: Afebrile, VSS No distress, A&Ox3 [**Year (4 digits) 13775**], EOMI, anicteric Irregular rhythm, lungs clear Abdomen firm but nontender Ext: trace edema Pertinent Results: Admission labs: [**2155-11-21**] 12:50PM BLOOD WBC-12.1*# RBC-2.37* Hgb-6.9* Hct-20.5* MCV-86 MCH-29.2 MCHC-33.8 RDW-17.1* Plt Ct-170 [**2155-11-21**] 12:50PM BLOOD Neuts-84.1* Lymphs-12.2* Monos-3.1 Eos-0.3 Baso-0.3 [**2155-11-21**] 12:50PM BLOOD PT-13.6* PTT-21.3* INR(PT)-1.2* [**2155-11-21**] 12:50PM BLOOD Glucose-202* UreaN-33* Creat-1.4* Na-144 K-3.7 Cl-107 HCO3-22 AnGap-19 [**2155-11-21**] 12:50PM BLOOD cTropnT-<0.01 [**2155-11-21**] 06:47PM BLOOD CK-MB-10 MB Indx-6.0 cTropnT-0.14* . Troponin trend: [**2155-11-21**] 06:47PM BLOOD CK-MB-10 MB Indx-6.0 cTropnT-0.14* [**2155-11-22**] 12:52AM BLOOD CK-MB-37* MB Indx-9.2* cTropnT-1.48* [**2155-11-22**] 11:36AM BLOOD CK-MB-28* MB Indx-9.2* cTropnT-1.82* [**2155-11-23**] 12:39AM BLOOD CK-MB-13* MB Indx-7.4* cTropnT-1.17* . Discharge labs: [**2155-11-23**] 12:39AM BLOOD WBC-12.2* RBC-3.66* Hgb-10.7* Hct-30.8* MCV-84 MCH-29.2 MCHC-34.7 RDW-18.0* Plt Ct-107* [**2155-11-23**] 06:18AM BLOOD Hct-28.7* [**2155-11-23**] 03:20PM BLOOD Hct-30.9* [**2155-11-23**] 09:30PM BLOOD Hct-29.7* Brief Hospital Course: Mr. [**Known lastname 1726**] was admitted 24 hours s/p fall onto left side. He now complains of severe fatigue and left sided chest pain. He was very pale on physical exam and an EKG demonstrated inverted T waves in the lateral leads. His hematocrit was 20 and he was hypotensive to the 90s. He was immediately resuscitated with packed RBCs and his color and feelings of fatigue resolved. A CTA was obtained to rule out an actively bleeding injury. It showed hemoperitoneum around the liver and in the pelvis along with two splenic artery pseudoaneurysms but no splenic injury. He immediately went to IR for emoblization of these two pseudoaneurysms. He received a total of 4units of packed RBCs and he hematocrit stablized in the 30s. He was monitored in the ICU. His troponin continued to peak at a level of 1.8. It is now trending down. His cardiologist was contact[**Name (NI) **] and with the EKG findings he was diagnosed as having a NSTEMI, which was treated medically. His aspirin was initially held and then restarted when his hematocrit was stable. His diet was advanced and he is having bowel function. His rib pain is well controlled and he is not having any chest pain. He was transferred to the floor where he continued to remain stable. He was evaluated by Physical Therapy and will need discharge to rehab. Medications on Admission: amlodipine 5mg daily, aspirin 162mg daily, metoprolol XL 25mg daily, sertraline 100mg [**Hospital1 **], vanco 125mg [**Hospital1 **] Discharge Medications: 1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for q5 min x3. 2. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO four times a day. 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Capsule Sig: [**1-24**] Capsules PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: s/p fall Left [**9-2**] rib fractures two splenic artery pseudoaneuryms s/p embolization NSTEMI Discharge Condition: Good Discharge Instructions: Call your physician if you experience, new chest pain, shortness of breath, persistent abdominal pain, nausea/vomiting, inability to eat or drink, lightheadedness or fatigue. . Continuing taking your aspirin and your lopressor. You had a heart attack and your cardiologist recommended medical management. . Continue deep breathing with your incentive spirometer. This will help prevent you from getting pneumonia. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in [**1-24**] weeks. Call his office at ([**Telephone/Fax (1) 61154**] to schedule your follow-up appointment. . Follow up with your Cardiologist in [**1-24**] weeks. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

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icd9cm

[ [ [] ] ]

[ "88.47", "39.79", "99.04" ]

icd9pcs

[ [ [] ] ]

4895, 4961

2456, 3796

286, 342

5101, 5108

1391, 1391

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79,600

169,524

44806

Discharge summary

report

Admission Date: [**2112-11-6**] Discharge Date: [**2112-11-26**] Date of Birth: [**2044-12-17**] Sex: F Service: MEDICINE Allergies: Lisinopril / Sulfamethoxazole/Trimethoprim / Atorvastatin / Compazine / Amitriptyline / Lactose / Tetanus / Pneumococcal Vaccine / Nitroglycerin Attending:[**First Name3 (LF) 2108**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 67 yo woman with CAD, obesity, hypertension, COPD, chronic pain syndrome, chronic pancreatitis, here with abdominal pain x 5 days, radiating to back with associated nausea, without vomiting. This is similar to her episodes of prior pancreatitis. She tried to eat a bland diet, and took extra oxycodone and tramadol, but she continued to have pain and presented to the ED. This pain is gnawing, in her epigastrium, and radiating toward her back. It is different from her pain from reflux and her chronic chest pain. She has had increased soft stools, that are lighter in color. No diarrhea. No blood in her stool. She has had no fevers, no chills. She has had a headache and dizziness for the past week. She has lost 5 lbs since last discharged 10 days ago. She had chronic shortness of breath, and chronic chest pain. Chronic difficulty initiating a urinary stream. No rashes. Otherwise, reviewed in 13 systems and negative. In the ER, she had stable vital signs and pain with palpation of her epigastrium. She received morphine 8 mg, zofran, and 1 L IV fluids. Labs were essentially unremarkable. EKG was unchanged. CXR was done prior to departure. Past Medical History: Hypertension Hyperlipidemia Diabetes mellitus, Type II, now on metformin Coronary artery disease s/p DES to the RCA, with chronic atypical chest pain Chronic diastolic CHF Pulmonary hypertension (PA systolic 54 in [**6-6**]) History of tobacco abuse COPD and asthma Chronic pain/Fibromyalgia Chronic pancreatitis, with pancreatic cystic lesion. GERD Stroke in [**2107**] with trace residual weakness of right arm and face Obesity Social History: Lives at home alone and gets out very rarely. The patient has a 43 pack-year tobacco history. She quit smoking in [**2101**]. She consumed alcohol in the past but quit 25 yrs ago; no history of illicit drugs or IVDU. She has not worked since [**2094**]. She is on disability. She has two daughters who are her HCPs: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 95859**] and [**Doctor First Name **] [**Telephone/Fax (1) 95860**]. Family History: Extensive history of MIs (ages 58-60) in siblings and mother. [**Name (NI) 2320**] throughout. Sister with CHF. Another sister with pulmonary fibrosis. Physical Exam: Exam VS T current 97 BP 141/83 HR 65 RR 18 93% 2L O2sat Gen: In NAD. HEENT: PERRL, EOMI. No scleral icterus. No conjunctival injection. Mucous membranes moist. No oral ulcers. Neck: Supple, no LAD, no obvious JVP elevation. Lungs: Bilateral scant wheezes, with decreased breath sounds, prolonged exp phase. Normal respiratory effort, breathing comfortably CV: RRR, no murmurs, rubs, gallops. Abdomen: soft, +BS. Tender in epigastrium to deep palpation, mild tenderness in RUQ. Extremities: warm and well perfused, no cyanosis, clubbing, edema. Neurological: alert and oriented X 3, CN II-XII intact. No pronator drift. Fast finger movements intact. Full strength in feet. Skin: No rashes or ulcers. Psychiatric: Appropriate. GU: deferred. Pertinent Results: ADMISSION LABS: - [**2112-11-6**] 10:05AM GLUCOSE-140* UREA N-15 CREAT-0.8 SODIUM-136 POTASSIUM-6.2* (repeat 3.8) CHLORIDE-95* TOTAL CO2-32 ANION GAP-15 ALT(SGPT)-17 AST(SGOT)-59* ALK PHOS-60 TOT BILI-0.4 LIPASE-38 cTropnT-<0.01 - [**2112-11-6**] 10:05AM WBC-5.6 (NEUTS-60.8 LYMPHS-31.7 MONOS-4.4 EOS-2.3 BASOS-0.8) RBC-3.77* HGB-11.0* HCT-32.8* MCV-87 MCH-29.1 MCHC-33.5 RDW-14.4 PLT COUNT-176 - [**2112-11-6**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 RBC-0 WBC-0 BACTERIA-OCC YEAST-NONE EPI-0-2 PRIOR TO DISCHARGE: [**2112-11-25**] 07:40AM BLOOD WBC-8.2 RBC-3.40* Hgb-9.7* Hct-28.9* MCV-85 MCH-28.6 MCHC-33.7 RDW-14.8 Plt Ct-236 [**2112-11-19**] 07:17AM BLOOD Neuts-85.5* Lymphs-7.7* Monos-6.6 Eos-0.1 Baso-0.1 [**2112-11-25**] 07:40AM BLOOD Glucose-93 UreaN-31* Creat-2.7* Na-140 K-3.5 Cl-111* HCO3-20* AnGap-13 [**2112-11-18**] 12:51PM BLOOD LD(LDH)-598* CK(CPK)-376* TotBili-0.3 [**2112-11-25**] 07:40AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.9 [**2112-11-18**] 12:51PM BLOOD calTIBC-295 VitB12-1364* Folate-11.0 Hapto-269* Ferritn-112 TRF-227 [**2112-11-18**] 12:51PM BLOOD TSH-0.24* [**2112-11-18**] 10:18PM BLOOD Type-ART pO2-58* pCO2-41 pH-7.33* calTCO2-23 Base XS--4 UPEP: MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING BASED ON IFE (SEE SEPARATE REPORT), NO MONOCLONAL IMMUNOGLOBULIN SEEN NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN INTERPRETED BY [**Name6 (MD) 761**] [**Name8 (MD) 762**], MD, PHD SPEP: NO SPECIFIC ABNORMALITIES SEEN INTERPRETED BY [**Name6 (MD) 761**] [**Name8 (MD) 762**], MD, PHD CXR [**11-6**]: CHEST, PA AND LATERAL: The lungs are clear, other than mild lingular and retrocardiac atelectasis. A small left pleural effusion persists. The heart is normal in size. The aorta is mildly tortuous. There is no pneumothorax, pneumomediastinum, or pneumoperitoneum. Mild degenerative changes are noted in the thoracic spine. IMPRESSION: No acute cardiopulmonary process. [**2112-11-25**] RENAL ULTRASOUND, BLADDER ULTRASOUND WITH POST VOID RESIDUAL: IMPRESSION: No evidence of hydronephrosis, stone, or mass. Echogenic appearance to the kidneys are suggestive of parenchymal renal disease. Brief Hospital Course: This is a 67 year old woman with a history of hypertension, diastolic heart failure, severe COPD on 3 L home oxygen, pulmonary hypertension, CAD with stent to RCA in [**2110**] and frequent readmissions for chronic "idiopathic pancreatitis" who presented with typical abdominal pain flare. This improved with bowel rest, narcotics, and anti-emetics. After several days of hospitalization, she developed acute fever, delirium and [**Last Name (un) **]. All CNS medications were stopped including Antihistamines, Ultram, and Morphine and her delirium resolved. Her fever also resolved after 5 days of empiric Ciprofloxacin for abnormal UA but negative urine cultures. The etiology of [**Last Name (un) **] was unknown (normal BUN and creatinine increased from 1 to 4.6) but we held diuretics and gave lots of IV fluids despite history of CHF. Kidney function did not recover despite IV fluids, and she developed wheezing, respiratory distress, and CXR showed increased pulmonary edema. She received Lasix 80 IV, BiPAP, and 24 hour admission to the MICU. Her respiratory distress resolved and did not require further Lasix treatment. However, the etiology of [**Last Name (un) **] remains unclear. She had no hydronephrosis on ultrasound and her post void residual was minimal on 2 occasions. She did not receive contrast or nephrotoxins. FENa indicated intrinsic renal problem. Nephrology was hesitant regarding renal biopsy because of obesity. Her creatinine did improve from 4 to 2.7 and upon discharge the patient reached a plateau. [**Last Name (un) **] - Creatinine improved but has plateu'd at 2.7. Her electrolytes are stable. It is very unclear what her [**Name (NI) **] is secondary to, and renal is concerned about an obstructive process, despite a renal u/s being negative (including post void residual via formal bladder ultrasound study) and bladder scan being normal, as her Cr mainly improved when a foley was in place the week prior. We placed a foley put in again as a trial, however, it was removed per the patients wishes. She was set up with early follow up with both renal (Dr. [**Last Name (STitle) 118**] and urology (Dr. [**Last Name (STitle) **] within 1 week of discharge. Pulmonary edema - resolved with diuresis and improving renal function. She was continued on a beta-blocker and nitrate. The dose of her nitrate was increased for optimal blood pressure control, as the lasix was discontinued in the setting of [**Last Name (un) **]. Chronic pain/pancreatitis - She was on tramadol, oxycodone, cymbalta at home. Due to delirium earlier in the course, all meds were discontinued, with improvement in her mental status. Due to persistent pain, she was restarted on a low-dose which she patient tolerated. This was discussed with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. The plan is to continue the low-dose oxycodone, without any scripts upon discharge. She will discuss her pain regimen in more detail with Dr. [**Last Name (STitle) **]. She will follow-up with her gastroenterologist, Dr. [**Last Name (STitle) 174**] after discharge. She needs an MRI with secretin 4 weeks after her symptoms resolve to evaluate a pancreatic head mass. CAD s/p PCI - o active issues. On ASA, BB, nitrate, statin. No ACE-I currently in the setting of [**Last Name (un) **]. COPD - on home 2 L, nebs prn. Stable. Hematuria - 2 episodes the week prior to discharge of gross hematuria withoit change in renal function. Her sediment was reviewed by Renal and was unremarkable. The hematuria resolved. She will needs outpatient evaluation and f/u with PCP and urology. Hematoma - She developed RLQ hematoma [**3-1**] heparin SC. Stable site, Hct stable. Monitoring, hep SC d/c'd. DM, type II - She had just been started on metformin as an outpatient, but this was discontinued in the setting of [**Last Name (un) **]. Due to her renal failure, she was started on 10 units of lantus with optimal control of blood glucose. She was discharged on 10 units of lantus, as oral medications are currently not recommended in the setting of her acute kidney injury. Medications on Admission: Confirmed with patient on admission. Fluticasone-Salmeterol 250-50 [**Hospital1 **] Isosorbide Mononitrate 60 mg daily Lipase-Protease-Amylase 1 pill [**Hospital1 **] Pantoprazole 40 mg daily (due to insurance restrictions) Ranitidine 150 mg daily Tramadol 50 mg TID Sucralfate 1 gram [**Hospital1 **] Aspirin 81 mg daily Calcium Carbonate 500 mg [**Hospital1 **] Cholecalciferol 400 unit daily Oxycodone 5 mg 2 tabs q6hrs prn Ipratropium nebs prn Albuterol nebs prn Furosemide 40 mg [**Hospital1 **] Carvedilol 50 mg [**Hospital1 **] Olmesartan 40 mg daily Rosuvastatin 40 mg daily Duloxetine 60 mg daily Trazodone 100 mg qhs prn insomnia Discharge Medications: 1. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for pain. 6. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 8. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheezing. 10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stools. Disp:*60 Tablet(s)* Refills:*2* 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. Disp:*60 Capsule(s)* Refills:*2* 15. insulin glargine 100 unit/mL Solution Sig: Ten (10) Subcutaneous at bedtime. Disp:*qs bottle* Refills:*2* 16. FreeStyle Lancets Misc Sig: One (1) Miscellaneous once a day: check BG in a.m. prior to breakfast daily. Disp:*30 lancets* Refills:*2* 17. FreeStyle Lite Meter Kit Sig: One (1) glucometer Miscellaneous once a day. Disp:*1 glucometer* Refills:*2* 18. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous once a day. Disp:*30 strips* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Acute on chronic pancreatitis Acute diastolic heart failure with pulmonary edema Acute kidney injury (acute renal failure) Delirium Obesity Severe COPD Pulmonary hypertension Non cardiac chest pain Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a flare of your chronic pancreatitis. This improved with bowel rest. It is important that you continue to eat a restricted diet with no lactose, fat, or fried foods until your pain has completely resolved. As we discussed, you will need to have either Dr. [**Last Name (STitle) 174**] or Dr. [**Doctor Last Name 43476**] reschedule your pancreas MRI 4 weeks after your symptoms have resolved. You also had acute heart failure and you were treated with Lasix. You developed acute renal failure from unclear causes and this has stabilized. You will close follow-up with the nephrologists and urologists to further monitor and evaluate your kidney function. Several medications were changed while you were in the hospital, mainly due to the kidney injury & the delirium/confusion that occured. Please note the following changes: 1. STOP these medications: Cymbalta, Tramadol, Clonzapam, Trazadone Olmesatan (Benicar), Lasix, Metformin 2. START these medications: - Lantus (insulin) 10 units at dinnertime - amlodipine 10 mg daily 3. DOSE CHANGES of current medications: - INCREASE Imdur to 90 mg daily (1.5 tablets daily) - DECREASE Oxycodone to 2.5 mg twice daily (0.5 tablet twice daily) Please eigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: RHEUMATOLOGY When: FRIDAY [**2112-12-30**] at 11:00 AM With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: MONDAY [**2112-11-28**] at 11:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7869**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2112-11-30**] at 1:45 PM With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2112-11-30**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: SURGICAL SPECIALTIES When: FRIDAY [**2112-12-2**] at 10:00 AM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

12701, 12772

5813, 9928

422, 429

13038, 13038

3513, 3513

14526, 16230

2557, 2710

10618, 12678

12793, 13017

9954, 10595

13189, 14265

2725, 3494

368, 384

14286, 14503

457, 1629

3530, 5790

13053, 13165

1651, 2082

2098, 2541

9,912

133,856

26182

Discharge summary

report

Admission Date: [**2153-2-24**] Discharge Date: [**2153-2-27**] Date of Birth: [**2127-8-11**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: mental status change, respiratory distress, cyanosis Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 42 yo unknown PMHx, presents to the ED intoxicated and somnolent. Per the notes, patient was intoxicated and found down. EMS called and patient was responsive and admitted to drinking ETOH. patient was alert and oriented times 3, but had slurred speech. Patient brought to the ED and en route, patient had episode of emesis (yellow and non-bloody). Patient brought to the ED and there was somnolent and ABG (? VBG per ED attending was 7.24/34/30).Patient initially normotensive with SBP 110 and HR 95 with ashy skin and pale conjunctiva. Was intubated for airway protection, then became hypotensive with SBP to 70s. EKG with impressive diffuse STD, cardiolgy consulted and felt EKG changes secondary to metabolic or toxic process. Patient's Tox screen pos forcocaine/methadone/opiates, and methemaglobin level 80. 3 amps bicarb given, and pt got 70mg methylene blue with improvement in skin color. Patient placed on 30mcg of On peripheral Neo for BP support. Patient also given Narcan, Bicarb, Activated Charcoal. Levofloxacin and Clindamycin given for imperic protention for possible aspiration event. Patient given 2 more doses of Methlene Blue for MetHB > 25. Lactate of 13 and patient given NS times 2L. CXR negative for PNA and + for over inflated cuff. Subclavian Line placed and patient sent to the MICU. Past Medical History: Pre-op transexual Social History: Pre-op transexual. Smoker. Denies EtOH. Drank amyl nitrate PTA. Denies other substances, but +opiates, cocaine on admission tox screen. Family History: NC Physical Exam: 98.2 110/70 94 indubated, sedated, perrl, pinpoint supple, no JVD, no LAD RRR, no M CATB- ant-lat +BS, soft, NT, ND no c/c/e Pertinent Results: [**2153-2-24**] 07:42PM FIBRINOGE-241 [**2153-2-24**] 07:42PM PT-13.3* PTT-22.8 INR(PT)-1.2* [**2153-2-24**] 07:42PM PLT COUNT-328 [**2153-2-24**] 07:42PM WBC-23.0* RBC-3.83* HGB-13.2* HCT-38.2* MCV-100* MCH-34.6* MCHC-34.7 RDW-12.7 [**2153-2-24**] 07:42PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-POS [**2153-2-24**] 07:42PM URINE HOURS-RANDOM [**2153-2-24**] 07:42PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2153-2-24**] 07:42PM ALBUMIN-5.2* CALCIUM-9.8 PHOSPHATE-5.3* MAGNESIUM-1.7 [**2153-2-24**] 07:42PM CK-MB-4 cTropnT-<0.01 [**2153-2-24**] 07:42PM LIPASE-21 [**2153-2-24**] 07:42PM ALT(SGPT)-9 AST(SGOT)-35 LD(LDH)-352* CK(CPK)-893* ALK PHOS-128* AMYLASE-65 TOT BILI-0.8 [**2153-2-24**] 07:42PM GLUCOSE-180* UREA N-14 CREAT-1.5* SODIUM-140 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-12* ANION GAP-33* [**2153-2-24**] 07:47PM URINE SPERM-FEW [**2153-2-24**] 07:47PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2153-2-24**] 07:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2153-2-24**] 07:47PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2153-2-24**] 07:53PM GLUCOSE-192* LACTATE-13.2* NA+-144 K+-3.6 CL--96* TCO2-15* [**2153-2-24**] 08:28PM freeCa-1.09* [**2153-2-24**] 08:28PM HGB-11.0* calcHCT-33 O2 SAT-15 CARBOXYHB-2 MET HGB-81* [**2153-2-24**] 08:28PM GLUCOSE-135* LACTATE-12.0* NA+-138 K+-3.7 CL--106 [**2153-2-24**] 08:28PM TYPE-ART RATES-22/16 TIDAL VOL-550 O2-100 PO2-30* PCO2-34* PH-7.24* TOTAL CO2-15* BASE XS--12 AADO2-655 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-ETT [**2153-2-24**] 08:38PM freeCa-1.02* [**2153-2-24**] 08:38PM HGB-11.5* calcHCT-35 O2 SAT-20 CARBOXYHB-0 MET HGB-80* [**2153-2-24**] 08:38PM GLUCOSE-122* LACTATE-13.7* NA+-141 K+-4.1 CL--103 [**2153-2-24**] 08:38PM TYPE-ART RATES-18/16 TIDAL VOL-550 PEEP-5 O2-100 PO2-521* PCO2-36 PH-7.36 TOTAL CO2-21 BASE XS--4 AADO2-162 REQ O2-36 -ASSIST/CON INTUBATED-INTUBATED [**2153-2-24**] 09:52PM freeCa-1.09* [**2153-2-24**] 09:52PM HGB-12.7* calcHCT-38 O2 SAT-43 CARBOXYHB-1 MET HGB-56* [**2153-2-24**] 09:52PM GLUCOSE-124* LACTATE-8.9* NA+-142 K+-4.2 CL--104 [**2153-2-24**] 09:52PM TYPE-ART RATES-/16 TIDAL VOL-600 PEEP-10 O2-100 PO2-126* PCO2-47* PH-7.26* TOTAL CO2-22 BASE XS--5 AADO2-546 REQ O2-90 -ASSIST/CON INTUBATED-INTUBATED [**2153-2-24**] 11:10PM PLT COUNT-173 [**2153-2-24**] 11:10PM WBC-18.0* RBC-3.26* HGB-11.5* HCT-30.4* MCV-93# MCH-35.4* MCHC-37.9* RDW-12.8 [**2153-2-24**] 11:10PM CORTISOL-15.6 [**2153-2-24**] 11:10PM ALBUMIN-3.1* CALCIUM-7.4* PHOSPHATE-3.1# MAGNESIUM-1.4* [**2153-2-24**] 11:10PM ALT(SGPT)-13 AST(SGOT)-64* LD(LDH)-287* ALK PHOS-95 TOT BILI-1.1 [**2153-2-24**] 11:10PM GLUCOSE-103 UREA N-14 CREAT-1.0 SODIUM-135 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-21* ANION GAP-20 [**2153-2-24**] 11:39PM freeCa-1.08* [**2153-2-24**] 11:39PM O2 SAT-69 MET HGB-30* [**2153-2-24**] 11:39PM LACTATE-1.3 [**2153-2-24**] 11:39PM TYPE-ART TEMP-36.8 RATES-20/ TIDAL VOL-500 PEEP-10 O2-100 PO2-558* PCO2-31* PH-7.51* TOTAL CO2-26 BASE XS-2 AADO2-130 REQ O2-32 -ASSIST/CON INTUBATED-INTUBATED --------- Methemoglobin on admission:80; last check: 1 --------- [**2-25**] CXR: The heart is upper limits of normal in size. There has been rapid development of a bilateral relatively symmetric alveolar pattern within the perihilar and basilar regions, slightly worse on the left than the right. Note is also made of underlying septal lines. Given the rapid development, and relatively symmetric distribution, pulmonary edema from fluid overload is considered most likely, although aspiration is also possible. . [**2-24**] EKG: Sinus tachycardia. Incomplete right bundle-branch block. Possible right ventricular hypertrophy with secondary ST-T wave changes. Diffuse ST segment depression suggestive of myocardial injury/ischemia. Clinical correlation is suggested. No previous tracing available for comparison . [**2-26**] EKG: Sinus rhythm Nonspecific ST-T wave changes Since previous tracing, diffuse ST-T wave changes are markedly improved Brief Hospital Course: 42 yo pre-op M->F transexual with unknown PMHx presented to the ED with MS changes and noted to have Met Hb of 80 and tox screen + for opiates and cocaine, as well as diffuse ST depressions, elevated lactate, and mild ARF. . Regarding MetHb: After pt extubated, pt gave history of have imbibed an unknown substance s/he was supposed to have inhaled instead (likely amyl nitrate). Pt denies exposure to topical anestetics or dapsone. Denies h/o G6PD. Pt was given Methylene blue (1mg/kg) x 4 doses as directed by q4-6h MetHB levels > 25. After fourth dose, pt's color had markedly improved and level was 5. Oxygenation, by ABG cooximetry, improved steadily, and pt was extubated on HD#2. Oxygenation dipped later that evening, with a CXR c/w fluid overload (I/O +7L), but improved rapidly to diuresis. G-6PD assay pending at discharge. . Regarding lateral EKG changes, elevated troponin, CK: Given profound hypoxemia, EKG changes not likely due to inherent CAD, though localized finding to later leads is somewhat concening. Echo essentially normal with good EF. Pt may need stress as outpt. . Regarding hypotension: Initial hypotension in ED in setting of intubation. Pt was hydrated with LR and started on Neo, which was easily weaned. . Regarding ID concerns: Pt presented with a leukocytosis likely secondary to stress response. However, given emesis in ED, patient initially given dose of Levo and CLinda. ABX not continued on the floor. However, pt developed low grade fever on HD#2 and blood and urine cx were sent (pending at discharge). UA was negative. Pt was afebrile for 24hr PTD. Pt instructed to have PCP f/u on cultures. . Regarding lactic acidosis: Lactate of 15 on admission, likely secondary to poor tissue oxydenation. Lactate level dropped precipitously with correction of methemoglobinemia. . Regarding ARF: Was likely prerenal and improved with hydration. . Regarding anemia: HCT aroun 30-31 throughout stay. This will need to be worked up as outpatient. . Regarding elevated tbili: On day of discharge, tbili was elevated. This will need to be followed as outpatient. . Regarding substance abuse: Pt counseled to quit smoking as well as abstain from illicit substances. Medications on Admission: None. Discharge Medications: None. Discharge Disposition: Home Discharge Diagnosis: 1) Methemoglobinemia 2) Polysubstance intoxication 3) Anemia Discharge Condition: Good. Discharge Instructions: Please schedule and attend all followup appointments. Please seek medical attention for any fever, nausea, weakness, dizziness, chest pain, difficulty breathing, or with other concerns. Followup Instructions: Please call your primary care physician to schedule an appointment for within the next week. You should explain to your PCP that you were admitted to the hospital for methemoglobinemia and that he/she should followup on your blood cultures and also should monitor/evaluate your anemia and elevate bilirubin. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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26789

Discharge summary

report

Admission Date: [**2113-9-29**] Discharge Date: [**2113-10-13**] Date of Birth: [**2048-10-3**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: syncope Major Surgical or Invasive Procedure: defibrillator placement History of Present Illness: Ms. [**Known lastname 53899**] is a 64 year old female with CAD, depression, CHF, and chronic pain who presented to [**Hospital3 4107**] today after syncope x 2. Patient reports that her legs "gave out" while she was in the kitchen last night and that she hit her head on the kitchen counter but did not remember wheter she had LOC. She elected to not seek medical attention last night but did have slight bleeding and pain at her left occiput where she hit her head. This morning she drove her husband to work, then stopped at a coffee shop. She described feeling light headed and nauseous and subsequently lost consciousness in the car while it was parked. EMS was called by passerbys and the patient was taken to OSH ED ambulance . Initial vital signs at OSH ED were 97.9 77 123/70 18 98% on RA. Repeat vital signs at OSH ED revelaed BP as low as 94/53 with HR of 72 for which she received 2L of NS IV. Serum toxicology screen and ammonia levels were negative. CT head and neck imaging were reassuring and her head laceration was stapled. Following admission to [**Hospital3 4107**], the decision was made to transfer her to [**Hospital1 18**] for consideration of ICD placement. . On arrival to the floor, the patient is comfortable and without additional complaints. . REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: CAD with NSTEMI [**2108**], STEMI [**9-/2112**] -PCI: BMS to LAD -Ischemic cardiomyopathy with LVEF of 20-25% on OSH TTE [**4-/2113**] 3. OTHER PAST MEDICAL HISTORY: COPD GERD Migraine headaches Osteroarthritis Chronic lower back pain Depression Social History: Patient is married, lives with husband. Family stress due to death of her son from heroin overdose. Also has daughter w/ current substance abuse problems. [**Name (NI) **] a 60 pack year history and currently smokes about one pack per day, but has plans to quit. . Family History: Mother had CHF, died from [**Name (NI) 11964**] at age 80. Father died from lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.2 70 105/52 18 95% on RA General: Alert, oriented, no acute distress HEENT: 4 cm laceration with 5 staples on left occiput. Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Soft heart sounds, regular rate and rhythm, normal S1 + S2, [**2-12**] holosystolic murmur best heard over mitral area. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: [**2113-9-30**] 03:23AM BLOOD WBC-7.0 RBC-3.93* Hgb-13.1 Hct-39.2 MCV-100* MCH-33.3* MCHC-33.4 RDW-14.6 Plt Ct-240 [**2113-9-30**] 03:23AM BLOOD Neuts-77.0* Lymphs-15.5* Monos-3.0 Eos-4.1* Baso-0.4 [**2113-9-30**] 03:23AM BLOOD PT-11.0 PTT-31.5 INR(PT)-0.9 [**2113-9-30**] 03:23AM BLOOD Plt Ct-240 [**2113-9-30**] 03:23AM BLOOD Glucose-75 UreaN-11 Creat-0.5 Na-141 K-3.4 Cl-109* HCO3-21* AnGap-14 [**2113-9-30**] 03:23AM BLOOD ALT-14 AST-21 CK(CPK)-78 AlkPhos-59 TotBili-0.4 [**2113-9-30**] 03:23AM BLOOD CK-MB-4 cTropnT-<0.01 [**2113-9-30**] 06:02AM BLOOD CK-MB-4 cTropnT-<0.01 [**2113-9-30**] 03:23AM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.4* Mg-2.1 [**2113-9-30**] 03:23AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG DISCHARGE LABS [**2113-10-13**] 05:43AM BLOOD WBC-11.5* RBC-4.05* Hgb-13.4 Hct-40.5 MCV-100* MCH-33.2* MCHC-33.2 RDW-15.1 Plt Ct-481* [**2113-10-13**] 05:43AM BLOOD PT-13.1 PTT-91.4* INR(PT)-1.1 [**2113-10-13**] 05:43AM BLOOD Glucose-131* UreaN-10 Creat-0.4 Na-138 K-3.8 Cl-98 HCO3-30 AnGap-14 [**2113-10-13**] 05:43AM BLOOD ALT-354* AST-232* AlkPhos-154* TotBili-0.7 [**2113-10-13**] 05:43AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.9 Mg-2.4 [**2113-10-7**] 12:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2113-10-7**] 12:30PM BLOOD HCV Ab-NEGATIVE [**2113-10-12**] 04:33AM BLOOD Type-ART Temp-36.4 Rates-/27 Tidal V-500 PEEP-5 FiO2-40 pO2-110* pCO2-44 pH-7.50* calTCO2-36* Base XS-10 Intubat-INTUBATED Vent-SPONTANEOU [**2113-10-8**] 06:39AM BLOOD Lactate-1.3 [**2113-10-12**] 04:33AM BLOOD freeCa-1.12 PERTINENT STUDIES ECHOCARDIOGRAM [**2113-9-30**] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction with mid to distal septal, anterior and apical akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CT chest/abd/pelvis: [**2113-10-8**] IMPRESSION: 1. Multiple bilateral pulmonary emboli. Evidence of pulmonary arterial hypertension and concern for right ventricular strain. 2. Small residual right pneumothorax with chest tube in place. 3. More consolidative changes in the right lower lobe. Early developing pneumonia is not excluded. 4. Enlarged liver with mottled enhancement pattern and periportal edema suggestive of congestive hepatopathy. Perihepatic and pelvic ascites. 5. Splenic infarct. 6. Generalized anasarca. . LENI [**2113-10-9**]: IMPRESSION: 1. Occlusive thrombus within the left profunda femoris vein which extends into the common femoral vein where there is partial, non-occlusive thrombus. 2. No right lower extremity DVT. . CXR [**2113-10-12**]: IMPRESSION: 1. Further withdrawal of the endotracheal tube, clinical correlation is recommended. 2. Improvement of right basilar atelectasis and left basilar pleural effusion, atelectasis, and consolidation. 3. Stable right apical pneumothorax. . RUQ US: [**2113-10-6**]: IMPRESSION: 1. No evidence for cholecystitis. 2. Thickened gallbladder wall, bilateral pleural effusions, trace perihepatic ascites, hepatomegaly and dilated hepatic veins/IVC compatible with fluid overload and congestive failure, with the patient's pain perhaps relating to congestive hepatopathy. . RUQ US: [**2113-10-13**]: Preliminary read: No cholecystitis, CBD not dilated, gall bladder edema present but improved in comparison to prior. . Microbiology: [**2113-10-1**] sputum culture: STREPTOCOCCUS PNEUMONIAE - sensitive to penicillin [**2113-10-5**] and [**2113-10-6**] Cdiff: negative [**2113-10-8**] urine culture: YEAST 10,000-100,000 ORGANISMS/ML. [**2113-10-1**], [**2113-10-3**], [**2113-10-5**], [**2113-10-6**], [**2113-10-7**], [**2113-10-8**], [**2113-10-9**] blood cultures: no growth to date [**2113-10-7**] EBV IGG positive and IGM negative [**2113-10-7**] CMV IGG negative and IGM negative Brief Hospital Course: 64 year old woman with CAD, COPD, chronic systolic heart failure with EF 20-25%, depression and chronic pain who was transferred from an outside hospital with recurrent syncope and need for ICD placement. . ACUTE CARE: # Shock: On admission to the CCU, pt was hypotensive to the 80s systolic and was given norepinephrine and phenylephrine as well as 4L NS to maintain MAPs above 60. Her hemodynamics were consistent with a mixed picture of cardiogenic and septic shock. An IABP was placed on [**10-1**] for pressure support, then removed on [**10-3**]. The patient was also supported with pressors, norepinephrine and phenylephrine, from [**10-1**] until [**10-4**]. She was empirically treated for a pulmonary embolism with a heparin drip, although this was initially discontinued after CT-A was negative and she developed melena. Pt was treated with ceftriaxone for a Streptococcus pneumoniae pneumonia, however because she remained febrile and unstable, was re-broadened to vanc/cefepime. She was extubated on [**10-5**], but remained delerious. On [**10-6**], she had tachypnea to RR 40-50's, and was re-intubated. Because her cardiac issues had become secondary to medical ones, she was transferred to the MICU. In the MICU, she was given continued on cefepime for 7 days ([**10-6**] to [**10-13**]) to treat S.pneumonia (sensitive to penicillin). She received a CT torso which showed new bilateral pulmonary emboli, RLL consolidation, splenic infarct, and signs of congestive hepatopathy. Lower extremity dopplers showed left femoral deep venous thrombosis. She was started on heparin drip and transitioned to lovenox on [**2113-10-13**]. Echocardiogram showed depressed LVEF 25-30% with worsening severe mitral regurgitation. She temporarily required pressors for blood pressure support while in the MICU. She was aggressively diuresed with a lasix drip (10+ liters of fluid were removed) and was successfully extubated on [**2113-10-12**]. On day of discharge she is still 5.9L positive for length of stay and thus will continue on lasix drip upon discharge to LTAC. . # Respiratory Failure: Patient was coded on the floor on [**10-1**] for respiratory distress and hypoxemia requiring intubation. Respiratory failure was initially thought to be secondary to pulmonary edema; however chest x-ray was more consistent with lobar pneumonia. She was eventually extubated on [**10-5**], but extubation was complicated by agitation. The patient responded well to haloperidol for agitation but developed long QTc so this was discontinued. On [**10-6**], she had tachypnea to RR40-50's, PaO2 72, but work of breathing too much and was thus re-intubated and transferred to MICU service. Please see above for MICU events. We think failure of intubation initially was multifactorial, but likely due to persistent pneumonia, new pulmonary embolism and most importantly, significant pulmonary edema due to mitral regurgitation. With diuresis, her respiratory status and MR have appeared to improve dramatically. We anticipate even further improvement with continued diuresis and management of her COPD. . # Systolic congestive heart failure: Patient has known severe systolic dysfunction with most recent LVEF of 20-25% from OSH TTE in [**Month (only) 216**]. Her EF on echocardiogram done here was 30%. Given STEMI > 30 days ago (in [**2112**]) and LVEF < 30% patient meets MADIT2 criteria for ICD placement, however ICD placement was postponed until medical stability was achieved and code status code be discussed. She is DNR, ok to intubate, therefore ICD placement does not coincide with her current wishes. She is currently on lasix drip, and lisinopril was started on [**2113-10-13**] for afterload reduction. She will likely need to have lisinopril uptitrated and a beta blocker started. Spironolactone is indicated and should be started once the lasix drip stops as long as her blood pressure tolerates. Statin was held due to elevated LFTs, but once liver function tests normalize, she should be re-started on statin. Aspirin and plavix were continued. . # Syncope: Patient has a complicated PMH with several possible causes for her syncopal episode including arrhythmia from known ischemic disease, iatrogenic hypotension in the setting of severe systolic dysfunction with unknown complaince/dosing of home antihypertensive medications and overuse of sedating medications including percocet and gabapentin. Additionally, discontinuation of Provigil may have also contributed to her syncopal event. ACS is less likely given the absence of her angial equivalent chest pain, EKG changes or cardiac enzyme abnormalities. It is unclear what causd her syncope. Cyclobenzaprine was held and decreased her gabapentin to 400mg [**Hospital1 **] dosing. Provigil was started. The patient was not orthostatic. As primary arrhythmia could not be ruled out as initial cause of syncope, patient will need to have an ICD placed for secondary prevention. This is scheduled for 8am on [**2113-10-17**]. Patient needs to monitored on telemetry at all times until ICD placed. Lovenox should be held the morning of device placement . # Elevated LFTs: Seen by hepatology and consensus was that she has congestive hepatopathy. RUQ US on [**10-6**] was consistent with congestive hepatopathy and did not show evidence of biliary infection or dilitation. LFTs did not trend down as expected with diuresis, therefore RUQ US was repeated on [**10-13**] which showed interval improvement in gall bladder edema and confirmed lack of presence of cholecystitis or CBD dilitation. We recommend repeating LFTs in [**1-8**] weeks when she follows up with her primary care physician. . # Chronic pain: Patient has known chronic pain with low back pain and arthritis managed with percocet and gabapentin. Overuse of these medications may have contributed to her syncopal event. Of note gabapentin was recently increased from 400mg [**Hospital1 **] to 800mg TID. OSH documentation suggest that percocet was discontinued [**2-8**] to hypotension. During her admission, gabapentin was continued at 400mg [**Hospital1 **] dosing. Opiates were discontinued. . # Depression: Patient has a history of depression with suicide attempts. Mood appears stable on admission. Continued her home buproprion, fluoxitine, topamax. Held quetiapine due to mental status not quite back to baseline prior to admission (suspect altered mental status likely due to prolongued affect of sedation used during intubation). . # GERD: developed melena when on heparin drip initially. She was started on IV PPI and transitioned to oral PPI. . # COPD: appears stable from this standpoint. . CODE: FULL CODE EMERGENCY CONTACT: [**Name (NI) 4906**] [**Name (NI) 65961**] [**Name (NI) 65962**] ([**Telephone/Fax (1) 65963**]) . Summary of transition of care issues: - ICD placement scheduled for [**2113-10-17**] at 8am, lovenox should be held the morning of procedure - monitor patient on telemetry until ICD placement - pulmonology follow up for treatment of COPD, will likely need to PFTs - start beta blocker for goal HR 60-70 if blood pressure tolerates - uptitrate lisinopril if blood pressure tolerates - start statin if LFTs normalize - repeat Echocardiogram in 2 weeks - consider starting spironolactone if EF remains <40% on repeat echocardiogram - monitoring of LFTs, if remains elevated will likely need referral to hepatology for further work up - wean lasix drip to lasix boluses once another 3-4L negative - needs PCP follow up to address chronic pain - PCP discussion of ICD placement in future Medications on Admission: Patient was unable to fully reconcile current medication list: xBupropion HCl 100 mg [**Hospital1 **] xSimvastatin 80 mg daily xAspirin 325 mg daily xxxGabapentin 800 mg TID xClopidogrel 75 mg daily xQuetiapine 25-50mg QHS xRanitidine HCl 150 mg [**Hospital1 **] xFluoxetine 60 mg daily xTopamax 100 mg [**Hospital1 **] xMultivitamin daily xFolic acid 1mg daily xThiamine 100mg daily xAllegra . Modafinil 100 mg [**Hospital1 **] (? not taking [**2-8**] to cost) Cyclobenzaprine 10 mg TID:PRN pain (? not taking [**2-8**] to dizziness) Percocet 5-325 mg Q4H:PRN pain (? not taking [**2-8**] to hypotension) Metoprolol XL 12.5 mg (? not taking [**2-8**] to hypotension) Furosemide 20 mg daily (? not taking) Hydrochlorothizide 25 mg daily (? not taking) Discharge Medications: 1. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: do not exceed 2g per 24 hours. 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 14. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 15. enoxaparin 100 mg/mL Syringe Sig: Seventy Five (75) mg Subcutaneous once a day. 16. fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. 17. furosemide 10 mg/mL Solution Sig: 10mg/hr Injection continuous infusion. 18. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: primary: chronic systolic heart failure coronary artery disease chronic obstructive pulmonary disease hypertension secondary: hyperlipidemia gastroesophageal reflux disease migraines chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 53899**], You were admitted after being found unconscious in your parked car. It is unclear what caused you to lose consciousness, but it may have been related to your heart. You underwent placement of an ICD (a defibrillator). You were intubated during which time you received antibiotics and medications to decrease the fluid in your lungs. You have significant heart valve disease (mitral regurgitation) and will need to follow up with cardiology upon leaving the hospital. You also developed a clot in your leg and lung for which you are now on medications to prevent future clots. You will also need to have an ICD implanted in case a heart arrhythmia caused you to lose consciousness. You will have this device placed on Tuesday [**2113-10-17**] at 8am. You should hold your dose of lovenox prior to the procedure. Please note the following changes to your medications: - START Lisinopril - START Pantoprazole - START Acetaminophen as needed for pain - START albuterol and ipratropium as needed for shortness of breath - START Enoxaparin - START fluconazole for 3 days - DECREASE gabapentin to 400mg twice daily - STOP ranitidine - STOP seroquel Please be sure to follow up with your physicians. Please stop smoking. If you need assistance with quitting, please talk to your primary care doctor to discuss strategies. Please weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs. Followup Instructions: Please make an appointment to see your Primary care doctor within one week after leaving the rehabilitation facility. You have an appointment to have an ICD placed on [**2113-10-13**] at 8am. Department: EP When: TUESDAY [**2113-10-13**] at 8am Where: [**Hospital Ward Name **] 4, electrophysiology lab Phone: ([**Telephone/Fax (1) 8793**] Please HOLD your lovenox the morning of the procedure Department: MEDICAL SPECIALTIES/PULMONARY When: THURSDAY [**2113-10-26**] at 1 PM (12:30 ARRIVAL) With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *Please arrive by 12:30 for breathing tests. Department: CARDIAC SERVICES When: FRIDAY [**2113-10-27**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2113-10-14**]

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icd9cm

[ [ [] ] ]

[ "34.04", "37.61", "88.56", "96.6", "37.21", "96.72", "96.71" ]

icd9pcs

[ [ [] ] ]

18087, 18153

8148, 15727

320, 346

18393, 18393

3639, 3639

20024, 21265

2840, 2931

16530, 18064

18174, 18372

15753, 16507

18544, 19426

2971, 3593

2292, 2427

19455, 20001

273, 282

374, 2198

3656, 8125

18408, 18520

2458, 2539

2220, 2272

2555, 2824

3620, 3620

77,443

114,480

19791

Discharge summary

report

Admission Date: [**2158-8-8**] Discharge Date: [**2158-9-5**] Date of Birth: [**2128-3-22**] Sex: F Service: MEDICINE Allergies: Penicillins / Haldol / Compazine / Desipramine / Chlorpromazine / Imipramine / Zoloft / Shellfish Derived Attending:[**First Name3 (LF) 5893**] Chief Complaint: transfered to [**Hospital1 18**] for Chest pain. Transfered to [**Hospital Unit Name 153**] for: unresponsiveness/respiratory failure Major Surgical or Invasive Procedure: endotracheal intubation central line arterial line History of Present Illness: 30 yo female morbid obesity past history of DVTs and PEs s/p IVC filter placement 2 years ago who was transferred to [**Hospital1 18**] ED for PE. Initially went to [**Hospital 26380**] hospital on Thursday and had bilateral DVTs + PEs (lower ext swelling) and was placed on heparin + coumadin. After discharge, she returned to OSH with horrible CP 2 days ago and also had leg pain. She was found to have a worsening PE w/ increased clot burden despite being supratherapeutic, with INR of 4.8, and filter placement. Repeat CT at [**Hospital1 18**] ED -> small subsegmental right lower lobe with no evidence of infarct; LENIs were not repeated. Patient reports that she has had 2 days of sharp throbbing chest pain that is worse upon respiration and radiates to lower L chest, similar to pain she had with previous PEs. Also has had 3-4 days of BL leg pain and numbness along with 'sores' on lower legs. Has difficulty moving legs, but unsure if due to pain or weakness. Has been at [**Hospital **] Rehab since discharge from [**Hospital 27217**] Hospital and reports being certain that she has been taking coumadin daily. . Also has had 4 days indwelling catheter -> dark + bloody urine; as per pt was being treated for UTI with ceftin Past Medical History: 1. Borderline personality disorder 2. Mood Disorder, NOS 3. History of self-mutilation 4. History of DVT/PE 5. Obesity hypoventilation vs. sleep apnea 6. Asthma 7. Urinary Incontinence 8. History of hypercarbic respiratory failure 9. Obesity 10. History of suicidal ideation with multiple past attempts 11. History of MRSA cellulitis 12. History of Pneumonia 13. History of Bacteremia Social History: After recent admission for PE at [**Hospital 27217**] hospital, has been at [**Hospital **] Rehab center in [**Location (un) **]. Pt reports having no family or contacts. Denies cigarette or recreational drug use. Previous social alcohol use but has not had drink for several months. Has history of psychogenic hyporesonsiveness episodes requiring intubation. Family History: Parents deceased; otherwise noncontributory. Physical Exam: 98.9 100/65 108 18 98%on 3L Gen: alert, cooperative, morbidly obese, in NAD. Pulm: anterior exam, ctab w/o coarse breath sounds. Cor: tachycardic, RR, nl S1S2 Abd: obese, protuberant, nontender. Extrem: multiple pink tender blisters on anterior lower legs 1cm. 1+ DP and 2+ radial pulses. Acyanotic extremities. Neuro: LE perception to light touch intact. Strength appears to be limited by pain. Pertinent Results: [**2158-8-12**] 3:39 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [**2158-8-14**]** GRAM STAIN (Final [**2158-8-12**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2158-8-14**]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 53485**] FROM [**2158-8-10**]. [**2158-8-11**] 12:10 am BLOOD CULTURE Source: Line-central line. **FINAL REPORT [**2158-8-17**]** Blood Culture, Routine (Final [**2158-8-17**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON REQUEST.. Brief Hospital Course: FLOOR COURSE: Ms. [**Known lastname **] was admitted with complaint of chest pain found to have right subsegmental PE and supratherapeutic INR. Patient has been maintained on room air while INR corrected in setting of warfarin being held. Two days after admission, patient was found incontinant of stool face down in her bed, unresponsive. Vitals at that time were afebrile, SBP 120-130's, HR 110's, RR 12-18, SpO2 100% RA, she had a pulse and did not appear to have respiratory difficulty. She was not responsive to verbal or tactile stimuli. Fingerstick was slightly elevated blood glucose. Patient recieved small amount of narcotic, Narcan given and she remained non-responsive. Also noted, patient had flickering of eyelids, concerning for seizure. She recieved 5mg ativan with no significant improvement. Due to concern for possible ICH and inability to protect airway, patient was transferred to [**Hospital Ward Name 332**] ICU for emergent intubation with plan for CT Head. Of note, patient was vomitting [**3-14**] to ambu bag. ICU course: #Unresponsiveness: Upon further investigation of Ms. [**Known lastname **] chart, it appears that she has a history of psychogenic hyporesponsivenss requiring multiple intubations in the past. Head CT returned negative and neuro team did not feel that this episode was a seizure. Psych was consulted and said there was nothing to do while patient was intubated. #Respiratory Failure: During the code, patient was found to have vomited resulting in an aspiration pneumonia. She was intubated and vented and treated with empiric antibiotics. Sputum and blood cultures grew staph aureus and she was continued on Vancomycin and Meropenem, [**Last Name (un) **] changed to Linezolid on Day 8 due to known MRSA in her sputum. On ICU Day 9, her left lower lobe asp PNA seems to have cleared, but patient developed a new right middle lobe infiltrate. She continued to have persistent infiltrate on CXR L > R and ID was consulted. They recommended continuing vancomycin therapy for MRSA and also obtaining input from interventional pulmonology to evaluate for possible empyema. IP did not feel there was an obvious complicated effusion present. The patient was continued on the ventilator and antibiotics. She had persistent hypoxic respiratory failure requiring increasing levels of PEEP and 100% FiO2. She was transitioned to APRV when unable to oxygenate on volume cycle ventilation. Eventually she was placed back on ACV, but required 100% FIO2 and high PEEP levels (20's). She desaturated with any re-positioning adn we were unable to wean from the ventilator.. #Septic shock: Found to have staph aureus in the blood. She was hypotensive requiring pressors. By ICU Day 10, patient is still dependent on pressors. She continues to spike fevers despite broad spectrum antibiotic coverage. Blood culture from [**8-19**] grew coag (-) staph in 1 of 2 sets; patient maintained on vancomycin. An IJ tip grew yeast and the patient was started on fluconazole per ID. A urine culture grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and the patient was treated with micafungin. The patient remained on pressor support. The patient remained persistently febrile during her hospital course. Infectious disease followed the patient each day. She had documented infections including [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] in urine, pseudomonas/klebsiella in sinuses, pseudomonas in sputum as well as urine, and MRSA in lungs. Unfortunately, due to the patient's body habitus, we were unable to evaluate her for abscess with CT and had to rely on U/S, which did not show an obvious abscess or loculated fluid. #Bipolar: patient was continued on all psych meds as well as her antidepressants until she began having high OG residuals and she was not able to tolerate PO meds. #Diabetes: given ISS, glargine, and closely monitored glucose levels. She had an increasing insulin requirement during her ICU course. #Guardianship: [**Name2 (NI) **] not found to have a guardian or proxy. Group home, Vinfen Corp, was contact[**Name (NI) **] and they reported that there was no oone appropriate to provide guardianship. Legal services at [**Hospital1 18**] is currently pursuing legal guardianship. Eventually, a guardian was assigned who determined that the patient's prognosis was extremely poor. Her code status was changed to comfort measures only. Medications on Admission: OxycoDONE (Immediate Release) 5 mg PO/NG Q3H:PRN pain Gabapentin 300 mg PO/NG Q8H Acetaminophen 325-650 mg PO/NG Q6H:PRN fever>101 Ciprofloxacin HCl 500 mg PO/NG Q12H Warfarin 5 mg PO/NG DAILY16 Insulin SC (per Insulin Flowsheet) Vitamin D [**2148**] UNIT PO/NG DAILY Omeprazole 40 mg PO DAILY Fluoxetine 40 mg PO/NG DAILY bipolar depression Divalproex (EXTended Release) [**2148**] mg PO Divalproex (DELayed Release) 500 mg PO DAILY Aripiprazole 30 mg PO/NG HS Amantadine 100 mg PO/NG [**Hospital1 **] Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Pulmonary embolus Psychogenic hyporesponsiveness Aspiration pneumonia Septic Shock Respiratory Failure Discharge Condition: patient died in ICU after code status changed to comfort measures only

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icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "38.91", "33.24", "38.93", "96.04", "00.14" ]

icd9pcs

[ [ [] ] ]

9291, 9300

4104, 8546

498, 550

9447, 9520

3096, 4081

2618, 2664

9263, 9268

9321, 9426

8572, 9240

2679, 3077

325, 460

578, 1816

1838, 2225

2241, 2602

8,554

189,588

615

Discharge summary

report

Admission Date: [**2152-3-23**] Discharge Date: [**2152-3-25**] Date of Birth: [**2079-4-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is 72 year Spanish speaking male with PMHx of Parkinson's Disease who presents to the ED for complaints of shortness of breath. Per patient daughter he was at his baseline health until night prior to admission when patient described shortness of breath and sensation that his airways were blocked. Patient was seen at [**Hospital1 112**] a few weeks ago for similar symptoms. Per daughter etiology of shortness of breath was not identified and thought breathing difficulty could be due to anxiety. Patient denies any chest pain or diaphoresis and is symptoms do not seem to coorelate with any medications. He has noticed no change in his speech or any trouble with swallowing or eating and drinking foods. During this episode of shortness of breath at home patient seemed anxious and paramedics were called. While they were present, he had brief unresponsiveness and was found to be in atrial fibrillation. A nasal trumpet was placed with return of responsiveness and of sinus rhythm. He was brought to [**Hospital1 18**]. On arrival to ICU patient comfortable denies any shortness of breath. He has a nasal trumpet in place. His O2Sat remains above 90% on room air but appears to drop when patient falls asleep. Patient denies any swelling of his throat or airway, he just feels congested in his nasal passages. . ROS: Patient denies any CP, HA, n/v, fevers, chills, cough, abdominal pain. Patient is urinating normally and besides constipation has normal bowel movements. His Parkinson's has gotten worse over the last year but no acute worsening over the past few months. Past Medical History: Parkinson's disease, diagnosed at age 66, followed by Dr. [**Last Name (STitle) 4742**] at [**Hospital1 2025**] PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4743**] at [**Hospital1 112**] Social History: Lives with wife and sister-in-law, who have been limiting his activities more recently, though he did go out of the house once last week by himself. Able to do laundry, for example, b/c did it last week but not allowed by his wife (per daughter). No tobacco, EtOH, drug use. Family History: noncontributory Physical Exam: T 98.1 BP 127/74 HR 77 O2Sat 93%-94% on RA Gen: NAD Heent: PERRL, EOMI, OP clear no pharyngeal swelling, nasal trumpet in place, MM dry. Neck: supple, no LAD Lungs: CTA B/L Cardiac: RRR S1/S2 no murmurs Abd: soft NTND NABS Ext: FROM, no edema Neuro: AAOx3, patient with resting tremors of UE and LE b/l, normal reflexes, sensory grossly intact Pertinent Results: [**2152-3-23**] BLOOD WBC-12.1* RBC-4.53* Hgb-14.1 Hct-40.9 MCV-90 MCH-31.0 MCHC-34.4 RDW-13.7 Plt Ct-258 [**2152-3-23**] BLOOD Neuts-86.4* Bands-0 Lymphs-9.7* Monos-3.1 Eos-0.6 Baso-0.2 [**2152-3-23**] BLOOD PT-12.1 PTT-24.7 INR(PT)-1.0 [**2152-3-23**] BLOOD Glucose-130* UreaN-12 Creat-0.9 Na-136 K-4.0 Cl-97 HCO3-25 AnGap-18 [**2152-3-23**] BLOOD CK(CPK)-103 [**2152-3-23**] BLOOD cTropnT-<0.01 [**2152-3-23**] BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2152-3-24**] BLOOD WBC-7.9 RBC-4.77 Hgb-14.6 Hct-42.4 MCV-89 MCH-30.7 MCHC-34.5 RDW-13.8 Plt Ct-274 [**2152-3-24**] BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-138 K-4.3 Cl-101 HCO3-30 AnGap-11 [**2152-3-24**] BLOOD Calcium-9.1 Phos-4.1# Mg-2.4 Imaging: CT neck ([**3-23**]): No soft tissue neck mass. Patent upper airway. Calcified granuloma in the lung. CT head ([**3-23**]): No acute intracranial hemorrhage. No mass effect. Neck soft tissues ([**3-23**]): There is no comparison. Upper airway is visualized, with a nasal airway tube terminating above the hyoid bone. There is no significant soft tissue swelling. There is no abnormal soft tissue calcification. CXR ([**3-23**]): Mild cardiomegaly. Left pleural effusion and bibasilar atelectasis. Brief Hospital Course: Mr. [**Known lastname **] is a 72 y/o male with h/o Parkinson's disease who presents from home with shortness of breath, now resolved. . ## Shortness of Breath: The patient was admitted and had one recurrent episode on his first night of admission which unimproved by Parkinson's meds. We hypothesized that his underlying Parkinson's disease may be contributing to these episodes. The episode was relieved by a small dose of Ativan; there appeared to be a large component of anxiety to the episodes, but that is unlikely to be the sole cause, as he does have objectively unusual breathing. He was evaluated by Neurology during his admission who recommended continuing his medical regimen for Parkinson's. - The patient will follow up in Pulmonary Clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. PFTs are planned as an outpatient. - The patient reportedly had an episode of atrial fibrillation per EMS; however, this did no recur while hospitalized. - The patient was discharged with clonazepam to use as needed during these episodes as this seemed to give relief. - He will have an outpatient sleep study as well to evaluate for sleep apnea. . ## Parkinson's Diease. The patient was continued on his usual medication regimen. . ## Cardiac. Patient with reported atrial fibrillation per EMS but none seen while in-house. It is doubtful that this was true a fib; it is more likely he had MAT secondary to respiratory distress. - PCP could consider outpatient holter monitor if deemed necessary. . ## PPx: The patient was given a bowel regimen, tylenol as needed, an H2 blocker, and heparin SC. . ## FEN: He tolerated a regular diet. . ## Comm: Daughter: [**First Name8 (NamePattern2) 1457**] [**Name (NI) **] [**Telephone/Fax (1) 4744**] . ## Dispo: As the patient was stable hemodynamically without further evidence of respiratory distress, he was discharged to home from the MICU. Medications on Admission: sinemet 25/100mg tid (7am, 11am, 5pm) sinemet 50/200mg qid (7am, 11am, 5pm, 10pm) klonopin 0.25mg daily (7pm) seroquel 0.25mg [**Hospital1 **] (11am, 10pm) citalopram 20mg daily ranitidine 150mg [**Hospital1 **] mirapex 0.5/1/0.5/1mg Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety or respiratory distress: Take one tablet as needed for respiratory difficulty or anxiety. If respiratory distress is not relieved, contact your doctor. [**Last Name (Titles) **]:*90 Tablet(s)* Refills:*0* 2. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO bid @ 7am and 5pm (). 3. Pramipexole 1 mg Tablet Sig: One (1) Tablet PO bid @ 11am and 10pm (). 4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig: One (1) Tablet PO QID (4 times a day). 8. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Home Discharge Diagnosis: Dyspnea, resolved Parkinson's disease Discharge Condition: Afebrile, normotensive, comfortable on room air Discharge Instructions: Please take your medications as prescribed. Please call your doctor or return to the emergency room should you have any of the following symptoms: fever > 101, chills, difficulty breathing, passing out, dizziness, falls, abdominal pain, chest pain, or any other concerns. . You have been evaluated for your shortness of breath. We think that your shortness of breath and trouble breathing is related to your Parkinson's disease. You Parkinson's can give you the sensation of trouble breathing which can make you feel anxious. We are prescribing a medicine which will help with the anxiety. Followup Instructions: You should follow up with your primary care doctor, Dr. [**Last Name (STitle) 4743**], within one week. Please call his office at [**Telephone/Fax (1) 4745**] to schedule this appointment. . You should also follow up with a lung specialist within [**1-4**] weeks. Please call [**Telephone/Fax (1) 612**] to schedule an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. You should have outpatient studies including a sleep study and pulmonary function testing. Completed by:[**2152-4-12**]

[ "786.09", "332.0", "300.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7272, 7278

4162, 6079

342, 349

7360, 7410

2897, 4139

8048, 8577

2500, 2517

6364, 7249

7299, 7339

6105, 6341

7434, 8025

2532, 2878

283, 304

377, 1962

1984, 2191

2207, 2484

19,493

155,882

12939

Discharge summary

report

Admission Date: [**2141-12-14**] Discharge Date: [**2141-12-19**] Date of Birth: [**2098-9-9**] Sex: F Service: SURGERY Allergies: Ciprofloxacin Hcl / Epinephrine / Pentothal / Flagyl Attending:[**Doctor First Name 5188**] Chief Complaint: acute cholecystitis Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. [**Known lastname 39729**] is a 43 year old woman with a h/o acute cholecystitis who is [**Known lastname 1988**] for an elective cholecystectomy with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2141-12-25**]. However, she comes into [**Hospital1 18**] complaining of intractable RUQ pain x 24 hours, that is worse with food consumption, and unrelieved with oral pain medications. In the ED, a RUQ was performed and was consistent with acute cholecystitis. The patient denies fevers or chills. She denies SOB, CP, N/V/D. Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Chronic fatigue 4. Chronic headaches 5. Fibromyalgia 6. Depression/Anxiety 7. Talus fracture 8. Cervical cancer 9. GERD 10. Hydronephrosis 11. Mild COPD 14. Chronic mesenteric ischemia - known occlusion of SMA and celiac, [**Female First Name (un) 899**] was re-implanted in [**2140-6-3**] by [**Year (4 digits) 1106**] surgery [**48**]. Recent admission [**7-10**] for ? TIA - foudn to have microvascular infarcts on MRI and HTN. 16. Admission for GI bleeding, antral ulcers Social History: History of heavy alcohol, stopped in [**2136**]. 20 pack year smoking history, has quit recently. Works as proofreader. No drug use Family History: Mother and aunt with coronary artery disease and carotid disease. Both parents died of lung cancer, mother at age 73, father at age 68. Physical Exam: On admission: VS: Afebrile, VSS NAD, WDWN, AAOx3 RRR, S1S2 CTAB Soft, non-distended, exquisitely tender in the RUQ and epigastrium. No rebound. Mininmal voluntary guarding. Normal bowel sounds. Old laparatomy scar is noted and is C/D/I. No C/C/E Pertinent Results: [**2141-12-14**] 01:30PM BLOOD WBC-17.2* RBC-3.51* Hgb-12.1 Hct-34.9* MCV-100* MCH-34.6* MCHC-34.8 RDW-12.5 Plt Ct-288 [**2141-12-14**] 10:30PM BLOOD WBC-10.0 RBC-2.92* Hgb-9.8* Hct-30.3* MCV-104* MCH-33.6* MCHC-32.4 RDW-11.9 Plt Ct-203 [**2141-12-15**] 04:33AM BLOOD WBC-9.6 RBC-2.86* Hgb-10.0* Hct-29.4* MCV-103* MCH-34.9* MCHC-34.0 RDW-12.0 Plt Ct-239 [**2141-12-17**] 06:25AM BLOOD WBC-7.0 RBC-3.20* Hgb-10.8* Hct-32.5* MCV-101* MCH-33.8* MCHC-33.3 RDW-12.1 Plt Ct-270 [**2141-12-14**] 01:30PM BLOOD Neuts-72.5* Lymphs-19.2 Monos-7.4 Eos-0.7 Baso-0.3 [**2141-12-14**] 10:30PM BLOOD Neuts-53.8 Lymphs-34.2 Monos-9.7 Eos-1.8 Baso-0.4 [**2141-12-14**] 01:30PM BLOOD Plt Ct-288 [**2141-12-14**] 10:30PM BLOOD PT-13.2 PTT-30.9 INR(PT)-1.1 [**2141-12-17**] 06:15PM BLOOD PT-12.8 PTT-36.1* INR(PT)-1.1 [**2141-12-14**] 01:30PM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-137 K-3.5 Cl-100 HCO3-26 AnGap-15 [**2141-12-14**] 10:30PM BLOOD Glucose-86 UreaN-5* Creat-0.7 Na-142 K-3.5 Cl-114* HCO3-21* AnGap-11 [**2141-12-15**] 04:33AM BLOOD Glucose-92 UreaN-5* Creat-0.7 Na-141 K-4.0 Cl-112* HCO3-22 AnGap-11 [**2141-12-17**] 06:25AM BLOOD Glucose-97 UreaN-3* Creat-0.8 Na-140 K-4.1 Cl-104 HCO3-29 AnGap-11 [**2141-12-14**] 01:30PM BLOOD ALT-20 AST-27 AlkPhos-117 TotBili-0.3 [**2141-12-14**] 10:30PM BLOOD ALT-13 AST-18 AlkPhos-89 TotBili-0.3 [**2141-12-15**] 04:33AM BLOOD ALT-17 AST-23 AlkPhos-97 TotBili-0.4 [**2141-12-17**] 06:25AM BLOOD ALT-18 AST-23 LD(LDH)-161 AlkPhos-210* TotBili-0.4 [**2141-12-14**] 10:30PM BLOOD Calcium-7.2* Phos-2.2*# Mg-1.4* [**2141-12-15**] 04:33AM BLOOD Calcium-7.5* Phos-2.7 Mg-3.4* [**2141-12-17**] 06:25AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9 [**2141-12-15**] 04:33AM BLOOD VitB12-241 Folate-17.1 [**2141-12-14**] 04:00PM BLOOD Lactate-1.0 RUQ U/S [**12-14**]: IMPRESSION: Findings worrisome for acute cholecystitis. The appearance of the gallbladder is similar to the ultrasound from [**2141-10-18**] at which time the patient also had evidence of acute cholecystitis. Brief Hospital Course: The patient was admited from the ED at [**Hospital1 18**] after she was found to have a RUQ U/S consistent with acute cholecystitis. She was also noted to have a leukocytosis. She was admitted to the 5 [**Hospital Ward Name 1950**] floor for further evaluation and treatment. She was deemed to be a poor operative candidate, and it was decided to treat her with conservative medical management, including NPO/IVF and IV antibiotics. She was initially treate with IV vanco and zosyn. She remaind NPO until HD 3 where she began tolerating sips of clear liquids. On HD 4 she began tolerating clear liquids. On HD 6 she was tolerating solid food. Pain: Her pain was controlled with IV narcotics, and then PO narcotics when she began tolerating PO. She was ambulating througout her hospital course. She was discharged to home in good and stable condition on HD 6. She was given prescriptions for PO pain medication and antibiotics. Medications on Admission: Fluoxetine 20 mg, Simvastatin 20 mg qday, Loperamide 4 mg qam, Dicyclomine 20mg qid, Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr qday Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). Disp:*30 Capsule(s)* Refills:*2* 5. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed. Disp:*30 Capsule(s)* Refills:*0* 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 8. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 14 days. Disp:*42 Tablet(s)* Refills:*0* 9. Omnicef 300 mg Capsule Sig: Two (2) Capsule PO once a day for 14 days. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute, chronic cholecystitis Hypertension Hyperlipidemia Chronic fatigue Chronic headaches Fibromyalgia Depression Anxiety Talus fracture Cervical cancer Gastroesophageal reflux Hydronephrosis Cobstructive pulmonary disease Chronic mesenteric ischemia with occlusion of the SMA, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 899**] reimplantation ([**June 2140**]) microvascular TIA Peptic ulcer disease, s/p Ileocecectomy for mesenteric ischemia Discharge Condition: good Discharge Instructions: Seek medical care for increased abdominal pain, nausea, vomitting, persistent fevers, or anything else concerning to you. Do not drink alcohol or drive while taking narcotic pain medications Followup Instructions: Call the office of Dr. [**Last Name (STitle) 39733**] to schedule a follow-up appointment in [**7-13**] days and to arrange for your planned cholecystectomy (removal of gallbladder) at a later date [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2141-12-29**]

[ "300.4", "401.9", "V10.41", "557.1", "496", "272.4", "575.12", "530.81", "729.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6256, 6262

4076, 5009

334, 340

6767, 6773

2060, 4053

7012, 7348

1640, 1779

5208, 6233

6283, 6746

5035, 5185

6797, 6989

1794, 1794

275, 296

368, 928

1808, 2041

950, 1474

1490, 1624

8,373

118,517

27190

Discharge summary

report

Admission Date: [**2145-4-14**] Discharge Date: [**2145-4-19**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2485**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is an 83 y/o female with moderate AS, s/p MVR [**57**] years ago, s/p PPM, DM, CHF, p/w dsypnea and increased work of breathing x 4-5 days. Per family, the patient has had worsening CHF/volume overload over the last several weeks, requiring supplemental O2 at rehab. Over the last few days, she has been noted to be more short of breath and having sats to 60% on RA. Her lasix was increased to 60 mg [**Hospital1 **]. Beginning today, she was noted to be in hypoxic respiratory distress, 87-91% on 2L/NC. She was increased to 5L, with her sats going up to 97%. She was also noted to be more confused over the last few days and especially today. She was given lasix and 2 mg IV morphine at [**Hospital 100**] Rehab, and sent to [**Hospital1 18**] for further evaluation. En route, she was given additional lasix of 60 mg IV and nitro spray x 2. . In the ED, her VS were Tc 97.2, BP 146/25, HR 70, RR 27, SaO2 95%/NRB. Foley was placed in ED. She was given 40 mg IV lasix and 325 mg ASA. She was placed on BiPAP for comfort at 30% FiO2, 5 PEEP, 12 PS. Admitted to the MICU for further management. . Per family, besides the dyspnea and SOB, the patient has had no other symptoms, including f/c/s, CP, palpitations, abd pain, n/v/diarrhea. She has had decreased appetite over the last few days in the context of increasing confusion. Past Medical History: 1. Moderate AS 2. s/p MVR 3. s/p PPM 4. A fib 5. DM 2 on insulin 6. Hypercholesterolemia 7. Gout 8. Depression 9. ?Pulmonary fibrosis 10. CHF/CAD, last EF 55% 4/06 Social History: Lives at [**Hospital 100**] Rehab. Prior h/o heavy tobacco use. Ambulates at baseline. Family History: Mother with h/o emphysema, CAD Physical Exam: General: Asleep, easily arousable. On BiPAP, NAD HEENT: NC/AT, PERRL, EOMI. MMM, OP clear Neck: +elevated JVD to earlobe, supple Chest: decreased BS at bases with few crackles b/l CV: RRR 3/6 HSM, loudest at LUSB Abd: soft, NT/ND, NABS Ext: 2+ pitting edema b/l, warm with faint DP Pertinent Results: [**2145-4-14**] 01:30PM WBC-9.6 RBC-4.02* HGB-11.4* HCT-36.3 MCV-90 MCH-28.4 MCHC-31.4 RDW-17.8* [**2145-4-14**] 01:30PM NEUTS-87.0* LYMPHS-6.7* MONOS-5.0 EOS-0.9 BASOS-0.4 [**2145-4-14**] 01:30PM PLT COUNT-161 [**2145-4-14**] 01:30PM PT-23.2* INR(PT)-2.3* [**2145-4-14**] 01:30PM cTropnT-0.08* [**2145-4-14**] 01:30PM CK(CPK)-37 [**2145-4-14**] 01:30PM cTropnT-0.08* [**2145-4-14**] 01:30PM CK-MB-NotDone proBNP-5313* [**2145-4-14**] 01:30PM GLUCOSE-173* UREA N-52* CREAT-1.5* SODIUM-145 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-40* ANION GAP-10 [**2145-4-14**] 01:45PM TYPE-ART PO2-249* PCO2-99* PH-7.28* TOTAL CO2-49* BASE XS-15 INTUBATED-NOT INTUBA [**2145-4-14**] 06:20PM TYPE-ART TEMP-37.0 O2-90 O2 FLOW-5 PO2-63* PCO2-81* PH-7.39 TOTAL CO2-51* BASE XS-19 AADO2-513 REQ O2-84 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] . Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is at least moderate aortic valve stenosis. A bileaflet mitral valve prosthesis is present. The gradients are higher than expected for this type of prosthesis. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2144-3-3**], the pressure gradient across the mitral valve prosthesis is increased. . IMPRESSION: AP chest compared to [**4-14**] through 26: Mild pulmonary edema is unchanged. Bilateral pleural effusion small on the right and moderate on the left is stable. Severe cardiomegaly and left lower lobe atelectasis unchanged. No pneumothorax. Transvenous right ventricular pacer lead in standard placement. . ECG: Ventricular paced rhythm. Compared to the previous tracing of [**2145-4-14**] no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 0 160 466/486.42 0 -71 112 Brief Hospital Course: A/P - 83yo F with valvular disorder, AF, and h/o CAD a/w hypercarbic respiratory failure. . # Respiratory failure- She was admitted to the MICU for her repiratory failure which was thought to be secondary to CHF. Pt was diuresed with iv lasix/acetazolamide and given iv morphine/prn for respiratory distress and BIPAP was tried. However, hypercarbia ([**12-25**] metabolic alkalosis) remained in the 90s. Pt was mentating okay, having conversations with intermittent somnolence despite hypercarbia. TTE showed preserved EF with moderate AS and moderate MS and mod pulm HTN. Cardiology was consulted and thought MS [**First Name (Titles) **] [**Last Name (Titles) 34106**] to her pulm edema and pulm HTN. Cardiology recommended d/cing digoxin and starting amiodarone. Family declined valvuloplasty. For possible COPD, pt was started on steroids and nebs on [**4-18**]. Pt is currently satting 90s on 1 L NC while sitting in a chair but needs more O2 when supine. Pt is a mouth breather and occasionally needs a face mask. Pt will need I/Os monitored to goal even to slightly negative as she was diursed 4.8 L during her MICU stay. Depending on her I/O, lasix and acetazolamide can be decreased or discontinued. If she were to decompensate at the rehab, goals of care will need to be readdressed. . # h/o CAD - There were new changes on EKG but pt was ruled out with 3 sets of negative cardiac enzymes. Pt was continued on BB, ASA, and nitrates. . # Acid/base status - Respiratory acidosis with metabolic compensation. Appears to be chronic in nature given degree of metabolic compensation with acute component earlier today. Pt failed BIPAP and pCO2 remained in the 90s but maintaining mentation. . # Renal insufficiency - baseline Cr unknown, may have CRI from DM. Creatinine stayed stable from 1.3-1.5. Will need to renally dose all medications. . # A fib - continued BB. Per cardiology consult recs, discontinued digoxin and started amiodarone. Due to elevated INR, coumadin was held. Pt is also paced. Pt needs to be on amiodarone 400mg [**Hospital1 **] x 7 days (loading dose) and then 400mg daily for maintenance. . # DM - insulin standing + HISS, FS qid . # Depression - continuedhome regimen . # F/E/N - NPO initially while on BIPAP and now low sodium cardiac diet. . # PPx - supratherpeutic INR . # Access - PIV . # Code - DNR/DNI. No pressors or central line per HCP. If she were to decompensate at the rehab, goals of care will need to be readressed. . # Communication - [**Name (NI) 553**] [**Name (NI) **] (niece) [**Telephone/Fax (1) 66710**], cell [**Telephone/Fax (1) 66711**] Medications on Admission: Coumadin 2.5 mg/3 mg Insulin - Humulin N 36 U daily/14 U qhs Lasix 40 mg [**Hospital1 **] Venlafaxine XR 75 mg qd Sorbitol Metoprolol 25 mg [**Hospital1 **] Imdur 30 mg qd Hydralazine 50 mg [**Hospital1 **] Digoxin 0.125 qd Oscal 250 mg + D Tylenol prn Morphine sulfate 4 mg q2 hrs prn Discharge Medications: 1. NPH 18 units qam and 7 units qhs 2. Humalog Per sliding scale qbreakfast, lunch, and dinner 3. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 4 days. 11. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection [**Hospital1 **] (2 times a day). 12. Acetazolamide Sodium 500 mg Recon Soln Sig: Two Hundred Fifty (250) Recon Soln Injection Q12H (every 12 hours). 13. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed. 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days. 15. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day: after finishing 400mg [**Hospital1 **] x 6 days. . Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary diagnoses: Diastolic congestive heart failure Aortic stenosis Mitral stenosis Possible chronic obstructive lung disease Secondary diagnoses: Coronary artery disease Chronic kidney disease Depression Diabetes mellitus Discharge Condition: Stable, satting 98% on 1L via NC, sitting up in a chair Discharge Instructions: Please call your doctor at the rehabilitation if you develop any shortness of breath, chest pain, nausea, vomiting, or any other concerning symptoms. . Please take medications as instructed. . Keep all your follow-up appointments. Followup Instructions: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2145-4-26**] 1:00

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

9101, 9166

4794, 7407

227, 234

9436, 9494

2257, 4771

9773, 9874

1907, 1939

7744, 9078

9187, 9316

7433, 7721

9518, 9750

1954, 2238

9337, 9415

180, 189

262, 1599

1621, 1787

1803, 1891

31,942

103,958

54543

Discharge summary

report

Admission Date: [**2124-7-2**] Discharge Date: [**2124-7-21**] Date of Birth: [**2073-1-25**] Sex: M Service: MEDICINE Allergies: Codeine / Compazine / Penicillins / Metformin / Heparin Agents Attending:[**First Name3 (LF) 2817**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: 51 year old gentleman with COPD on home O2 and several admissions for COPD flare requiring intubation, smoking, diabetes type II, s/p IVC filter for DVT, and recent admission for cellulitis presents from a nursing home with respiratory failure. Noted at nursing home to be hypoxic to 70's, treated with duonebs with O2 to 92% afterwards. Taken to emergency department. In [**Name (NI) **], pt in respiratory distress on presentation--placed on NRB and given continuous nebulizers, O2 sats began to trend to high 80's and pt became unresponsive. ABG at that time pH 7.35 pCO2 99 pO2 69 HCO3 57, pt intubated at that time. Of note, the respiratory therapist removed a large mucus plug shortly after intubation. Hemodynamically the pt was tachycardic in the 110's with SBP in the 150 systolic range. Also given ceftriaxone. Pt was already on vancomycin and ciprofloxacin for cellulitis for which he was admitted on [**6-30**]. Past Medical History: DM2 on RISS COPD on oxygen + prednisone CHF osteoporosis w/ related thoracic fracture h/o MRSA (but cleared by ID at OSH) h/o DVT s/p filter hepatitis B Social History: Shx:currently lives at the [**Doctor First Name **] [**Doctor First Name **] rehab since the vertebrate fracture; extensive smoking history, but still smokes [**2-12**] cig/day; extensive alcohol abuse in the past, but now sober. Has used IV drugs before, but also quit. Not married, but has children. His HCP is mother living at [**State 2748**]. Family History: Fhx: non-contributory Physical Exam: Gen: Cushingoid Neck: old trach wound Chest: Decreased air movement bilaterally, insp and exp wheezes Cor: RRR, no M/R/G Abd: Obese, soft, NT, ND, minimal bowel sounds. Ext: Mild erythema bilaterally in ankles about [**1-12**] way up shin extr: erythema b/l starting above the anles to upper leg area, temp same as temp of other parts of leg although a bit colder than temp of [**Last Name (un) **] extr, tender to palpation, distal pulses 2+, 2+ edema b/l Neurol: No focal deficits Back: kyphoscoliosis Pertinent Results: [**2124-7-2**] TYPE-ART TEMP-36.7 PO2-289* PCO2-91* PH-7.35 TOTAL CO2-52* BASE XS-19 LACTATE-1.3, O2 SAT-100, freeCa-1.20 TEMP-36.6 PO2-257* PCO2-87* PH-7.39 TOTAL CO2-55* BASE XS-22 LACTATE-2.1* O2 SAT-99 TYPE-ART RATES-/24 O2 FLOW-10 PO2-69* PCO2-99* PH-7.35 TOTAL CO2-57* BASE XS-22 INTUBATED-NOT INTUBA GLUCOSE-150* LACTATE-2.5* NA+-139 K+-3.6 CL--80* TCO2-48* GLUCOSE-139* UREA N-13 CREAT-0.7 SODIUM-140 POTASSIUM-3.4 CHLORIDE-87* TOTAL CO2-49* ANION GAP-7* CK(CPK)-111 CK-MB-12* MB INDX-10.8* cTropnT-0.06* proBNP-28 WBC-17.5* RBC-4.71 HGB-13.5* HCT-39.3* MCV-83 MCH-28.7 MCHC-34.4 RDW-13.3 NEUTS-74.9* LYMPHS-16.5* MONOS-7.2 EOS-1.1 BASOS-0.3 PLT COUNT-294 . ([**2124-7-21**]) BLOOD WBC-14.1* RBC-4.19* Hgb-11.6* Hct-36.3* MCV-87 MCH-27.8 MCHC-32.0 RDW-13.6 Plt Ct-248 PT-11.1 PTT-27.1 INR(PT)-0.9 Glucose-136* UreaN-11 Creat-0.5 Na-138 K-4.7 Cl-90* HCO3-42* AnGap-11 Albumin-3.7 Calcium-9.4 Phos-4.6*# Mg-2.2 Type-ART pO2-94 pCO2-72* pH-7.43 calTCO2-49* Base XS-18 . LIVER ULTRASOUND IMPRESSION: 1. Unremarkable liver. 2. No ascites. 3. No hydronephrosis. Caliceal diverticulum with crystals in lower pole of left kidney ([**2124-7-19**]) CT Trachea IMPRESSION: 1. Marked tracheobronchomalacia, demonstrated by near collapse of the central airways on expiration. 2. Moderate subglottic tracheal stenosis; irregularity of the wall suggests prior therapy by dilatation. 3. Persistent near-collapse of the right middle and lower lobes. 4. Similar focal skeletal deformity centered at T7, unchanged over one month. However, earlier studies are not available to confirm stability. Correlation with prior imaging if available, any clinical factors suggesting recent or prior infection, and consideration of MR are suggested to evaluate further. Discussed with Dr. [**Last Name (STitle) 111595**] on [**2124-7-21**]. Brief Hospital Course: Upon admission, the patient was on a prednisone taper for COPD flare and finishing his course of antibiotics for bilateral lower extremity cellulitis (the reason why he had been admitted a few days prior) During this admission, we addressed the following issues: . 1) Hypoxic respiratory failure--from mucus plug/pneumonia. The patient was intubated in the MICU. Suctioning and bronchoscopy were successfull removing large mucus plug. Pneumonia was treated with cefepime and vancomycin. He was initially on solumedrol 125 TID. He was extubated on day and transferred to the floor for continuous management of his COPD flare and secretions. On the floor, he transitioned quickly from face mask to nasal cannula 4 Liters. Initially on solumedrol 80 TID, then by day 2 started on prednisone taper. MICU Course: Breathing difficulty continued however and bronchoscopy was performed, and a severe stenosis secondary to fibrous tissue was found. Patient was again transfered to MICU for airway monitoring. Patient continued to have increased work of breathing and required ET intubation. Interventional Pulmonary was able to re-perform tracheotomy and secure the airway using a T-piece device. Patient had an uneventful and rapid recovery and was only requiring supplemental O2 by time of discharge. . 2) Hypercarbia, at one point the pt had Co2>100, which is very above his baseline of 60-70. This was accompanied by marked alkalosis >60. Both parameters improved steadily. Initially lasix was decreased to once a day, later discontinued altogether without worsening of the patient's volume status and marked improvement in his alkalosis. . After above procedure, hypercarbia improved and blood gases returned to baseline of pCO2 near 70. . 3) COPD. Exacerbation was managed with steroids, albuterol and atrovent nebulizers, as well as saline nebs. . After airway procedure, predinsone taper was begun and patient continued to improve. . 6) DM : Due to steroid induced hyperglycemia, the patient was kept on a humalog sliding scale thorughout admission, including MICU course. . 7) Smoking, on going: received smoking cessation counseling, kept on nicotine patch Medications on Admission: Fluticasone-Salmeterol 250-50 mcg/Dose Disk Inhalation [**Hospital1 **]. 2. Spironolactone 25 mg PO DAILY. 3. Lasix 60 mg PO twice a day. 4. Cholecalciferol (Vitamin D3) 400 unit PO BID (2 times a day). 5. Omeprazole 20 mg PO once a day. 6. Hexavitamin PO DAILY (Daily). 7. Insulin Regular Sliding Scale. 8. Docusate Sodium 100 mg PO BID. 9. Senna 8.6 mg PO BID as needed. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. 11. Terbinafine 1 % [**Hospital1 **]. 12. Ipratropium Bromide 0.02 % One Inhalation Q6H. 13. Prednisone taper 60 mg PO once a day, was on taper 14. Albuterol Sulfate 0.083 % Inhalation Q2H (every 2 hours) as needed. 15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal TID (3 times a day) as needed. 17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 18. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q3H (every 3 hours). 19. Vancomycin 1 g Intravenous Q 12H (Every 12 Hours) for 11 days. 20. Oxycodone 5 mg, 1-2 Tablets PO PRN pain Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for breakthrough. 10. Ipratropium Bromide Inhalation 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours) as needed for low back pain. 13. Lorazepam 0.5-2 mg IV Q4H:PRN 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 15. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal TID (3 times a day) as needed. 17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO BID (2 times a day). 19. Guaifenesin 100 mg/5 mL Syrup Sig: Twenty (20) ML PO Q6H (every 6 hours). 20. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): [**7-17**] and 10. 21. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: [**7-19**] and 12. 22. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: [**7-21**] and 14. 23. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: From [**7-23**] on. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: COPD exacerbation CHF Metabolic Alkalosis Discharge Condition: Good. At baseline oxygen (3 Liters) Discharge Instructions: Admitted for shortness of breath. Initially you were in the MICU intubated, then transitioned to the floor for steroid taper and continued management of your shortness of breath. Please take your medications as directed. Take the prednisone as indicated in the taper. Continue your breathing exercises as well. Don't miss any doctor's appointments. Followup Instructions: With your primary care doctor within 1 week of discharge

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icd9cm

[ [ [] ] ]

[ "31.99", "33.91", "96.04", "96.05", "31.1", "96.71", "33.24", "33.22" ]

icd9pcs

[ [ [] ] ]

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10415, 10475

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283, 304

383, 1308

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50,227

183,663

44380+44381

Discharge summary

report+report

Admission Date: [**2109-9-6**] Discharge Date: [**2109-9-9**] Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 45**] Chief Complaint: cold right leg Major Surgical or Invasive Procedure: None History of Present Illness: 87 yo F with PMh of STEMI 2 weeks ago, severe PVD s/p multiple stents and a fem/[**Doctor Last Name **] bypass, HTN, DM admitted from [**Location (un) 620**] where she was found to have an ischemic right leg and a STEMI. . Per family, patient has been in and out of the hospital recently. She was admitted to [**Location (un) 620**] 2 weeks ago for AMS and found to have a UTI and STEMI. At that time, because of her comorbiditis the family decided against intervention for the STEMI and she was treated with iv abx for her UTI and discharged back to her nursing home on [**2109-8-30**]. Per family, prior to her STEMI/UTI 2 weeks ago, she was verbal, enjoyed [**Location (un) 1131**] and while she was non-ambulatory since a stroke 7 years ago, she was interactive with them. More recently, she has not been herself and did not return to her baseline after she went home from [**Location (un) 620**] on the 25th. . Today at her nursing home, she was found to have a cold purple right leg and she was brought to [**Location (un) 620**] for evaluation. Her EKG there showed ST elevations in v3-v4-v5, with positive troponin indicating anterior distribution. . She was transferred here for further management. Of note, she is currently non-verbal so history as above was obtained from her family. . In the ED here, VS: 103 (Afib) 22 100% on 4L 141/81. She got ASA per report and was placed on heparin gtt as family did not want patient to go to cath. Of note, she was guaiac positive without e/o frank bleed. EKG with STE v3-v6. Cardiology saw patient and had long discussion with family regarding goals of care, risk of heparin gtt given patient's prior history of hemorrhagic stroke. Outside thrombolysis window. Familiy agreed to conservative management with heparin. Was unable to get a beta blocker because cannot take po. Vascular surgery saw (see OMR note) who felt that leg was unsalvageable. . Upon transfer to floor, unable to obtain history or revie of systems as patient is non-verbal. Past Medical History: STEMI 2 weeks ago Recent UTI Diabetes mellitus CVA - both hemorrhagic and ischemic (embolic vs thrombotic) Congestive heart failure EF 25% Hypertension Atrial fibrillation Severe PVD s/p stenting and fem [**Doctor Last Name **] bypass Cholelithiasis, status post cholecystectomy and history of abnormal LFTs, status post stent Anemia Previously also required a PEG tube Social History: From [**Country 532**], was a neonatologist there. Been in US since [**2090**]. Has 1 daughter. Lives in [**Location **], dependant for all ADLs. Never used tobacco, no EtOH or drugs. Family History: NC Physical Exam: VS: T=98 BP=144/82 HR=113 RR=26 O2=95% on RA GENERAL: chronically ill-appearing elderly female in NAD but moans in pain when rolled. HEENT: NC/AT. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. CARDIAC: irregularly irregular, tachycardic. No murmurs, rubs or [**Last Name (un) 549**]. JVP=cannot assess as patient will not allow me to move her neck LUNGS: Rhonchorous throughout, with decreased breath sounds at the bases. ABDOMEN: +bs, soft reducible peri-umbilical hernia. soft, NTND. EXTREMITIES: RLE: Pulses not dopplerable, foot is cold with acute on chronic ischemic changes. Skin sloughing off in areas of trauma. Calf cold to touch and mottled, thigh cool to touch. LLE: Warm to touch with out significant skin breakdown. Dopplerable DP pulse. SKIN: flaking skin on face. LE NEURO: alert, not responsive. Withdraws to pain. Decerebrate posturing. Pertinent Results: Labs on admission: [**2109-9-6**] 05:35PM GLUCOSE-241* UREA N-20 CREAT-0.8 SODIUM-144 POTASSIUM-4.4 CHLORIDE-114* TOTAL CO2-22 ANION GAP-12 [**2109-9-6**] 05:35PM WBC-12.3*# RBC-3.75* HGB-11.5*# HCT-36.7# MCV-98# MCH-30.7# MCHC-31.4 RDW-15.6* [**2109-9-6**] 05:35PM NEUTS-85.0* LYMPHS-11.5* MONOS-2.9 EOS-0.5 BASOS-0.1 [**2109-9-6**] 05:35PM PLT COUNT-198 [**2109-9-6**] 05:35PM PT-15.0* PTT-27.3 INR(PT)-1.3* [**2109-9-6**] 05:58PM LACTATE-1.9 [**2109-9-6**] 05:35PM CK(CPK)-523* [**2109-9-6**] 05:35PM cTropnT-1.31* [**2109-9-6**] 05:35PM CK-MB-15* MB INDX-2.9 Micro: [**2109-9-8**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2109-9-7**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2109-9-7**] URINE URINE CULTURE-FINAL NEGATIVE [**2109-9-6**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2109-9-6**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] Imaging: CXR: Findings compatible with congestive heart failure with bilateral pleural effusions and likely left basilar atelectasis. Brief Hospital Course: 87 yo F with signifcant PVD, DM, HTN, recent STEMI without intervention [**1-7**] family preference who presented to [**Location (un) 620**] with ischemic right leg and STEMI 2 weeks ago, transferred here for further management. . #. Ischemic Right Leg: Known severe PCD, presented to [**Location (un) 620**] with cold, purple leg. Vascular Surgery saw the patient here and they did not feel there is a reasonable intervention, given that the patient would likely require amputation even if flow was restored, which family does not want. Family did request that heparin be continued during her stay at [**Hospital1 18**], despite extremely miniscule chance that heparin would restore any flow. She had no improvement over the course of her stay, and the drip was stopped on [**2109-9-9**], the day of her discharge. The family is well aware of her poor prognosis, and the fact that she will likely become septic from her ischemic leg. It was agreed that the patient be transitioned to hospice care and transferred back to nursing facility with goals of comfort/pain control and no escalation of care. She received IV dilaudid inhouse (allergy to morphine- pruiritis). Patient should receive concentrated oxycodone for pain control every four hours (standing) and every two hours as needed. #. History of STEMI: Patient with ST elevations in anterior distrubution on EKG, residual from STEMI 2 weeks prior to admission. 2 weeks ago, patient had no intervention, as per family request. Family would like patient to be managed conservatively. They understand the many complications s/p such a massive MI and that she may pass away from acute arrhythmia at any time. . #. Atrial Fibrillation: Patient was in AF with RVR at [**Location (un) 620**]. Had been on dilt drip and was unable to take home beta blocker given inability to take PO ([**1-7**] mental status). Patient now able to take PO and able to restart home lopressor 25mg TID. Goal is to prevent her from going into afib with RVR to prevent discomfort. . # Bacteremia: Patient with 2/2 bottles coag negative staph and leukocytosis. Possibly element of bacteremia from ischemic leg. Patient has been afebrile. Family wants no escalation of care. No antibiotics or continued cultures. . #. Chronic Systolic CHF: EF 25%. Was diuresed on admission and discharge with lasix 20mg IV for comfort of breathing. She can take 20mg PO lasix as needed for shortness of breath or fluid overload. . #. Diabetes: Insulin sliding scale was held during hospital course to minimize overall finger sticks and increase comfort. She does not need finger sticks or medications on discharge. . #. HTN: SBP's 120-140's while inhouse. Goal bp 110-130 given STEMI and did not want to decrease cardiac perfusion. Patient discharged on home dose of beta blocker. . # Altered Mental Status: Likely toxic metabolic encephalopathy in setting of STEMI and ischemic leg. Per family, patient had UTI 2 weeks ago and was not herself at that time and has not returned to her baseline. CT head at [**Location (un) 620**] was without acute bleed. Of note, patient has h/o ICH while on coumadin per family. Family expressed understanding of risks and benefits of starting heparin for ischemic leg, and wanted to continue it inhouse. On admission, patient with decerebrate posturing. No changes on neuro exam upon discharge, although neuro exam extremely difficult as patient is nonverbal and does not follow commands even with Russian interpreter. . #. H/O CVA: [**First Name8 (NamePattern2) **] [**Location (un) 620**] d/c summary on [**8-30**], new stroke was identified - left posterior/ occipital stroke. [**2106**] R MCA stroke. Neurology evaluation at [**Location (un) 620**] during prior hospitalization stated that it could be a new stroke or something old. Family decided on no intervention at that time given patient's comorbidities. . # FEN: dysphagia diet, no further labs . # PPX: -Bowel regimen for comfort -Pain management with oxycodone (concentrated) . # CODE STATUS: DNR/DNI . # EMERGENCY CONTACT: Daughter [**Name2 (NI) **] cell: [**Telephone/Fax (1) 95150**], home: [**Telephone/Fax (1) 95151**] Medications on Admission: Compazine prn Novolin 9 units every morning and 3 units at 4:30 p.m. Lopressor 25 mg tid Lasix 20 mg qd Aspirin 81 mg p.o. Multivitamin Senna Colace Dulcolax SSI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed for pain. 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Oxycodone 20 mg/mL (1 mL) Concentrate Sig: Five (5) mL PO every four (4) hours. 7. Oxycodone 20 mg/mL (1 mL) Concentrate Sig: [**4-14**] mL PO Q2H as needed for pain. 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for shortness of breath or fluid overload. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Ischemic right leg 2. h/o STEMI 2 weeks prior 3. Bacteremia SECONDARY DIAGNOSES: 1. Atrial Fibrillation 2. Chronic systolic CHF 3. Diabetes 4. Hypertension 5. H/o Cerebrovascular accident 6. Dementia Discharge Condition: Vital signs stable. Right leg pulseless and cold/mottled to mid-thigh. Patient saturating 97% on 2L NC. Discharge Instructions: You were admitted to [**Hospital1 18**] on [**2109-9-6**] with an ischemic right leg. You were evaluated by our vascular surgery team, who determined your leg was not salvageable. According to your family, you would not have wanted an amputation of your right leg, which was the only option we could provide to prevent infection. Despite the low chances of blood thinners helping the clot, we pursued this option while you were the hospital, but there was no change in your leg. You also suffered from a large heart attack two weeks ago, and your heart is not functioning well. As per your family, no intervention was done. Your medications have been minimized, and we are not recommending blood draws or finger sticks for your diabetes at this time in order to optimize your comfort. You will be continued on IV pain medications and transitioned to hospice care. At this point, our main goal is to optimize your comfort and make sure you are free of pain. There is no need to return to the hospital for fevers, low blood pressure, or high heart rate. You will be followed closely by a hospice nurse. Followup Instructions: You are being transitioned to hospice care and should be in touch with your hospice worker on a regular basis. Please call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 589**] if you have other issues that arise and have not been addressed on this hospitalization. There is no need to return to the hospital for fevers, high heart rate, or low blood pressure. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**] Admission Date: [**2109-9-9**] Discharge Date: [**2109-9-11**] Service: MEDICINE Allergies: Haldol / Morphine Attending:[**First Name3 (LF) 689**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. [**Known lastname 95152**] is an 87 y.o. F with recent STEMI in mid-[**Month (only) **] and then in [**2109-9-5**], HTN, s/p CVA, CHF with EF 25%, and atrial fibrillation, admitted for shortness of breath. In mid-[**2109-8-6**], the patient had been admitted to [**Hospital1 **] [**Location (un) 620**] for AMS and found to have a UTI and STEMI. At that time, family decided against intervention for STEMI. She was treated wtih abx for her UTI and sicharged back to NH on [**2109-8-30**]. She was then transferred from [**Location (un) 620**] to [**Hospital1 18**] on [**2109-9-6**] for cold purple R leg and EKG with ST elevations in V3-V5 with positive troponins. She was placed on heparin gtt after discussion with family. Vascular surgery was consulted who believed that there was not a reasonable intervention, given that the patient would likely require amputation even if flow was restored, which family declined. Heparin gtt was continued until day of discharge. Per d/c summary, agreed that pt be transitioned to hospice care and transferred back to nursing facility with goals of comfort / pain control and no escalation of care. Pt also noted to have bacteremia (coag negative staph), likely from ischemic leg, and family did not want escalation of care. No abx or cultures continued. Patient was discharged [**2109-9-9**] to NH. . In the ED, initial VS: T 98.2 HR 91 BP 109/69 RR 22 O2 sat 97% RA HR ranged from 100-135 with SBPs in 100-120/56-70. Labs obtained. EKG and CXR completed. Pt was given metoprolol tartrate 5 mg IV x 1 and metoprolol tartrate 25 mg po x 1, levofloxacin 750 mg IV x 1, IV lasix 20 x 1 in [**Hospital1 18**]-[**Location (un) 620**] ED. Foley placed. Cards was consulted in ED and recommended rate control. . Currently, the patient is yelling in pain with movement of her legs. . ROS: Unable to be obtained. Past Medical History: STEMI 2 weeks ago Recent UTI Diabetes mellitus CVA - both hemorrhagic and ischemic (embolic vs thrombotic) Congestive heart failure EF 25% Hypertension Atrial fibrillation Severe PVD s/p stenting and fem [**Doctor Last Name **] bypass Cholelithiasis, status post cholecystectomy and history of abnormal LFTs, status post stent Anemia Previously also required a PEG tube Social History: From [**Country 532**], was a neonatologist there. Been in US since [**2090**]. Has 1 daughter. Lives in [**Location **], dependant for all ADLs. Never used tobacco, no EtOH or drugs. Family History: NC Physical Exam: Vitals - T: 98.3 BP: 75/35 --> 122/53 HR: 109 RR: 20 02 sat: 90% 4 L NC GENERAL: elderly female, nonverbal, moaning in bed with movement of lower extremities HEENT: anicteric, PERRL, OP - MM dry, no cervical LAD CARDIAC: irreg irreg, no m/r/g LUNG: CTAB anteriorly ABDOMEN: NDNT soft NABS EXT: RLE appreciable thinner than LLE, RLE cold without pulse NEURO: nonverbal Pertinent Results: [**2109-9-9**] 10:05PM GLUCOSE-218* UREA N-29* CREAT-1.1 SODIUM-141 POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-16* ANION GAP-24* [**2109-9-9**] 10:05PM CK-MB-9 cTropnT-1.00* proBNP-[**Numeric Identifier 95153**]* [**2109-9-8**] 07:25AM WBC-12.4* RBC-3.43* HGB-10.0* HCT-32.9* MCV-96 MCH-29.2 MCHC-30.5* RDW-15.4 [**2109-9-8**] 07:25AM PLT COUNT-205 [**2109-9-8**] 07:25AM PT-16.2* PTT-82.7* INR(PT)-1.4* cxr: Limited study with moderate-to-large bilateral pleural effusions and mild pulmonary edema. Brief Hospital Course: This hospital course summary is a modified version of recent d/c summary from [**2109-9-9**]. Only differences are that she was formally made Comfort measures only. She was readmitted on [**2109-9-9**] for acute shortness of breath, requiring HR control and diuresis in the ICU. She is now comfortable and made CMO. If there is a recurrence of SOB, tachycardia, hypotension, fevers, etc., she will not return to the hospital as per discussion with family. She is being sent to [**Location (un) **] with hospice care. ------------------ 87 yo F with signifcant PVD, DM, HTN, recent STEMI without intervention [**1-7**] family preference who presented to [**Location (un) 620**] with ischemic right leg and STEMI 2 weeks ago, transferred here for further management x 2. This admission focused on acute SOB [**1-7**] systolic CHF exacerbation and family requested diuresis for further comfort. She has now been made comfort care only and will not receive any further interventions. This has been discussed extensively with family with help of paliative care team. . #. Ischemic Right Leg: Known severe PCD, presented to [**Location (un) 620**] with cold, purple leg. Vascular Surgery saw the patient here and they did not feel there is a reasonable intervention, given that the patient would likely require amputation even if flow was restored, which family does not want. Family did request that heparin be continued during her stay at [**Hospital1 18**], despite extremely miniscule chance that heparin would restore any flow. She had no improvement over the course of her stay, and the drip was stopped on [**2109-9-9**], the day of her initial discharge. The family is well aware of her poor prognosis, and the fact that she will likely become septic from her ischemic leg. It was agreed that the patient be transitioned to hospice care and transferred back to nursing facility with goals of comfort/pain control and no escalation of care. She received IV dilaudid inhouse (allergy to morphine- pruiritis). Patient should receive concentrated oxycodone for pain control every three hours for pain. #. History of STEMI: Patient with ST elevations in anterior distrubution on EKG, residual from STEMI 2 weeks prior to admission. 2 weeks ago, patient had no intervention, as per family request. Family would like patient to be managed conservatively. They understand the many complications s/p such a massive MI and that she may pass away from acute arrhythmia at any time. . #. Atrial Fibrillation: Patient was in AF with RVR at [**Location (un) 620**]. Had been on dilt drip and was unable to take home beta blocker given inability to take PO ([**1-7**] mental status). Agreed that medications be minimized and that no further medications be given for rate control. . # Bacteremia: Patient with 2/2 bottles coag negative staph and leukocytosis. Possibly element of bacteremia from ischemic leg. Patient has been afebrile. Family wants no escalation of care. No antibiotics or continued cultures. . #. Chronic Systolic CHF: EF 25%. Was diuresed during hospitalization. Patient comfortable on 2L oxygen now. No further diuresis for SOB. Should be given oxycodone for any discomfort. . #. Diabetes: Insulin sliding scale was held during hospital course to minimize overall finger sticks and increase comfort. She does not need finger sticks or medications on discharge. . #. HTN: SBP's 120-140's while inhouse. Goal bp 110-130 given STEMI and did not want to decrease cardiac perfusion. Patient discharged on home dose of beta blocker. . # Altered Mental Status: Likely toxic metabolic encephalopathy in setting of STEMI and ischemic leg. Per family, patient had UTI 2 weeks ago and was not herself at that time and has not returned to her baseline. CT head at [**Location (un) 620**] was without acute bleed. Of note, patient has h/o ICH while on coumadin per family. Family had expressed understanding of risks and benefits of starting heparin for ischemic leg, and wanted to continue it inhouse. On initial admission, patient with decerebrate posturing. No changes on neuro exam upon discharge, although neuro exam extremely difficult as patient is nonverbal and does not follow commands even with Russian interpreter. . #. H/O CVA: [**First Name8 (NamePattern2) **] [**Location (un) 620**] d/c summary on [**8-30**], new stroke was identified - left posterior/ occipital stroke. [**2106**] R MCA stroke. Neurology evaluation at [**Location (un) 620**] during prior hospitalization stated that it could be a new stroke or something old. Family decided on no intervention at that time given patient's comorbidities. . # FEN: dysphagia diet, no further labs . # PPX: -Bowel regimen for comfort -Pain management with oxycodone (concentrated) . # CODE STATUS: DNR/DNI . # EMERGENCY CONTACT: Daughter [**Name2 (NI) **] cell: [**Telephone/Fax (1) 95150**], home: [**Telephone/Fax (1) 95151**] Medications on Admission: Metoprolol Tartrate 25 mg po TID Acetaminophen 650 mg PR q4 hours prn pain Bisacodyl 10 mg PR daily prn constipation Colace 100 mg po BID prn constipation Senna 8.6 mg po BID prn constipation Oxycodone 5 mL po q4 hours Oxycodone [**4-14**] mL po q 2 hours prn pain Lasix 20 mg po daily prn SOB or fluid overload Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 3. Oxycodone 20 mg/mL Concentrate Sig: 2.5-5 mg sublingual PO Q3 as needed for pain. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: PRIMARY DIAGNOSIS: Acute on chronic systolic CHF Ischemic right leg h/o STEMI 2 weeks prior Bacteremia SECONDARY DIAGNOSES: Atrial Fibrillation Diabetes Hypertension H/o Cerebrovascular accident Dementia Discharge Condition: Vital signs stable. Right leg pulseless and cold/mottled to mid-thigh. Patient saturating 97% on 2L NC. Discharge Instructions: You were admitted to [**Hospital1 18**] on [**2109-9-6**] with an ischemic right leg, and readmitted on [**2109-9-9**] with shortness of breath. You have been evaluated by our vascular surgery team, who determined your leg was not salvageable. According to your family, you would not have wanted an amputation of your right leg, which was the only option we could provide to prevent infection. You also suffered from a large heart attack two weeks ago, and your heart is not functioning well. As per your family, no intervention was done. Your shortness of breath is from your heart failure (worse from your heart attack) and your rapid heart rate. We gave you medicines to make your breathing more comfortable. Your medications have been minimized, and we are not recommending blood draws or finger sticks for your diabetes at this time in order to optimize your comfort. You will be continued on pain medicines and followed by hospice care at your facility. At this point, our main goal is to optimize your comfort and make sure you are free of pain. There is no need to return to the hospital for fevers, low blood pressure, shortness of breath, or high heart rate. You can eat if you are able to, but if you aspirate, you should not return to the hospical and we will focus on your comfort. No VS should be monitored- instead the pt should be assessed for pain using non verbal assessment and for resp distress. Any sign of pain or resp distress should be treated with SL oxycodone and PR acetaminophen. Oxygen may be used to treat SOB. PLEASE NOTE: THIS PATIENT IS COMFORT MEASURES ONLY AND SHOULD NOT RETURN TO THE HOSPITAL. Hospice nurse will be closely focusing. Followup Instructions: PLEASE NOTE: THIS PATIENT IS COMFORT MEASURES ONLY AND SHOULD NOT RETURN TO THE HOSPITAL. Hospice nurse will be closely following.

[ "250.00", "428.22", "428.0", "790.7", "787.20", "294.8", "041.19", "440.20", "349.82", "428.23", "V66.7", "038.19", "401.9", "440.4", "440.29", "410.82", "V12.54", "438.82", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

21602, 21679

15986, 19546

12544, 12551

21928, 22034

15456, 15963

23760, 23894

15048, 15052

21254, 21579

21700, 21700

20917, 21231

22058, 23737

15067, 15437

21825, 21907

12485, 12506

12579, 14436

21719, 21804

3810, 5030

19561, 20891

14458, 14830

14846, 15032

23,156

172,022

8193

Discharge summary

report

Admission Date: [**2177-4-4**] Discharge Date: [**2177-4-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3283**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: right femoral central line placement History of Present Illness: Pt is an 85 yo M h/o DM 2, ESRD on HD x1 year, HTN who was recently hospitalized here [**Date range (1) 29120**] for mechanical trauma related R knee pain and gout flare who presented to ED from outpatient HD complaining of chest pain which started at the end of his dialysis session today. Pain described as sharp, anterior, nonradiating severe chest pain, pleuritic, only present when coughing or taking deep breath, not at rest. HD was discontinued early after 1.5 hrs due to tachycardia, noted to be in rapid AF 150-180, BP initially 102/72, given 10mg IV diltiazem, became hypotensive to 80s. He had two attempts at DCCV, wtihout success then started on diltiazem drip with HR improving to 90-100s, started on neo and levophed for BP support. Levophed has since been titrated off. In addition, pt received vancomycin, ceftriaxone, levofloxacin in ED. Head CT, chest CTA performed. Pt seen on arrival to CCU, denies any dyspnea, admits to persistent pleuritic anterior chest pain. Aside from recent increase in knee pain, has been feeling at his baseline. No recent fever, chills, cough, nausea. He has ocassional vomiting for the last several months. No abdominal pain, BRBPR, melena, he has ocassional loose stools. He make minimal urine. Past Medical History: -h/o Bilateral knee replacements 6 yrs ago -ESRD thought [**2-15**] DM and HTN ---dialyzed T,Th,Sat at [**Doctor First Name 12074**] in [**Location (un) **] -Hypertension -DM -Hyperlipidemia -Severe DJD of the cervical spine with resultant gait disturbance -Gout -Known thyroid cancer (Patient has declined resection) -Probable renal cell cancer (noted by MRI, not biopsied) Social History: Lives with wife, worked in social work supervising children with drug problems. [**Name (NI) **] tobacco, EtOH, drugs. Had used cane since knee surgery, more recently uses walker. Family History: + hx heart problems, HTN, stroke. Physical Exam: VS: T 97.4, BP 124/53, HR 86, RR 16, O2 sat 96% on 4L NC Gen: elderly AA male in no acute respiratory distress, moderate discomfort with movement of R leg. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP no visualized as pt lying flat. CV: Irregularly irregular, no m/r/g. Chest: CTA b/l anteriorly without crackles or wheezes. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. R femoral RLC in place. R leg much cooler, which is chronic according to pt, 2+ DP/PT in L leg, tr PT in R and dopplerable DP. R knee in immobilizer brace, no significant tenderness over R knee, significant tenderness over R femur. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: EKG demonstrated AF with ventricular rate of 68, nl axis, no LVH, no ischemic changes, ST depression noted on previous EKG resolved. . [**4-3**] Head CT: No acute intracranial process. . [**4-3**] CTA chest: 1. No evidence of aortic dissection or pulmonary embolism. 2. Small bilateral pleural effusions and regions of discoid and subsegmental atelectasis. 3. Cardiomegaly and marked left atrial enlargement. 4. Mild vasculopathy. 5. Right thyroid goiter resulting in mild tracheal compression and leftward tracheal deviation. . [**2177-4-5**] ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis or regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. At least mild mitral regurgitation. Mild pulmonary hypertension. . Compared with the prior study (images not available for review) of [**2176-6-10**], the findings are similar. . [**4-8**] UGI IMPRESSION: 1. No esophageal stricture or mucosal abnormality. 2. Gastroesophageal reflux. Brief Hospital Course: 85 yo M hx ESRD on HD, HTN, DM II who presented with new onset atrial fibrillation, rapid ventricular rate and hemodynamic compromise associated with chest pain. . # Atrial fibrillation-Exacerbating factor was unclear and pt did not tolerate the RVR well and developed hypotension. There was no clear evidence of fluid overload. Pt had continued hypotension after IV diltiazem, DCCV attempts were unsuccessful in ED x 2. Pt was started on IV diltiazem at 10mg/hr with pressor support for hypotension and admitted to CCU. Pt responded well to diltiazem drip, HR improved to 80s and hypotension resolved gradually, able to be weaned off pressors overnight. He converted back to NSR the day following admission. An echocardiogram was obtained to look for structural abnormalities, showing mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], mild symmetric LVH with preserved global biventricular systolic function. Thyroid function tests were normal. After discussion with PCP & family, decision was made to hold off on anti-coagulation given recent h/o fall. PT will continue on sc heparin while at rehab & re-address plan for anti-coagulation with PCP after return home. Pt was transferred to floor & monitored on telemetry. He was noted to have some intermittent runs of A.fib or atrial arrythmia, but HR was well controlled on Amiodarone 400mg [**Hospital1 **] & Metoprolol 25mg TID. Pt should continue Amiodarone 400mg [**Hospital1 **] until [**4-18**], then decrease dose to 200mg [**Hospital1 **] ongoing. . # Chest pain - Pt was admitted with c/o chest pain & was evaluated with cardiac enzymes which were not elevated from baseline. CTA of chest in the ED showed no evidence of PE or dissection. CP resolved after conversion to SR & did not recur during the remainder of the hospitalization. . # Vomiting: Pt noted a sense to food being stuck in chest & then had intermittent episodes of non-bilious, non-bloody emesis. UGI swallow showed normal peristalsis, reflux and upper esophageal deflection [**2-15**] enlarged thyroid mass (known h/o thyroid cancer, decision made with patient & PCP to avoid intervention). Pt denied abd pain but was noted to have one guaiac positive stool. It was thought likely that he had developed a gastritis due to high dose NSAIDs. Ibuprofen was stopped and pt was switched to PPI [**Hospital1 **]. Stool guaiacs should be monitored for resolution as outpt, and pt may need a follow up EGD/Colonoscopy if this does not clear after stopping NSAIDs. . # Right leg pain-Pt was recently hospitalized [**Date range (1) 29120**] for mechanical fall related right knee pain and gout flare. Pt had continued to have right knee/upper thigh pain at rehab. X-rays obtained were neg for fracture & pelvic/lower extr CT showed DJD but no e/o fracture. Pain improved on Ibuprofen & Oxycontin 10mg [**Hospital1 **], and he continued to have good pain control after stopping NSAIDs. Pt will need continued rehab for his RLE injury. . # ESRD - Pt was followed by renal throughout hospitalization & was continued on his outpatient medications including cinacalcet. Pt should resume his regular Tu/Th/Sa dialysis schedule at [**Location (un) **]. . # HTN - BP meds initially held given hypotension, then Metoprolol was restarted after resolution of hypotension. Candesartan, Lisinopril & Nifedipine were stopped on admission and were not restarted. BP was well controlled and these agents can be restarted as needed while outpt. . # Hyperlipidemia: Pt was continued on Atorvastatin 80mg. . # DM: Glipizide was stopped while in house & pt was covered with Humalog Insulin Sliding Scale with decent BS control. . # PPX: Heparin 5000u sc TID & PPI [**Hospital1 **] Medications on Admission: Nifedipine 30mg daily Lisinopril 40mg daily Metoprolol XR 100mg daily Candesartan 32 mg daily Atorvastatin 80mg daily Glipizide 5 mg daily Omeprazole 20 mg daily Cinacalcet 30mg daily Tylenol prn Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. 3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for reflux. 11. Reglan 5 mg Tablet Sig: One (1) Tablet PO QID ACHS. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): continue taking 400mg [**Hospital1 **] until [**4-18**], then decrease the dose to 200mg [**Hospital1 **] ongoing . 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Atrial Fibrillation with RVR ESRD on HD Gastritis HTN DMII Thyroid Cancer Severe DJD Discharge Condition: Good Discharge Instructions: You were admitted with chest pain & found to be in Atrial fibrillation with a rapid ventricular rate. You have been treated with medications to help slow the heart rate. You have been started on a new medication called Amiodarone to help suppress this arrythmia & slow your heart rate. . You should continue taking Amiodarone 400mg twice a day until [**Month (only) **] 4rth, then you should decrease the dose to 200mg twice daily. We have increased the dose of the Protonix to 40mg twice daily due to possible gastritis. We have started Reglan 5mg QID, Oxycontin 10mg [**Hospital1 **], Metoprolol 25mg TID. We have stopped the Glipizide, Candesartan, Lisinopril, Nifedipine & Toprol. Please discuss these changes with your PCP at your next follow up. . If you develop any new chest pain, shortness of breath or any other general worsening of condition, please call your PCP or come directly to the ED. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2177-5-12**] 11:30

[ "272.4", "715.90", "403.91", "189.0", "V45.1", "427.31", "E935.9", "193", "535.50", "585.6", "786.50", "250.00" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

10184, 10257

4770, 8490

272, 310

10386, 10393

3098, 3243

11350, 11473

2197, 2232

8736, 10161

10278, 10365

8516, 8713

10417, 11327

2247, 3079

222, 234

338, 1585

3252, 4747

1607, 1984

2000, 2181

81,701

165,329

39487

Discharge summary

report

Admission Date: [**2124-6-19**] Discharge Date: [**2124-6-29**] Date of Birth: [**2042-8-3**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: back pain Major Surgical or Invasive Procedure: T6 thoracotomy and vertebrectomy History of Present Illness: HPI:81 y/o female with hx of endometrial CA s/p hysterectomy on [**5-30**] sent here from [**Hospital **] hospital after imaging obtained from oncologist revealed a T6 pathologic fracture concerning for cord compression. Patient's daughter presents history of one month history of upper back pain, preceeding her hysterectomy which seemed to get worse after the operation. Family denies loss of strength or hx of trauma. Past Medical History: Dementia, left knee sugery, left cataract sugery. Social History: unknown. Family History: unknown Physical Exam: PHYSICAL EXAM: T: 98.9 BP: 203 / 110 HR:90 R 18 O2Sats: 100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils:left irregular, right 4 and reactive EOMs Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, HOH, exam difficult affect. Orientation: Oriented to person, place, and date. Motor: D B T IP Q H AT [**Last Name (un) 938**] G Sensation: Intact to light touch Propioception intact Toes mute bilaterally Rectal exam normal sphincter control per report Clonus Negative. Exam on discharge: Awake, alert, dementia at baseline. MAE antigravity but difficult to have patient cooperate with strength testing but appears 4- -5 secondary to pain and effort. Sensation intact. Ambulating with assist. Incision clean, dry, and intact. Pertinent Results: CT CHEST: 1. Numerous intraparenchymal and pleural-based pulmonary nodules bilaterally. 2. Pathologically enlarged mediastinal, hilar and retroperitoneal lymph nodes. 3. Small pleural effusions and associated atelectases bilaterally. 4. The wall of the gallbladder is calcified consistent with porcelain gallbladder. Several gallstones are present within the neck of the gallbladder. Dilated CBD is seen at the level of porta hepatis measuring approximately 11 mm. Inferiourly, at the level of the duodenum, CBD is of normal caliber measuring 7 mm. 5. A soft tissue metastatic lesion at the level of T6 extending into the spinal canal. 6. Extensive diverticulosis without associated inflammatory changes. MRI T-SPINE W/O CONTRAST 1. Pathologic fracture of T6 vertebral body, with retropulsion and compression of the spinal cord. Possible faint edema in the spinal cord at this level. 2. Expansion of the left posterior elements of T6, consistent with tumor involvement. Narrowing of the T6-T7 neural foramen. 3. Signal abnormality in the T5-6 disc is likely related to the T6 fracture. However, signal abnormalities in the T5 and T7 vertebral bodies are suggestive of tumor involvement. T5 inferior endplate fracture versus Schmorl's node. 4. Chronic compression fracture of L1 without evidence of underlying tumor. Mild associated retropulsion without compression of the cauda equina. 5. Poorly assessed pulmonary abnormalities, which could be better assessed by chest CT scan, if one has not been recently performed elsewhere. 6. Multiple renal lesions, measuring up to 4.5 cm in the lower pole of the left kidney. If these were not previously characterized at another institution, then further characterization by son[**Name (NI) 867**] or CT scan is recommended. [**2124-6-29**] 05:05AM BLOOD WBC-10.9 RBC-3.78* Hgb-11.3* Hct-34.7* MCV-92 MCH-30.0 MCHC-32.7 RDW-15.2 Plt Ct-351 [**2124-6-29**] 05:05AM BLOOD Plt Ct-351 [**2124-6-29**] 05:05AM BLOOD Glucose-156* UreaN-17 Creat-0.5 Na-145 K-2.9* Cl-107 HCO3-29 AnGap-12 [**2124-6-28**] 02:16PM BLOOD Glucose-162* UreaN-19 Creat-0.5 Na-144 K-3.1* Cl-107 HCO3-30 AnGap-10 [**2124-6-28**] 05:05AM BLOOD Glucose-156* UreaN-19 Creat-0.6 Na-145 K-2.8* Cl-108 HCO3-30 AnGap-10 [**2124-6-27**] 05:45AM BLOOD Glucose-162* UreaN-20 Creat-0.6 Na-146* K-3.2* Cl-110* HCO3-27 AnGap-12 [**2124-6-26**] 02:36AM BLOOD Glucose-144* UreaN-21* Creat-0.6 Na-148* K-3.6 Cl-112* HCO3-27 AnGap-13 [**2124-6-27**] 05:45AM BLOOD Calcium-10.7* Phos-2.1* Mg-1.9 [**2124-6-29**] 05:05AM BLOOD Calcium-10.1 Phos-1.7* Mg-1.4* [**2124-6-28**] 02:16PM BLOOD Calcium-10.2 Phos-1.7* Mg-1.5* [**2124-6-28**] 05:05AM BLOOD Calcium-10.5* Phos-1.8* Mg-1.5* Brief Hospital Course: 81F who presented to the ER with back pain. Patient had been recently diagnosed with endometrial carcinoma in [**2124-5-18**] and imaging of her spine showed a T6 lesion with compression fracture. On [**6-20**] she had a CT Torso done to evaluate for further lesions which showed the lungs, pleura, and lymph nodes and an abnormal gall bladder. Hem/Onc was consulted on [**6-21**] and Rad Onc was consulted on [**6-23**]. On [**2124-6-22**] she underwent T6 thoracotomy/vertebrectomy and fusion with Dr. [**Last Name (STitle) 548**]. Post-operatively she was kept in the ICU for monitoring, she was extubated [**2124-6-23**]. She was neurologically intact. She transferred to step down unit [**6-26**] and to the floor [**6-27**]. Her diet and activity were advanced. She was followed by speech and swallow and advanced. She had some confusion post-op but this cleared to her baseline dementia by [**2124-6-27**]. her wound was clean and dry. She was out of bed with PT/OT who recommended that she would need rehab. Her foley was removed on [**2124-6-27**] and she had no difficulty voiding. She was screened for rehab on [**6-27**] and on [**6-28**] was accepted on [**2124-6-29**]. She takes HCTZ at home but was discontinued as her Calcium level was elevated and has normalized. Her K level has also been low and she has been replaced PRN; has been asymptomatic. Her Mg level was low this morning and was replaced PO. She was unable to stand for her standing films so these were done with her sitting on the edge of the bed. She was discharged to Sancta [**Doctor Last Name **] in [**Hospital1 8**], MA on [**2124-6-29**] ([**Telephone/Fax (1) 87223**]) Medications on Admission: synthroid 75mcg colace 100 [**Hospital1 **] vit D Ramipril dose unknown tylenol # 3 Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: Two (2) units Injection ASDIR (AS DIRECTED). 8. Metoprolol Tartrate 5 mg IV Q6H:PRN SBP>180 9. Heparin (Porcine) 5,000 unit/mL Cartridge Sig: One (1) Injection TID (3 times a day). 10. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO DAILY (Daily): Hold for K > 4.5. Discharge Disposition: Extended Care Facility: [**First Name9 (NamePattern2) 87224**] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: endometrial cancer T6 compression/pathologic fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up but take daily showers. ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have your incision checked daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation Followup Instructions: Please follow up with Dr. [**First Name (STitle) 13014**] - radiation oncology on [**7-7**],[**2123**] at 3pm on [**Hospital Ward Name **] [**Hospital Ward Name 23**] [**Location (un) 442**]. Please follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks, you will need xrays at the same time - please call [**Telephone/Fax (1) 2992**] to schedule this appt. Oncology will setup a appointment with you once pathology has been finalized. They will call the Rehab facility with this info. Completed by:[**2124-6-29**]

[ "244.9", "458.29", "336.9", "285.1", "182.0", "198.5", "575.9", "196.8", "294.8", "276.8", "275.2", "197.2", "197.6", "197.0", "427.31", "401.9", "733.13" ]

icd9cm

[ [ [] ] ]

[ "80.99", "84.51", "77.71", "81.04", "81.62" ]

icd9pcs

[ [ [] ] ]

7179, 7310

4492, 6162

328, 363

7408, 7408

1793, 4469

8370, 8893

930, 939

6296, 7156

7331, 7387

6188, 6273

7586, 8347

969, 1182

279, 290

391, 815

1536, 1774

7423, 7562

837, 888

904, 914