Split (1)

train · 26.9k rows

subject_id int64 12 100k	_id int64 100k 200k	note_id stringlengths 1 41	note_type stringclasses 4 values	note_subtype stringclasses 35 values	text stringlengths 449 78.2k	diagnosis_codes listlengths 1 39	diagnosis_code_type stringclasses 1 value	diagnosis_code_spans listlengths 1 21	procedure_codes listlengths 0 35	procedure_code_type stringclasses 1 value	procedure_code_spans listlengths 1 5	Discharge Disposition: stringlengths 0 12	Brief Hospital Course: stringlengths 0 12	Major Surgical or Invasive Procedure: stringlengths 0 12	Discharge Condition: stringlengths 0 12	Pertinent Results: stringlengths 0 12	Followup Instructions: stringlengths 0 12	Family History: stringlengths 0 12	DISCHARGE DIAGNOSES: stringlengths 0 12	DISCHARGE MEDICATIONS: stringlengths 0 12	[Hospital 93] MEDICAL CONDITION: stringlengths 0 12	DISCHARGE DIAGNOSIS: stringlengths 0 12	MEDICATIONS ON DISCHARGE: stringclasses 983 values	MEDICATIONS ON ADMISSION: stringlengths 0 12	HOSPITAL COURSE: stringlengths 0 12	CARE RECOMMENDATIONS: stringclasses 32 values	DISCHARGE INSTRUCTIONS: stringlengths 0 12	What to report to office: stringclasses 286 values	Discharge labs: stringlengths 0 12	[Last Name (NamePattern4) 2138]p Instructions: stringclasses 138 values	HOSPITAL COURSE BY SYSTEM: stringclasses 79 values	-Cranial Nerves: stringclasses 297 values	Incision Care: stringclasses 388 values	Past Surgical History: stringlengths 0 12	PHYSICAL EXAM: stringlengths 0 12	SECONDARY DIAGNOSES: stringlengths 0 12	2. CARDIAC HISTORY: stringclasses 715 values	HOME MEDICATIONS: stringclasses 441 values	Blood Culture, Routine (Preliminary): stringclasses 146 values	Discharge exam: stringclasses 736 values	CLINICAL IMPLICATIONS: stringclasses 128 values	FOLLOW UP: stringclasses 645 values	RESPIRATORY CULTURE (Preliminary): stringclasses 133 values	SUMMARY OF HOSPITAL COURSE: stringclasses 286 values	Blood Culture, Routine (Pending): stringclasses 88 values	PHYSICAL EXAMINATION: stringlengths 0 12	Physical Exam on Discharge: stringclasses 198 values	At discharge: stringlengths 0 12	ON DISCHARGE: stringlengths 0 12	Transitional issues: stringclasses 965 values	FOLLOW-UP PLANS: stringclasses 188 values	Changes to your medications: stringclasses 809 values	REVIEW OF SYSTEMS: stringlengths 0 12	Medication Changes: stringclasses 665 values	Discharge PE: stringclasses 99 values	General Discharge Instructions: stringclasses 84 values	CHIEF COMPLAINT: stringlengths 0 12	REASON FOR THIS EXAMINATION: stringlengths 0 12	Active Issues: stringclasses 353 values	TRANSITIONAL CARE ISSUES: stringclasses 69 values	WOUND CULTURE (Preliminary): stringclasses 63 values	DISCHARGE FOLLOWUP: stringclasses 182 values	LABS ON DISCHARGE: stringclasses 566 values	Review of sytems: stringclasses 249 values	Labs at discharge: stringclasses 119 values	Immunizations recommended: stringclasses 34 values	FOLLOW UP APPOINTMENTS: stringclasses 38 values	HOSPITAL COURSE BY PROBLEM: stringclasses 131 values	WOUND CARE: stringclasses 425 values	FOLLOW-UP APPOINTMENT: stringclasses 54 values	HISTORY OF PRESENT ILLNESS: stringlengths 0 12	CRANIAL NERVES: stringlengths 0 12	CT Head: stringclasses 955 values	secondary diagnosis: stringlengths 0 12	Head CT: stringclasses 601 values	ADMISSION LABS: stringlengths 0 12	PRIMARY DIAGNOSIS: stringlengths 0 12	On admission: stringlengths 0 12	MENTAL STATUS: stringlengths 0 12	TRANSITIONS OF CARE: stringclasses 92 values	3. OTHER PAST MEDICAL HISTORY: stringclasses 667 values	Chronic Issues: stringclasses 245 values	Active Diagnoses: stringclasses 63 values	Past medical history: stringlengths 0 12	SOCIAL HISTORY: stringlengths 0 12	CONDITION ON DISCHARGE: stringlengths 0 12	Meds on transfer: stringclasses 242 values	Discharge physical exam: stringclasses 473 values
23,974	189,536	44292	Discharge summary	report	Admission Date: [2116-3-14] Discharge Date: [2116-3-17] Date of Birth: [2047-2-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: HPI: 69 yo M w/ DM2, CAD s/p MI 3 wks ago s/p stents transferred from [Hospital6 33] after having an episode of marroon stool about 18 hours ago. Pt. was not having any complications after his cath (not exerting himself, however), tolerating the aspirin and plavix. He also chronically takes sulindac for joint/muscle aches. . Pt. called 911 today, when he felt so weak that he couldn't get up. At [Name (NI) 34], pt. was never tachycardic or hypotensive (beta blocked). Pt. developed L sided chest pain while in the hospital, localized, nonradiating, non-pleuritic, without any diaphoresis, SOB, palp. or n/v. Pain was [3-31], very similar in nature to the pain he had peri-MI 3 wks ago. Pain was controlled with nitro gtt. EKG was notable for 1mm ST elevations in V1-2 with 2mm ST depressions in the inferior leads, worrisome for instent restenosis. Labs were notable for hct of 24.5 (had been 42.6 on [2-22]). CK and trop. flat. Pt. was given 1 unit of PRBCs and transferred to [Hospital1 ]. No further GIB noted. . Upon transfter, vitals notable only for tachycardia up to 100 bpm. NGL was performed - notable for coffee grounds, but no fresh blood. . In ROS, pt. denies any SOB, orthopnea, PND. He only had one episode of exertional angina prior to his cath. . He was transferred to CCU for EGD today which was notable for ulcers. Currently, patient denies nausea, vomiting, abdominal pain, chest pain, shortness of breath. Past Medical History: 1. DM2 2. CAD s/p MI 3 wks ago with STE in I and L. Cath with 3 vessel disease. (100% mid diag, 95% tubular LAD, 65% distal RCA, 70% mid OM2, circumflex 50% lesion) 3. ECHO [2116-2-22] at [Hospital6 33]: Trace MR, trace TR. Left ventricular ejection fraction in range of 55 to 60% with regional wall motion abnormalities of the lateral wall at the apex and mild hypokinesis noted. 3. Hypertension 4. OSA 5. Arthritis 6. Hernia repair Social History: No tobacco or ETOH. Lives at home with wife Family History: No known early CAD Physical Exam: PE: 98.7, 103, 137/70, 20, 97% on 2L gen - nad HEENT - pale sclera, PERRLA, EOMI neck - supple, no LAD lungs - CTAB c/v - tachy, regular rhtyhm, no m/g/r abd - s/nt/nd, nabs extr - no c/c/e, 2+DP pulses b/l neuro - A+Ox3, no focal signs Pertinent Results: Chemistry: [2116-3-14] 02:38AM GLUCOSE-227* UREA N-45* CREAT-0.7 SODIUM-138 POTASSIUM-4.2 CHLORIDE-112* TOTAL CO2-21* ANION GAP-9 [2116-3-14] 02:38AM CK(CPK)-140 [2116-3-14] 02:38AM CK-MB-11* MB INDX-7.9* cTropnT-0.10* [2116-3-14] 02:38AM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-1.3* CBC: [2116-3-14] 02:38AM WBC-18.8* RBC-2.98* HGB-8.9* HCT-27.0* MCV-91 MCH-29.8 MCHC-32.8 RDW-14.1 [2116-3-14] 02:38AM NEUTS-87.0* LYMPHS-9.9* MONOS-2.9 EOS-0.1 BASOS-0.1 Coags: [2116-3-14] 02:38AM PT-13.5 PTT-19.5* INR(PT)-1.2 Brief Hospital Course: A/P 69 yo M w/ DM2, CAD, s/p MI, with 3vd s/p cath 3 wks ago with diag stenting, now p/w UGIB and chest pain. . #GI bleed - The etiology was felt to be likely a combination of asa, plavix and sulindac. EGD on [3-14] showed ulcers in the gastroesophageal junction which were injected and treated with thermal therapy. Erosions were also seen in the gastroesophageal junction and in the proximal bulb. The pt was started on Protonix 40 mg twice a day. He should continue taking this twice a day for two weeks and then change to protonix 40 mg once a day thereafter. He was advised to stop sulindac and use Tylenol as needed for his joint complaints. If Tylenol does not control his symptoms adequately, he will return and see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for further discussion of how to best manage these sx's without exacerbating his ulcers. The pt was found to be negative for H.pylori so treatment was not initiated. He was instructed to continue with aspirin/plavix since these meds are important given his cardiac disease. His Hct remained stable after his EGD and on day of discharge his Hct was 31.1. He will have his labs checked on [Last Name (LF) 2974], [3-20]. His PCP may follow these labs. . #Cardiac: a. Coronaries: Patient was felt to likely have had demand ischemia in setting of GIB given large drop in hct and known 3 vessel disease. He was transfused to keep his hct > 30. Cardiac enzymes were followed and peaked with a CK of 324, trop of 0.88. He had no events on telemetry. He was continued on asa, plavix, statin. He had no further chest pain. . b. Pump: Pt was continued with enalapril, lopressor and HR and BP remained in good range. . #DM - pt's metformin/glipizide were held in house but restarted on discharge. Medications on Admission: asa 325 qd, lipitor 40 qd, lopressor 50 [Hospital1 ], plavix 75 qd, imdur 30 qd, enalapril 5 qd, sulindac 200 [Hospital1 ], metformin 850 mg twice a day, glipizide 10 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): Take one tablet twice a day for 2 weeks, then take once a day thereafter. . Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Outpatient Lab Work Please have the following labs drawn: hematocrit, potassium, magnesium. Please have results called in to Dr. [Last Name (STitle) ],[First Name3 (LF) 1216] R at [Telephone/Fax (1) 94985] Discharge Disposition: Home Discharge Diagnosis: gastric ulcers Discharge Condition: stable Discharge Instructions: Please do not take sulindac any longer. If you have joint aches, please try Tylenol, up to 4 grams daily as needed. If you continue to have joint aches, please return to Dr. [Last Name (STitle) ] and discuss other medications that would be more gentle on your stomach than Sulindac. If you have chest pain that does not resolve with nitroglycerin, please come to the emergency department or call 911. Followup Instructions: Please have your labs drawn and the results sent to Dr. [Last Name (STitle) ]. Please also follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8467] at [Hospital1 2025] on [4-9]. Please check with his office prior to having the stress test.	[ "250.00", "531.40", "414.00", "285.9", "410.71", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "99.04", "43.41" ]	icd9pcs	[ [ [] ] ]	6375, 6381	3220, 5015	322, 327	6439, 6447	2643, 3197	6901, 7187	2350, 2370		5249, 6352		6402, 6418		5041, 5226			6471, 6878								2385, 2624																						274, 284														355, 1806													1828, 2273	2289, 2334
51,596	158,471	37368	Discharge summary	report	Admission Date: [2118-10-19] Discharge Date: [2118-10-29] Date of Birth: [2053-11-10] Sex: F Service: MEDICINE Allergies: Zosyn / ceftriaxone Attending:[First Name3 (LF) 602] Chief Complaint: hypotension, altered mental status, apnea Major Surgical or Invasive Procedure: [2118-10-20] central venous catheter placed [2118-10-20] arterial line placed [2118-10-21] left percutaneous nephrostomy tube placed History of Present Illness: Ms. [Known lastname ] is a 64 year old female w/MS (bedbound), DM, COPD [Hospital 4045] transferred from rehab facility w/acute onset AMS. Reportedly hypoxic to high 80s. The history is obtained from her son who is at bedside. . Of note, she has frequent UTIs and was hospitalized in [Month (only) 116] for urosepsis (E.coli sensitive to Zosyn, Meropenem, Gent). . In the ED, she very rapidly deteriorated, began vomiting and her BPs rose to 200s systolic initially in the ED. She underwent a CT head - no bleed. She became not responsive to voice or sternal rub, then became apneic. There was ?seizure, no known seizure disorder --> given 2mg ativan. Due to ongoing hypoxia, she was given ketamine to take a look at the cords --> laryngospasm --> intubation. Intubated with ketamine, lidocaine and fentanyl for airway protection; fent and midaz for sedation. During the intubation, she actively vomited and aspirated gastric contents. She was given gentamicin and admitted to the MICU. Son reports that this all happened over a matter of 1 hour this afternoon. She has needed to be intubated in the past for urosepsis. Additionally, she had minimal UOP and was given 3L NS. However, she was never hypotensive, 102/78 at lowest (usually 110s-120s). Febrile to 103 rectally. ABG: pH 7.25 pCO2 55 pO2 87 HCO3 25 BaseXS -3 (done after intubation, before adjustment of vent setting). . On transfer: 103 rectal, 102/68, 94, 97% on AC 400/18/5/100%. . 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 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: Multiple Sclerosis -- about 14yrs, followed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Location (un) 2274] - wheelchair at baseline, lives in nursing home - has no use of her lower extremities, sometimes spastic movements, bladder chronically contracted UTI with ESBL E.coli--sensitive to zosyn, [Last Name (un) 2830], gent Chronic Depression Anxiety PVD s/p lower extremity bypass COPD Osteoporosis Hx of +PPD bilateral femur supracondylar fractures [2113] hx of Urosepsis - hospitalized about once/yr, per husband Neurogenic bladder - indwelling foley x [4-26] [Last Name (LF) 1686], [First Name3 (LF) ] husband Recurrent C. Diff Hx of Sacral [First Name3 (LF) ] LE spasticity Hx of jaw pain -- ?TMJ, improved on Tegretol Social History: Lives in nursing home for last 4 [First Name3 (LF) 1686]. Husband is HCP, lives with one of their daughters. [Name (NI) ] daughter married and lives in the area. Wheelchair at baseline, dependent for transfers and some of ADLs. Has no use of lower extremities at baseline. Tobacco: started at age 20, quit about 15yrs ago ETOH: social, occasional, per husband [Name (NI) 3264]: none Family History: No family members with Multiple Sclerosis. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 100.3 BP: 111/70 P: 91 R: 22 O2: 100% (vented) General: intubated, sedated, not responsive to voice or sternal rub HEENT: Sclera anicteric, MMM, pinpoint pupils Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi Abdomen: mildly tense, non-tender, non-distended, bowel sounds present, no organomegaly GU: chronic foley Ext: cool, pale, 1+ pulses, no clubbing, cyanosis or edema Neuro: non-focal . DISCHARGE PHYSICAL EXAM: Vitals: T: 99 BP: 150/80 P: 88 R: 22 O2: 96% 4LNC Neck: no JVD not elevated CV: RRR normal s1/s2 no mrg Lungs: CTABL Abdomen: NT/ND GU: chronic foley Ext: no c/c/e Pertinent Results: ADMISSION LABS: [2118-10-19] 02:40PM BLOOD WBC-11.6# RBC-4.83# Hgb-14.8# Hct-44.9# MCV-93 MCH-30.6 MCHC-32.9 RDW-13.9 Plt Ct-229 [2118-10-19] 02:40PM BLOOD Neuts-93.3 Lymphs-5.1* Monos-0.9* Eos-0.4 Baso-0.2 [2118-10-19] 02:40PM BLOOD PT-10.7 PTT-29.3 INR(PT)-1.0 [2118-10-19] 02:40PM BLOOD Glucose-167* UreaN-27* Creat-1.2* Na-140 K-4.5 Cl-100 HCO3-27 AnGap-18 [2118-10-19] 02:40PM BLOOD ALT-61* AST-84* AlkPhos-176* TotBili-0.7 [2118-10-19] 02:40PM BLOOD Lipase-17 [2118-10-19] 02:40PM BLOOD cTropnT-<0.01 [2118-10-19] 02:40PM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.9# Mg-2.1 [2118-10-19] 02:40PM BLOOD Carbamz-9.3 [2118-10-19] 03:29PM BLOOD Type-ART FiO2-100 O2 Flow-100 pO2-87 pCO2-55* pH-7.25* calTCO2-25 Base XS--3 AADO2-566 REQ O2-94 -ASSIST/CON Intubat-INTUBATED [2118-10-19] 02:55PM BLOOD Glucose-159* Lactate-3.7* Na-143 K-4.3 Cl-102 [2118-10-20] 05:15AM BLOOD freeCa-0.98* . DISCHARGE LABS: [2118-10-29] 05:09AM BLOOD WBC-6.0 RBC-3.48* Hgb-10.4* Hct-32.2* MCV-93 MCH-30.0 MCHC-32.4 RDW-14.4 Plt Ct-321 [2118-10-29] 05:09AM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-140 K-3.1* Cl-102 HCO3-31 AnGap-10 [2118-10-29] 05:09AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.0 . IMAGING: [10-19] CT HEAD: FINDINGS: No hemorrhage, evidence of acute major vascular territorial infarction, edema, or shift of normally midline structures is present. Extensive confluent periventricular and subcortical white matter hypodensities are consistent with small vessel ischemic changes. The ventricles and sulci are enlarged consistent with cortical atrophy, likely secondary to patient's known multiple sclerosis. Basal cisterns are patent. Air-fluid levels in the maxillary and sphenoid sinuses are consistent with sinusitis. Mastoid air cells are well pneumatized. IMPRESSION: No acute intracranial process . [10-20] CT CHEST/ABD/PELVIS: CHEST: There is a consolidation in the right lower lobe, consistent with patient's history of aspiration pneumonia. There are bilateral trace effusions. There is a possible tiny right pneumothorax, which is incompletely imaged. There are no pulmonary nodules or masses. The base of the heart is normal in size. There is calcifications of the coronary arteries. There is no pericardial effusion. ABDOMEN: The liver is normal shape and contour. There are no discrete hepatic masses. There is no intra- or extra-hepatic biliary duct dilation. The portal veins are patent. There is no gallbladder. The spleen and pancreas are unremarkable. The bilateral adrenal glands are normal. In the right kidney, there is a large renal staghorn calculus without hydronephrosis or hydroureter. In the left kidney, there is a 16 mm calculus within the left proximal ureter. There is associated mild-to-moderate hydronephrosis, likely secondary to ureteral obstruction. Three smaller non-obstructing left renal calculi are present. They measure 10 mm, 6 mm and 5 mm. The kidneys enhance heterogeneously. On the right, it appears to be more due to artifact. On the left, the heterogeneous enhancement appears somewhat more geographical, is concerning for pyelonephritis. There is no excretion of the contrast into either ureter on the right or the left. The right ureter, although nor opacified, is normal in course and caliber. The left ureter has peripheral rim enhancement, suggesting underlying infection. There is a Foley in place in a collapsed bladder. There are no stones seen within the bladder. The stomach is unremarkable. The duodenum and jejunum are normal in course and caliber. There is no mesenteric stranding. There is a large amount of fecal material within the rectum. The sigmoid and descending colon are relatively collapsed. There is some fat stranding in the left retroperitoneum, which is likely due to the kidney and ureter, rather than the colon. There are multiple diverticula, but no definite evidence of diverticulitis. There is no abdominal, mesenteric, pelvic or inguinal lymphadenopathy. The abdominal vasculature is normal in course and caliber, other than a calcified splenic artery aneurysm, which is stable since [11]/[2117]. OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic lesions. The right hip appears malrotated with the acetabular notch approximating the anterior acetabulum. There are no fractures. IMPRESSION: 1. 16-mm calculus within the left proximal ureter with moderate hydronephrosis. Heterogenous enhancement of the kidney and rim enhancement of the ureter suggest infection. 2. Three nonobstructing left renal calculi. 3. Right renal staghorn calculus without hydronephrosis or hydroureter. 4. Right lower lobe consolidation. 5. Possible tiny right pneumothorax, which is incompletely imaged. 6. Calcified splenic artery aneurysm. . MICRO: [10-19] BLOOD CULTURE POSITIVE FOR GNR [10-20] BLOOD CULTURE POSITIVE FOR GPR PRESUMPTIVE CORYNEBACTERIUM . Brief Hospital Course: Mrs. [Known lastname ] is a 64 year old female with history of recurrent urinary tract infections, including extended-spectrum beta-lactamase producing organisms, multiple sclerosis with spastic bladder, and nephrolithiasis admitted for urinary tract infection, E. coli septicemia, and sepsis. #Sepsis/E. coli bacteremia/urinary tract infection/nephrolithiasis/hydronephrosis: Patient was admitted with sepsis and was admitted to the intensive care unit. She required vasopressor support and was noted to have an obstructing left renal stone. Urology was consulted and Infectious Disease was consulted and a percutaneous nephrostomy tube was placed to facilitate urinary drainage. The patient improved with antibiotics and was transferred to the floor to complete a 14 day course of IV Meropenem with Ertapenem to be used to complete course following discharge. Although it was noted that without removal or the left renal stone the patient would be at risk for recurrent infections, the patient was felt to be at too high risk for surgical nephrolithotomy or extra-corporeal shock wave lithotripsy. Therefore, the patient was discharged with percutaneous nephrostomy tube to be changed every 3 months and the patient will follow up in [Hospital 159] clinic. #Respiratory failure/Chronic obstructive pulmonary disease/Multiple sclerosis: Patient developed hypercarbic respiratory failure in the setting of her infection and required intubation. She was treated with bronchodilators and steroids and had improvement in her symptoms. She was extubated but had a persistent oxygen requirement felt to be due to a combination of respiratory muscle weakness in the setting of multiple sclerosis and infection. There was also intermittent aspiration that improved when diet was changed to a dysphagia diet. Patient completed her steroid course in the hospital and was discharged to rehab on 4L supplemental oxygen which had been a stable requirement for >48 hours prior to discharge. #Dysphagia: Ms. [Known lastname ] was seen by speech and swallow following a witnessed aspiration on [2118-10-26]. She was approved for nectar thick liquids and pureed solids. #Encephalopathy: This was felt to be due to sepsis. Head CT was negative for bleeding and mental status improved slowly over hospital course. #Acute kidney injury ([Last Name (un) ])/Acute Renal Failure: Baseline creatinine was 0.6 and upon admission was elevated. She was treated with IV fluids and antibiotics as above. By the time of discharge, her Cr had improved to baseline. #Hypertension: When she was NPO her home amlodpine and diltiazem were held. This resulted in her systolic blood pressures increasing to 170s-180s with tachycardia. She had worsening respiratory distress with elevated blood pressures. Thus, she was controlled with an esmolol drip in the ICU with improvement in her oxygen saturations. When she was able to take oral medications again, her home diltiazem and amlodipine were restarted also with good control of blood pressure and heart rate. . CHRONIC ISSUES BY PROBLEM: #Hyperlipidemia (HLD): Continued statin . #Multiple sclerosis (MS): Continued her home copaxone and after extubation she was restarted on her muscle relaxants . # Depression: Citalopram was initially held then restarted . # Hypertension: Amlodipine was held and then restarted. . TRANSITIONAL ISSUES: # Nephrostomy tube: per urology consult this will remain in place until outpatient followup with Dr. [Last Name (STitle) ] [Last Name (STitle) ] Urologist. [Month (only) 116] need nephrostomy tube indefinitely. Medications on Admission: (According to nursing home records with the patient) methenamine hippurate 1gm [Hospital1 ] simvastatin 20 mg QHS carbamazepine 300mg XR [Hospital1 ] carbamazepine 100 mg daily at noon cyclobenzaprine 10 mg [Hospital1 ] baclofen 5 mg [Hospital1 ] Copaxone 20 mg Subcutaneous once a day Os-Cal 500 + D Oral alendronate 70 mg weekly citalopram 40 mg daily donepezil 10 mg HS trazodone 25 mg hs cranberry Oral Norvasc 5 mg daily aspirin 81 mg albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution qam prn ipratropium bromide 0.02 % Solution qam prn acetaminophen 650 mg q6 prn vitamin E Oral senna 8.6 mg potassium chloride 20 mEq daily Fleet Enema 19-7 gram/118 mL M/W/F docusate sodium 50 mg/5 mL Liquid [Hospital1 ] Flovent HFA 110 mcg/Actuation Aerosol 2puffs [Hospital1 ] Discharge Medications: 1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO twice a day. 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q 24H (Every 24 Hours). 4. carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day). 5. baclofen 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily (). 7. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 8. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 12. cranberry 250 mg Tablet Sig: One (1) Tablet PO once a day. 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) 2.5mg nebulization Inhalation Q4H (every 4 hours). 15. ipratropium bromide 0.02 % Solution Sig: One (1) nebulization Inhalation Q6H (every 6 hours). 16. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 17. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 19. potassium chloride 20 mEq Packet Sig: One (1) PO once a day. 20. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal q M/W/F. 21. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 22. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 24. 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. 25. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 26. meropenem 500 mg Recon Soln Sig: One (1) Intravenous every eight (8) hours for 5 days. Discharge Disposition: Extended Care Facility: [Location (un) 583] House Rehab & Nursing Center Discharge Diagnosis: PRIMARY DIAGNOSIS Septicemia/bloodstream infection secondary to urinary tract infection urinary tract infection. SECONDARY DIAGNOSIS multiple sclerosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname ], . It was a pleasure taking care of you at [Hospital1 18]. You were admitted to the hospital because you had an infection in your bloodstream which caused your blood pressure to drop and you stopped breathing. You were treated with antibiotics and medications to keep your blood pressure up. Also we put you on a ventilator to breath for you. . The following changes were made to your medications: Continue Meropenem . It is very important that you keep all of the follow-up appointments listed below. Start Meropenem IV for 5 more days for your urinary tract infection Stop norvasc due to normal blood pressure Followup Instructions: Department: SURGICAL SPECIALTIES When: MONDAY [2118-11-28] at 2:00 PM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 164] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "038.42", "584.9", "300.00", "787.20", "512.89", "599.0", "V46.3", "507.0", "518.81", "995.92", "272.4", "414.01", "591", "478.75", "340", "250.00", "733.00", "592.0", "311", "491.21", "596.54" ]	icd9cm	[ [ [] ] ]	[ "55.03", "38.93", "96.72", "38.91", "96.04", "00.17" ]	icd9pcs	[ [ [] ] ]	16172, 16251	9442, 12808	324, 470	16448, 16448	4521, 4521	17273, 17583	3680, 3724		13902, 16149		16272, 16427		13080, 13879			16599, 17250		5470, 5765						3764, 4310															12829, 13054			1991, 2439				243, 286														498, 1972		5774, 9419			4537, 5454			16463, 16575					2461, 3247	3263, 3664			4335, 4502
78,745	149,185	40659	Discharge summary	report	Admission Date: [2180-6-21] Discharge Date: [2180-7-8] Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [2180-7-4] Aortic Valve Replacement(21mm Pericardial Valve) and Single Vessel Coronary Artery Bypass Graft(left internal mammary artery to left anterior descending) History of Present Illness: 86 y/o F with reported critical AS initial present to OSH with acute dyspnea and transferred to [Hospital1 18] for definitive therapy of aortic valve. . Per report, patient has had recurrent dyspnea on exertion for several months which has acutely worsened since Saturday until patient unable to go several steps without feeling short of breath. This am, patient felt worse, "too weak to do anything" and complaining of dyspnea at rest. Also reported burning indigestion, no nausea/ vomiting or diaphoresis. The patient called an ambulance and was found to be 88% on RA. Of note, patient had been evaluated at ED several times for dyspnea but had always previously refused admission/ intervention for valve [3-8] psychiatric comorbidies. . Exam notable for rales 2/3 up lung fields, peripheral edema and elevated JVD. Initially placed on CPAP and given 20mg IV lasix with improvement in symptoms (no UOP recorded). She was transferred to [Hospital1 18] for definitive management of valve. Upon arrival to [Hospital1 ], VS: 97.4 66 102/53 18 100% 4LNC. Labs notable for BNP > [2169], Hct of 33.4, trop 0.02. EKG showed nonspecific anterolateral changhes, no signs of ischemia. CXR consistent with volume overload. Patient transferred to the medicine service without further intervention. . On the floor, patient appears acutely dyspneic and unable to answer questions in full sentances. Repeated complains of skin infection despite attempted redirection towards cardiac symptoms. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Aortic stenosis - OCD - Anxiety - Delusional parasitosis - Colonic polyps Social History: - Lives alone. Daughters very involved in care - Tobacco: Quit over 23 years ago - Denies IVDA, ETOH use Family History: Denies premature coronary artery disease Physical Exam: Physical Exam on Admission: VS: T95 BP 119/67 HR 59 RR 20 SaO2 96% on 4LNC GENERAL: Well-appearing man in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, JVD at approx 12 cm HEART: RRR, grade III/VI SEM with obliteration of S2 LUNGS: crackles b/l midway up lung fields ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: 2+ PE b/l SKIN: multiple excoriations of L hand and legs b/l; no warmth, pustular discharge LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact Physical Exam on Discharge: Pertinent Results: Admission labs: [2180-6-21] WBC-6.6 RBC-3.60* HGB-11.4* HCT-33.4* MCV-93 MCH-31.8 RDW-15.3 [2180-6-21] NEUTS-85.0* LYMPHS-9.2* MONOS-4.3 EOS-1.0 BASOS-0.5 [2180-6-21] CK-MB-5 proBNP-[2093]* [2180-6-21] cTropnT-0.02* [2180-6-21] CK(CPK)-78 [2180-6-21] GLUCOSE-106* UREA N-24* CREAT-0.6 SODIUM-141 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14 . [2180-6-21] CHEST (PA & LAT) FINDINGS: Cardiomegaly is moderate to severe. Pulmonary vascular congestion and pulmonary edema is noted with small bilateral pleural effusions. Mediastinal contour is notable for atherosclerotic calcification of the aorta which is also unfolded. No pneumothorax is seen. Bony structures appear grossly intact. . [2180-6-22] TTE (Complete) The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal (LVEF 50-55%). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. . [2180-6-22] CT CHEST W/O CONTRAST IMPRESSION: 1. No radiographic evidence of intrathoracic malignancy or active infection. 2. Widespread atherosclerotic calcification involving coronary arteries, spares the ascending thoracic aorta. 3. Probable pulmonary hypertension. 4. Severe aortic valvular calcification, moderate left atrial and left ventricular enlargement. No pulmonary edema. Minimal pleural and pericardial effusions. . [2180-6-23] Cardiac Catheterization: 1. Coronary angiography in this left-dominant system demonstrated two vessel disease. The LMCA was without angiographically apparent disease. The LAD had 70% mid lesion. The LCx was dominant with <50% disease. The RCA was very small and non-dominant with severe mid vessel disease. 2. Resting hemodynamics revealed elevated right and left heart filling pressures with RVEDP 14 mmHg and PCWP 28 mmHg. There was moderate-severe pulmonary artery hypertension with PASP 54 mmHg. The cardiac index was preserved at 2.8 L/min/m2. There was mild systemic arterial systolic hypertension with SBP 144 mmHg. . [2180-6-26] CAROTID SERIES COMPLETE Findings: Right ICA less than 40% stenosis. Left ICA less than 40% stenosis. . Brief Hospital Course: MEDICINE COURSE: 86 y/o woman with reported critical aoric stenosis presnetin with acute dyspnea. # Critical aortic stenosis: The patient on arrival was acutely dyspnic, and was on 4 L NC. The patient was diuresed with PO Furosemide, her weight dropped by [4-7] pounds, and subsequently her breathing improved. When the patient was given 20 mg IV Lasix, although this helped to diruese her, the patient would become hypotense into systolics 80s; as such, the team avoided IV diuresis in Ms. [Known lastname 88941]. On admission, her results were notable for a proBNP of [2093], and the patient was troponin negative x3, with stable CK, CK-MBs. Her CXR on admission showed cardiomegaly and pulmonary edema with small bilateral pleural effusions, and her admission EKG showed a sinus rhythm. She diuresed well, and was subsequently satting well on room air with stable vitals. An ECHO was performed which showed LVEF of 55% as well as critical aortic valve stenosis (valve area <0.8cm2) (see full report in results section for more details). Based on this ECHO, the patient was evaluated by the cardiothoracic surgery team, who believed that she would be a candidate for aortic valve replacement. She underwent several tests to ensure her candidacy for valve replacement, including a CT chest, which showed no radiographic evidence of intrathoracic malignancy or active infection. She also underwent cardaic catheterization, which revealed a left-dominant system, with LAD 70% mid lesion, LCx with <50% disease, and a small and non-dominant RCA with severe mid vessel disease. Hemodynamic were also performed which showed elevated right and left heart filling pressures with RVEDP 14 mmHg and PCWP 28 mmHg. There was moderate-severe pulmonary artery hypertension with PASP 54 mmHg. Based on this result, it was decided that CABG would also be performed at the time of aortic valve replacement. A Panorex showed lucencies within the upper right incisor as well as within the lower right molars, likely representing caries, but without active infection or abscess. By ultrasound, the patient had patent lower extremity superficial veins with small diameters, and carotid ultrasound showed right ICA less than 40% stenosis, as well as left ICA less than 40% stenosis. The surgery was initially schedule for mid-week Wednesday, but the surgery was postponed in the setting of a urinary tract infection, as discussed below. # UTI: The patient initially had a Foley in place for mointoring of urine output in the setting of diuresis of a patient with aortic stenosis. On [2180-6-25], the patient had a U/A and culture drawn as a work-up prior to surgery, which revealed an infection with KLEBSIELLA PNEUMONIAE as well as ENTEROCOCCUS. Treatment empirically began on [2180-6-25] with Ciprofloxacin, and ID was consulted. ID initially recommended continuing Cipro and treating the enterococcus with Daptomycin, which was done for a day. CKs and LFTs were checked, and were within normal limits. The bacteria subsequently speciated as described in the microbiology section, and both species of bacteria were found to be sensitive to Augmetin, which was started. The total duration of antibiotic treatment was planned to be 7 days, starting [2180-6-25] and ending on [2180-7-1]. The patient upon questioning did endorse symptoms of burning and irritation, supporting her diagnosis of UTI. # Dentition: Panorex showed lucencies are seen within the upper right incisor as well as within the lower right molars, likely representing caries. As an outpatient, these should be managed by the patient's dentist. # Hypothyroidism: The patient is on thyroid replacement, and repeat TSH and T4 performed in house indicated that she was on appropriate therapy, which was left alone. # Coronaries: Cardiac cath shows three vessel disease, although worst in the LAD. The patient was started on Atorvastatin 80 mg daily for LDLc 126, and HgBA1c checked in house was wnl at 5.4%. The patient was not given a beta-blocker nor an ACE-I out of concern for her preload dependence prior to surgery. She was continued on ASA 81 mg Daily # OCD/delusional parasitosis: The patient has a multiple self-inflicted excoriations on hands and legs, that during hospitalization did not appear to be actively infected. The patient was continued on her home dose of Orap for delusional parasitosis. The plan is for a bioprosthetic valve instead of a mechanical valve due to the risk of bacteremia from the patient's self-inflicted excorations. # Nasal congestion: The patient complained of some nasal congestion in house, which had some allergic characteristics to it. She was started on Flonase [Hospital1 ]. SURGICAL COURSE: The patient was brought to the Operating Room on [2180-6-6] where the patient underwent AVR (21mm tissue), CABG x 1 (LIMA-LAD) with Dr. [Last Name (STitle) 914]. She was closed with DSS sternal plates. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged POD #4 in good condition with appropriate follow up instructions. Medications on Admission: Norvasc 5 mg daily Orap 1 mg [Hospital1 ] Seroquel 25 mg Daiy Zyprexa 5 mg ([2-6] in the AM, 1 at bedtime, one year ago) Prednisone 10 mg Daily Discharge Medications: 1. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days: then decrease to 200mg by mouth [Hospital1 ] x 1 week, then decrease to 200mg by mouth daily. Disp:28 Tablet(s) Refills:1 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 3. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:7 Tablet, ER Particles/Crystals(s) Refills:0 4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [2-6] Inhalation Q6H (every 6 hours) as needed for wheezes. Disp:QS Refills:0 6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush for 2 weeks. Disp:QS ML(s) Refills:0 7. pimozide 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). Disp:QS Refills:0 9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:0 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 12. 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 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:QS ML(s) Refills:0 14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:30 Suppository(s) Refills:0 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 16. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. Disp:QS Refills:0 18. Ondansetron 4 mg IV Q8H:PRN nausea Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 5176] Discharge Diagnosis: Aortic Stenosis, Coronary Artery Disease - s/p AVR/CABG Preop Urinary Tract Infection Hypertension Delusional Parasitosis OCD/Anxiety Discharge Condition: Alert and oriented x3 nonfocal Deconditioned Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 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] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge 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) ] [Last Name (NamePattern1) 914] [Telephone/Fax (1) 170] Date/Time:[2180-8-1] 1:15 Please call to schedule appointments with your Primary Care Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] in [5-9] weeks, [Telephone/Fax (1) 35502] Cardiologist: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] 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:[2180-7-8]	[ "599.0", "041.3", "300.00", "300.29", "416.8", "244.9", "041.04", "424.1", "300.3", "401.9", "414.01", "428.31", "427.31", "428.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21", "36.15", "37.23", "88.54" ]	icd9pcs	[ [ [] ] ]	14449, 14527	5973, 11837	263, 434	14705, 14902	3137, 3137	15826, 16467	2452, 2494		12040, 14426		14548, 14684		11863, 12017			14926, 15803								2509, 2523												3118, 3118										216, 225														462, 2215					3153, 5950		2537, 3089						2237, 2314	2330, 2436
45,724	101,742	42608	Discharge summary	report	Admission Date: [2194-12-29] Discharge Date: [2195-1-1] Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1271] Chief Complaint: Subarachnoid hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 89yo M presents as transfer from [Hospital ] hospital with SAH. Pt was having lunch with his wife when he fell and struck his head. Pt was unconscious, but was reportedly alert and moving all extremities. He later deteriorated and required intubation through his tracheostomy. He was transferred to [Hospital1 18] for further management. Past Medical History: PMHx: esophageal cancer Social History: LIVES WITH WIFE Family History: Family Hx: unknown Physical Exam: On admission: PHYSICAL EXAM: GCS 9T E: 3 V: 1T Motor 5 O: T: BP:112/76 HR: 82 R 16 O2Sats 98 HEENT: laceration to left forehead Neuro: intubated via tracheostomy, sedation recently initiated w/ propofol, EO to voice, non-verbal, pupils [3-12] bilaterally, cough and gag in tact, following simple commands, moving all extremities, toes equivocal bilaterally On discharge - he is awake and alert o x 3/ non verbal at baseline due to laryngectomy and tracheostomy stoma. His pupils are [4-13] bilaterally, EOMI, no facial and tongue is midline. His motor strength is near full throughout and somewhat effort dependent. His facial laceration / abrasion is clean / sutures intact. He is attentive and follows commands readily. Pertinent Results: [2194-12-29] CTA CT HEAD: There is evidence of subarachnoid hemorrhage in bilateral frontal and right parietal lobes. Small amount of blood is also seen in bilateral lateral ventricles. There is no hydrocephalus or midline shift. Note is made of soft tissue swelling in the left preseptal and facial soft tissues. There is no acute intracranial infarction. Ventricles and sulci appear age appropriate. Bilateral vertebral artery and intracranial carotid artery calcifications are seen. CTA HEAD: Atherosclerotic changes are seen in bilateral vertebral and cavernous and supraclinoid ICAs. There is no significant stenosis, occlusion, dissection or aneurysm formation. IMPRESSION: Mild increase in Subarachnoid and intraventricular hemorrhage as described above with left preseptal and facial soft tissue swelling. Pattern of hemorrhage is compatible with history of trauma. CTA head reveals no significant vascular stenosis or aneurysm formation. [2194-12-30] CT BRAIN FINDINGS: Subarachnoid hemorrhage overlying both cerebral hemispheres, right greater than left, is not significantly changed in quantity compared to the previous study from [12-29], [2194]. IMPRESSION: 1. No significant interval change in the overall quantity of subarachnoid hemorrhage overlying the cerebral hemispheres, right greater than left. Similarly, the quantity of intraventricular hemorrhagic extension is not significantly changed, allowing for redistribution. Decrease in the previously noted left temporal extra-axial hemorrhage. ( se 2, im 14) 2. No acute large vascular territorial infarction. [2194-12-29] CXR Final Report REASON FOR EXAMINATION: Evaluation of the patient with intracranial hemorrhage. Portable AP radiograph of the chest was reviewed with no prior studies available for comparison. The patient is after tracheostomy placement with the tip of tracheostomy being 4.5 cm above the carina. There is a pacemaker in the left hemithorax with its leads terminating in the expected location of right atrium and right ventricle. The assessment of the cardiac silhouette demonstrates mild cardiomegaly. There is also presence of the mediastinal shift to the left, most likely due to left lower lobe atelectasis, partially imaged. Patient is in mild interstitial edema. Bibasilar atelectasis is seen as well. Infectious process in the lung bases cannot be entirely excluded. Followup after diuresis to assess the remaining opacities that might potentially worrisome for infection is recommended. Brief Hospital Course: Pt was seen and examined in the emergency room for LOC and SAH/IVH after transfer from [Hospital ] Hospital. He had a tracheostomy in place related to history of esophageal cancer. On arrival to the outside hospital he was stable and then deteriortated. He was then connected to a ventilator for support and transferred to [Hospital1 18]. (PLEASE NOTE: HE IS NOT ABLE TO BE INTUBATED DUE TO LARYNGECTOMY / HE MUST HAVE A TRACH PLACED FOR VENTILATION IF NEEDED) He was seen and admitted to the ICU after trauma clearance. He was placed to trach mask the following am and tolerated this well. Repeat imaging on [12-30] was stable and he was transferred to the step down unit. On [12-31] he remained stable and was transferred to floor status. He tracheostomy was removed and his stoma is well healed and remains intact. He was seen by PT OT ST and cleared for discharge to rehab facility. The family is aware and agrees with this plan. Medications on Admission: unkown Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. repaglinide 2 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times a day (before meals)). 6. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 14. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 18. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Ondansetron 4 mg IV Q8H:PRN N/V 20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 21. Morphine Sulfate 2-4 mg IV Q4H:PRN pain hold for sedation 22. CefazoLIN 1 g IV Q8H facial laceration Duration: 7 Days Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: subarachnoid hemorrhage loss of consciousness intraventricular hemorrhage tracheostomy / old secondary to esophageal cancer facial lacerations 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: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed. Followup Instructions: ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [First Name (STitle) ] in the Traumatic Brain Injury (TBI) clinic the phone number is [Telephone/Fax (1) 6335]. If you have any problems booking this appointment please ask for [First Name8 (NamePattern2) 16367] [Last Name (NamePattern1) 16368]. As always, please call your primary care physician for an appointment to be seen. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2195-1-1]	[ "V49.87", "852.02", "E849.6", "V44.0", "E888.9", "V45.01", "873.42", "518.81", "V10.03" ]	icd9cm	[ [ [] ] ]	[ "08.81", "96.71" ]	icd9pcs	[ [ [] ] ]	6811, 6881	4110, 5068	279, 286	7068, 7068	1567, 1588	7893, 8690	765, 786		5125, 6788		6902, 7047		5094, 5102			7244, 7870								831, 1548																						216, 241														314, 667		1597, 4087					816, 816	7083, 7220					689, 715	731, 749
32,765	191,799	31337	Discharge summary	report	Admission Date: [2191-8-9] Discharge Date: [2191-8-15] Date of Birth: [2134-10-29] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3376] Chief Complaint: Cecal mass bleed Major Surgical or Invasive Procedure: lap R colectomy History of Present Illness: Mr. [Known lastname ] is a 56yo male with a h/o anxiety, arthritis, and an achilles tendon repair who presented to [Hospital ] [Hospital1 14360] with 2 days of rectal bleeding. He had a syncopal episode at work and was admitted on [2191-8-9]. He underwent a colonoscopy at that time which revealed a large mass at cecum. He was transfused with 2 units at PRBC and transferred to [Hospital1 18]. Past Medical History: PMH: bleeding cecal mass, asthma as child, achilles repair, arthritis, and anxiety. Social History: Drinks occasional wine, about 2x/week. Smoking history, smoked on & off, quit. Family History: noncontributory Physical Exam: Vitals in SICU: T-98.4, HR-75, BP-133/67, RR-14, O2 sat 97% on RA Neuro: A&Ox3 HEENT: PERRLA, EOMI Cardiac: RRR RESP: CTAB ABD: NT/ND, bowel sounds x4 Ext: No periph edema INC: C/D/I. Rectal: positive gross blood. Pertinent Results: [2191-8-13] 06:30AM BLOOD WBC-4.5 RBC-2.92* Hgb-8.7* Hct-24.9* MCV-85 MCH-29.9 MCHC-34.9 RDW-15.3 Plt Ct-64* [2191-8-9] 06:26PM BLOOD WBC-6.5 RBC-2.83* Hgb-8.3* Hct-23.7* MCV-84 MCH-29.5 MCHC-35.1* RDW-14.8 Plt Ct-122* [2191-8-13] 06:30AM BLOOD Plt Ct-64* [2191-8-11] 02:46AM BLOOD PT-12.0 PTT-23.7 INR(PT)-1.0 [2191-8-13] 06:30AM BLOOD Glucose-122* UreaN-15 Creat-1.1 Na-142 K-3.7 Cl-109* HCO3-25 AnGap-12 [2191-8-9] 06:26PM BLOOD Glucose-110* UreaN-12 Creat-1.0 Na-143 K-3.5 Cl-114* HCO3-22 AnGap-11 [2191-8-9] 06:26PM BLOOD ALT-14 AST-14 LD(LDH)-98 AlkPhos-35* Amylase-63 TotBili-0.5 [2191-8-13] 06:30AM BLOOD Calcium-7.6* Phos-2.2* Mg-2.0 [2191-8-9] 06:26PM BLOOD Albumin-3.0* Calcium-7.4* Phos-3.3 Mg-1.7 [2191-8-9] 06:26PM BLOOD CEA-1.1 . RADIOLOGY Final Report CHEST (PRE-OP AP ONLY) PORT [2191-8-10] 9:15 PM [Hospital 93] MEDICAL CONDITION: 56 year old man with bleeding cecal mass and colonic angiodysplasia REASON FOR THIS EXAMINATION: preoperative CXR, please evaluate for cardiopulmonary pathology PA AND LATERAL CHEST, [8-10] IMPRESSION: AP chest reviewed in the absence of lateral or prior chest radiographs: Minimal vascular engorgement is present in the lungs but there is no pulmonary edema. Heart is normal size. Lungs are clear and there is no pleural effusion or pneumothorax. . Pathology Report from [2191-8-11]-PENDING. . [2191-8-10] EGD Impression: Nodule in the middle third of the esophagus Erythema in the duodenum compatible with duodenitis Nodule in the stomach body Otherwise normal EGD to second part of the duodenum Recommendations: [Hospital1 ] PPI Avoid NSAIDs Repeat endoscopy in [4-8] wks . [2191-8-10] Colonoscopy Impression: Mass in the cecum, across from the ileocecal valve Numerous small submucosal venous blebs, measuring 3 to 8 mm, were found in the sigmoid to a distance of 30 cm. None were bleeding. They do not appear to be AVM's or likely to be the source of bleeding, although this pattern of vascularity is rarely associated with a more extensive intramural network of vascular malformations. Old blood in the distal colon Otherwise normal colonoscopy to cecum Brief Hospital Course: Mr. [Known lastname ] is a 56 yo male admitted to General Surgery for surgical management of a cecal mass bleed. Cardiac-He had an episode of tachycardia and hypertension in the SICU and was treated with IV Lopressor. His BP & HR have remained stable during his stay on [Wardname 7911]. The Lopressor was discontinued. No furhter treatment is required post-discharge at this time. He was advise to follow-up with his primary doctor. Heme-He was treated with 2 units of PRBC at OSH prior to transfer to [Hospital1 18]. He was treated with PRBC and FFP again on [2191-8-10] with serial HCT checks. His HCT stabilized, and is currently 24.9%. Pain-He was intially treated with an IVPCA post-operatively with adequate relief. He was transitioned to oral Dilaudid with adequate effect. His pain has ranged between [2194-3-7]. He will be discharged home with a prescription for Dilaudid for 2 weeks. Nutrition-His diet was advanced to a regular food. He has been tolerating food, but reports feeling of fullness, and occasional nausea. He last regurgitated food this morning, about 20cc;no emesis since. GI/Elimination-GI was consulted. He underwent an EGD & colonoscopy on [2191-8-10], please refer to results section.An H.Pylori antibody was obtained, and cam back positive. He was started on a Pre-pac on [2191-8-15], and was instructed to complete the full 2 weeks and follow-up with GI out-patient, avoid NSAIDs. He has been urinating adequate amounts. His bowel function has been stable post-operatively. His last bowel movement was [2191-8-15]. He was instructed to take Colace while taking Dilaudid to prevent constipation. Skin-He has a midline abdominal incision intact with staples which will be removed during his follow-up appointment with Dr. [Last Name (STitle) 1120]. He was provided with this instruction. Activity-He ambulates and performs all ADL's independently at baseline. He has been ambulating independently post-operatively with no limitations. ID-He has remained afebrile. Neuro-He is alert and oriented x3. Medications on Admission: [Last Name (un) 1724]: ASA 81, lorazpam pr, multivitamin Discharge Medications: 1. Hydromorphone 2 mg Tablet [Last Name (un) ]: Two (2) Tablet PO Q4H (every 4 hours) as needed for 2 weeks. Disp:45 Tablet(s) Refills:0 2. Acetaminophen 500 mg Tablet [Last Name (un) ]: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain. 3. Lorazepam 0.5 mg Tablet [Last Name (un) ]: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 4. Colace 100 mg Capsule [Last Name (un) ]: One (1) Capsule PO twice a day as needed for constipation for 1 months. Disp:60 Capsule(s) Refills:1 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day) for 13 doses. Disp:13 Tablet,Rapid Dissolve, DR(s) Refills:0 6. Clarithromycin 250 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times a day) for 13 doses. Disp:26 Tablet(s) Refills:0 7. Amoxicillin 250 mg Capsule [Last Name (STitle) ]: Four (4) Capsule PO BID (2 times a day) for 13 doses. Disp:52 Capsule(s) Refills:0 8. Lorazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO at bedtime for 2 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Cecal mass Syncope r/t GI bleed Gastrointestional bleed treated with blood product transfusion Acute tachycardia and hypertension treated with IV Lopressor. GERD, postive H. Pylori-treated with PrevPak Secondary: Arthritis Asthma anxiety Discharge Condition: Good Tolerating a Regular diet Adequate pain control with oral medications 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 vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, 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 skin, or the whites of your eyes become yellow. * 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. **Please finish the PREV-PAC to treat the H.Pylori infection in your stomach. -----Make sure to follow-up with a Gastroenterologist (Stomach & bowels doctor). Call your primary doctor for a referral. Continue to amubulate several times per day. Please check your weight once a day in the morning. Followup Instructions: Please call Dr.[Name (NI) 3377] office at [Telephone/Fax (1) 160] for a follow-up appointment in [1-4] weeks. Please follow-up with Gastroenterology in [2-5] weeks for management of GERD and H.Pylori. Obtain a referral from your primary doctor. Completed by:[2191-8-15*]	[ "716.90", "300.00", "041.86", "530.81", "285.9", "427.89", "578.9", "153.4", "401.9" ]	icd9cm	[ [ [] ] ]	[ "45.73", "45.93", "45.23", "45.13" ]	icd9pcs	[ [ [] ] ]	6828, 6834	3490, 5558	331, 349	7126, 7203	1279, 2144	8547, 8839	1013, 1030		5669, 6805	2181, 2249	6855, 7105		5584, 5646			7227, 8524								1045, 1260																						275, 293	2278, 3467													377, 794													816, 901	917, 997
13,733	196,357	44	Discharge summary	report	Admission Date: [2143-4-20] Discharge Date: [2143-4-26] Date of Birth: [2070-10-21] Sex: F Service: CARDIOTHORACIC Allergies: Hydrochlorothiazide / Zoloft / Compazine Attending:[First Name3 (LF) 492] Chief Complaint: SOB Major Surgical or Invasive Procedure: L thoracotomy with pericardial window and chest tube placement History of Present Illness: 72 W from [First Name8 (NamePattern2) 466] [Country 467], with multiple cancers including ovarian (s/p s/p TAH SBO and 6 cycles of ctaxol/carboplatinium) and cholangiocarcinoma (s/p whipple) with mets of uncertain origin to liver and lung, recently admitted [4-6]-22 for CAP (treated with azithro), originally admitted to [Hospital Unit Name 153] for SOB, orthopnea, and coughing which was initially attributed to CHF, symptomatic hyponatremia (increasing confusion, lethary), and ARF. Cards was consulted and an echocardiogram revealed a pericardial fluid collection with tamponade. She was sent urgently to the OR for a pericardial window via L thoracotomy. She was out of the OR by [8-28] PM, extubated by 0400 the day of transfer, and seemed to be doing well. She was sitting up in a chair when she was noticed to be unresponsive, but still breathing and with a pulse. She was transferred back to her bed and at that ppint was noticed to be in full cardiac and respiratory arrest without pulse or spontaneous respirations. Patient did have a rhythm on monitor so patient was diagnosed with PEA arrest. CPR was initiated, she received 2 amps of epi and an an of calium, she was intubated, started on Neo, and had a femoral line placed. Within 15 minutes pulse returned. A stat repeat ECHO was performed at that time and patient was found to have [Male First Name (un) ] (systolic anterior motion), severe MR, and new wall motion abnormalities but no re-accumulation of pericardial effusion. She is now being transferred to the MICU for further work-up and management. Past Medical History: Pancreatic cancer s/p whipple [2141-7-18], metastatic to liver Ovarian ca s/p carboplatinum/taxol ([2126]) HTN AAA OA Depression Vertigo Social History: Occupation: former storekeeper in [First Name8 (NamePattern2) 466] [Country 467], moved to US in [2134] after husband disappeared during their pilgrimage to [Location (un) 481] in [2133] Drugs: None Tobacco: None Alcohol: None Family History: NC Physical Exam: General Appearance: Thin Eyes / Conjunctiva: PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic, dry MM Lymphatic: Cervical LAD Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur: [1-23] soft Systolic Ejection Murmur) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : [12-19] way up bilaterally) Abdominal: Soft, Non-tender, No bowel sounds present, nontender palpaple mass in epigastrium Extremities: Right: 2+, Left: 2+ DP pulses Skin: Warm Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to): person and place, Movement: Not assessed, Tone: Not assessed Pertinent Results: U/S Lower extremities: No DVT of the right lower extremity . Renal U/S: No son[Name (NI) 493] evidence of hydronephrosis . Echocardiogram: Moderate sized pericardial effusion (up to 1.3cm in greatest diameter - near the RV apex). The effusion is located mostly anterior to the right ventricle and near the apex. There is RV diastolic collapse, consistent with tamponade physiology. Mild symmetric LVH with small LV size and probably normal function. . CXR: One portable view. Comparison with the previous study done [2143-4-20]. The lung apices are not included. Bilateral diffuse reticulonodular infiltrates are again demonstrated. A focal area of increased density at the right base persists. The costophrenic sulci are blunted as before. Mediastinal structures are unchanged. There is no definite interval change. . KUB: Single supine view shows non-obstructive bowel gas pattern. Reticulonodular opacities at the lung bases. Calcified granuloma projecting over left pelvis. Upper portion of pessary projects over lower pelvis. Calcifications along aorta. Degenerative changes along spine. -ALee . [2143-4-20] 08:58PM PT-13.7* PTT-26.7 INR(PT)-1.2* [2143-4-20] 08:58PM PLT COUNT-155# [2143-4-20] 08:58PM WBC-13.4* RBC-4.90 HGB-13.8 HCT-40.1 MCV-82 MCH-28.2 MCHC-34.5 RDW-13.6 [2143-4-20] 08:58PM GLUCOSE-141* UREA N-41* CREAT-1.6* SODIUM-118* POTASSIUM-4.2 CHLORIDE-76* TOTAL CO2-23 ANION GAP-23* [2143-4-20] 08:58PM CALCIUM-8.9 PHOSPHATE-5.0# MAGNESIUM-3.3 [2143-4-20] 08:58PM CK-MB-NotDone proBNP-5461* [2143-4-20] 08:58PM CK(CPK)-46 [2143-4-20] 08:58PM cTropnT-0.01 [2143-4-20] 11:00PM URINE HOURS-RANDOM UREA N-293 CREAT-80 SODIUM-19 URIC ACID-31.5 [2143-4-20] 11:00PM URINE OSMOLAL-286 Brief Hospital Course: 72 W from [First Name8 (NamePattern2) 466] [Country 467], with multiple cancers originally admitted to [Hospital Unit Name 153] for SOB and orthopnea [1-19] to pericardial tamponade, s/p pericardial window [4-22], now s/p PEA arrest, transferred to MICU for further care. Patient remained unresponsive after the PEA arrest and EEG was negative for seizure. Neurology felt her mental status was consistent with global hypoxic injury after PEA arrest. Patient remained peristantly acidemic and began to have multi-organ symtem failure including oliguric renal failure and transaminitis concerning for shock liver. Patient's grim prognosis was discussed at length with the patient's family. Patient was made comfort measures only and was terminally extubated with patient's family at her bedside. She expired within minutes of being extubated and was pronounced dead at 12:25 PM. The family declined autopsy. Medications on Admission: Paxil 10 daily Diovan 80 daily Nifedipine 60 daily Lopressor 50 twice daily Zocor 10 daily Megace 1 tsp thrice daily Vicodin prn MVI Senna Colace Lactulose Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494]	[ "570", "785.50", "428.0", "V10.09", "198.89", "584.9", "427.5", "348.1", "276.52", "276.1", "428.33", "197.7", "197.0", "401.9", "V10.43" ]	icd9cm	[ [ [] ] ]	[ "96.04", "34.04", "38.93", "37.12", "96.71" ]	icd9pcs	[ [ [] ] ]	6223, 6232	5049, 5984	311, 375	6283, 6292	3261, 5026	6348, 6470	2457, 2461		6191, 6200		6253, 6262		6010, 6168			6316, 6325								2476, 3242																						268, 273														403, 2007													2029, 2176	2192, 2441
7,552	104,082	51396	Discharge summary	report	Admission Date: [2167-11-16] Discharge Date: [2167-11-17] Date of Birth: [2097-9-6] Sex: M Service: VASCULAR DATE OF EXPIRATION: [2167-11-17]. HISTORY OF PRESENT ILLNESS: The patient is an unfortunate 70 year old gentleman with a past medical history that is significant for a coronary artery bypass graft times three that was done in [2167-2-28] here at [Hospital1 190]. He had a history of a right carotid endarterectomy done in [2156] and a history of mitral valve regurgitation and atrial fibrillation that was cardioverted in [2165], and the patient was taking Amiodarone. He also had a history of gout and hypertension. He was found to have an abdominal aortic aneurysm and most recently he underwent an abdominal CT scan for surveillance and it revealed that his abdominal aortic aneurysm had increased ins size to 5 cm. He was evaluated in the office on the Vascular Service and he was found to be not an adequate candidate for a usual stent graft repair of this aneurysm. He was offered an open elective repair for which the patient agreed. He was scheduled to have this operation electively on [2167-11-16]. He had a cardiac and medical clearance by his primary care physician as well as his Cardiologist and he was deemed to be in good condition to undergo this operation. On [2167-11-16], the patient was taken to the Operating Room and underwent an open abdominal aortic aneurysm repair with an aorta [Hospital1 ]-iliac Dacron graft. The operation was complicated with a lower pole splenic tear that was tried to be repaired primarily and which ultimately required a splenectomy for persistent bleeding. In the Operating Room he received 11 liters of crystalloid and made only 150 cc of urine and there was an estimated blood loss of 4.5 liters. He received a total of four units of packed red blood cells and [Pager number ] cc of Cellsaver. He was transferred to the Recovery Room where he persistent aneuric and acidotic requiring pressors and fluid in order to maintain his hemodynamics. Ultimately, he was transferred to the Surgery Intensive Care Unit on the sixth floor to continue his monitoring by the surgical house staff as well as the attending. Once in the Intensive Care Unit, his acidosis worsened and despite aggressive intravenous fluid resuscitation and pressor medications, the patient remained hypotensive. An emergent Cardiology consultation and a transthoracic echocardiogram was obtained but unfortunately at that time, this study revealed poor windows and there was no obvious or acute evidence of hypokinesis nor pericardial effusion. Despite these results, because once again due to poor windows and due to the body habitus of this patient, a transesophageal echocardiogram was recommended and obtained. This study revealed marked left ventricular hypokinesis as well as an akinetic septum with severe left ventricular function depression. There was a very poor ejection fraction despite the pressor medications. Renal was consulted as well because the patient was anuric for many hours and he had a worsening acidosis. The recommendation for the nephrologist was to start him on a Dopamine drip, trying to improve perfusion to his kidneys. In spite of all the above mentioned measures, the patient remained hypotensive and his hematocrit drifted down, becoming progressively more distended in the abdominal region. At that time, upon discussion with Dr. [Last Name (STitle) ], the attending of record, the decision was made to take him back to the Operating Room for a re-exploration. Upon taking him back to the Operating Room, approximately [2163] cc of blood and clot were found in the left upper quadrant but upon evacuating this hematoma, there was no obvious source of bleeding identified. The patient was closed loosely with a rubber [Doctor Last Name ] and a big Ioban and it was elected to leave the abdomen open with two medium sized [Location (un) 1661]-[Location (un) 1662] drains on the lateral aspect. Once again, the patient was transferred to the Intensive Care Unit on multiple pressors including Levophed, Neo-synephrine, vasopressin, dopamine and intravenous fluids running at 200 cc an hour. Within the next couple of hours, the acidosis persisted and the patient continued to bleed extensively from his [Location (un) 1661]-[Location (un) 1662] drains. A new set of coagulation studies was sent and the INR at this point was found to be 11.0 with a PTT in the mid 100s and an elevated PT. The fibrinogen was low and further repletion with fresh frozen plasma, Cryo, and more units of packed red blood cells were also started and initiated. The case was discussed again with the attending of record and upon consultation with the Surgical attendings on the vascular service. It was decided to continue to fully support him and try to correct his coagulopathy before trying to explore him again in the Operating Room as he was very unstable to be transferred anywhere. The patient's abdomen progressively became more distended and a Foley catheter pressure was transduced and came back high on 33 mm of water. Because he was markedly unstable to be moved to the Operating Room, the decision was made to open his abdomen in the Intensive Care Unit for which purpose an abdominal kit and a bulb electrocardia as well as pulse suction and multiple canisters were brought to the Intensive Care Unit to do the abdominal wound exploration. At this point, the patient had received 26 units of packed red blood cells, 14 units of fresh frozen plasma, 6 units of platelets, one unit of cryo, 5 gram load of Amicar as well as a continuous rip and a Factor VII that included 4800 micrograms infused. Upon opening the abdomen, we found about 3000 cc of half clotted blood that was evacuated with a bulb sucker. Once again, no obvious source of bleeding was found nor identified. The aorta repair appeared to be intact with no clot extravasation. The bowel was noted to be diffusely edematous with multiple patches of ischemia all along its length. There was a feculent smell in the abdomen with no obvious bowel perforation identified. Upon packing all four quadrants, the abdomen was closed again with a rubber [Doctor Last Name ] and an Ioban and two medium sized [Location (un) 1661]-[Location (un) 1662] drains were left on the lateral aspect of the wound. At his point, the patient was still on Levophed, epinephrine, dopamine and pitressin to keep his systolic blood pressure barely above 90s. He remained anuric and his acidosis progressively worsened despite bicarbonate infusions. The patient's family was aware of the patient's condition and upon their request, they were allowed to enter the Intensive Care Unit room to see the patient. Despite full support, the patient expired and was pronounced at 12:14 p.m. [2167-11-17]. The family was present as well as a catholic priest and the Surgery Intensive Care Unit staff. Medical examiner was notified and he declined the case. The family was offered a post mortem examination which was accepted. We will arrange for this to happen in our Pathology Department. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) ], M.D. [MD Number(1) 19472] Dictated By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. MEDQUIST36 D: [2167-11-17] 14:23 T: [2167-11-17] 14:56 JOB#: [Job Number 106555]	[ "518.5", "584.9", "998.11", "557.0", "286.6", "427.5", "785.59", "998.2", "441.4" ]	icd9cm	[ [ [] ] ]	[ "41.5", "54.12", "99.05", "38.44", "99.04", "99.06", "99.07" ]	icd9pcs	[ [ [] ] ]																																																												211, 7550
66,574	188,759	13017	Discharge summary	report	Admission Date: [2141-5-28] Discharge Date: [2141-6-3] Date of Birth: [2059-1-20] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: R foot pain/weakness Major Surgical or Invasive Procedure: [2141-5-28] - R SFA-AKA [Doctor Last Name ] stent, R BK [Doctor Last Name 39865] PTA [2141-5-29] - b/l CIA stent, evac retroperitoneal hematoma, R CFA repair, L CFA endarterectomy [2141-6-1] - L brachial artery exploration History of Present Illness: 82yo F with CAD s/p MI developed R foot weakness and pain last evening, called her daughter at 2am. She noted the foot to appear pale, feel cool, and absent pulses. Brought to [Hospital3 9683] where noted pulmonary infiltrate c/w PNA, rx'd Levaquin, and obtained Head CT (reportedly negative). Upon transfer to [Hospital1 18], CTA obtained and vascular surgery subsequently consulted. Pt currently reports constant pain in R foot. No prior episodes. ROS: recent cough/URI symptoms, with mild dyspnea currently. no CP or palpitations. no HA or dizziness. no dysuria. no history of CVA, remote h/o gastric ulcer Past Medical History: CAD s/p MI (~5y ago), hypothyroid, gastroparesis, glaucoma, peptic ulcer PSH: appy, hysterectomy Social History: former Tob, quit 20y ago after 2ppd. no EtOH Family History: EtOH cirrhosis, CVA/CAD Physical Exam: on admission: 97.9 79s 174/82 32 100% on NRB A&Ox3, NAD BL rales RRR sans M/R/G soft, mild distended, NT. well-healed lower midline scar without hernia. (rectal deferred during setup of CPAP, but reportedly guaiac negative per ED) RLE: below ankle is cool to touch (not cold), pale, insensate, with decreased motor strength compared to contralateral side that is normal is those regards. Pulses: Fem [Doctor Last Name ] DP PT R 1+ none none none L 2+ dop mono none Pertinent Results: [2141-5-28] 09:10AM WBC-8.6 RBC-3.26* HGB-10.6* HCT-30.1* MCV-92 MCH-32.6* MCHC-35.3* RDW-13.6 [2141-5-28] 09:10AM cTropnT-0.29* [2141-5-28] 09:10AM CK-MB-6 proBNP-1646* [2141-5-28] 09:10AM GLUCOSE-134* UREA N-24* CREAT-0.8 SODIUM-126* POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-22 ANION GAP-16 Brief Hospital Course: Ms. [Known lastname 9201] was seen by our vascular surgical service in the ER on [2141-5-28], and was diagnosed with occlusion of both of her superficial femoral arteries resulting in RLE ischemia. She was started on a heparin drip and bolus, and taken to the operating room emergently, where an angiojet thrombectomy of the right SFA and popliteal thrombus and R SFA stent was placed and angioplasty performed on the R BK poplitial arteria and AT artery and a lysis catheter was placed in the bk [Doctor Last Name ] / AT. She was continued on her TPA and low dose heparin drip, and transferred to the CVICU. She was found to have a pulseless L foot, so her sheath was downgraded to a 5Fr sheath, the lysis catheter was removed and the TPA was stopped and full dose heparin was started with immediate return of doppler signals to her foot after the sheath change. Her troponin also increased dramatically, and the cardiology service was consulted. She was found to have a L common iliac artery rupture on [5-29] and taken back to the operating room emergently on [2141-5-29] for treatment of a retroperitoneal bleed, b/l iliac stent grafts, b/l CFA repairs, left SFA embolectomy, and an aortic stent. Given her recent esophageal dilatation for CREST syndrome she was not a candidate for TEE and underwent a TTE which showed no apical thrombus. She was presumed to have either left atrial thrombus (as she had evidence of likely bilateral lower extremity embolization and had a history of palpitations with multiple prior holter monitors) or a severe prothrombotic state with hypoperfusion/dehydration related to MI and CHF as the etiologic event. However, given her severe hemorrhage we elected to proceed without heparin at this time. She remained anemic, requiring multiple units of PRBC, and developed evidence of shock liver. On [2141-6-1] she developed rapid AFib, and was started on an amiodarone drip. Her L hand was noted to be acutely ischemic, and she was taken back to the OR, where brachial artery exploration revealed no evidence of thrombus or embolus. Renal was consulted for her gradually rising creatinine, and determined that she likely had contrast and hypoperfusion-related ATN, and would likely need dialysis. The family, who remained quite involved throughout her hospital stay, decided that she would not have wanted to undergo a prolonged hospital stay or dialysis, with likely chronic nursing home care to follow, and as her renal failure and liver failure continued to worsen, decided to withdraw care on [2141-6-3]. Medications on Admission: ecASA 81', prednisone 5', lopressor 25', nifedipine XL 60', isosorbide dinitrate 20'', lipitor 10', SL nitro prn, prilosec 20', levothyroxine 50', metamucil, miralax, MVI, floragen, vitD [Numeric Identifier 1871]', vitC, vitE 400', Fe, compazine prn, zofran prn, timolol 0.5% OU, travatan 0.004% OU hs, tylenol prn Discharge Medications: none. Discharge Disposition: Expired Discharge Diagnosis: Peripheral arterial disease Acute ischemia of RLE Acute ischemia of L hand Multisystem organ failure Discharge Condition: Deceased Discharge Instructions: none. Followup Instructions: none. Completed by:[2141-6-3]	[ "444.21", "492.8", "414.01", "285.1", "V58.65", "428.0", "570", "365.9", "710.1", "486", "536.3", "244.9", "443.22", "996.74", "412", "584.5", "401.9", "518.84", "444.22", "276.2", "440.22", "998.11", "428.23", "410.71", "441.02", "427.31" ]	icd9cm	[ [ [] ] ]	[ "39.90", "96.72", "00.40", "00.47", "88.47", "39.71", "39.50", "00.42", "38.93", "99.10", "38.03", "96.6", "88.42", "54.19", "39.79", "38.18", "88.48" ]	icd9pcs	[ [ [] ] ]	5322, 5331	2339, 4923	334, 578	5475, 5485	2002, 2316	5539, 5574	1434, 1459		5292, 5299		5352, 5454		4949, 5269			5509, 5516								1474, 1474																						274, 296														606, 1235							1489, 1983						1257, 1356	1372, 1418
71,722	164,786	40463	Discharge summary	report	Admission Date: [2193-3-24] Discharge Date: [2193-4-2] Date of Birth: [2114-7-23] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin Attending:[First Name3 (LF) 1406] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: Coronary artery bypass graft x1 (Saphenous vein graft >right coronary artery), Aortic valve replacement ([First Name8 (NamePattern2) 17167] [Male First Name (un) 923] Epic Supra Porcine) [2193-3-27] Cardiac catheterization [2193-3-27] History of Present Illness: 78 year old gentleman with history of aortic stenosis followed by serial echocardiograms. In [2190] his aortic valve area was 0.9cm2 and he had a 60% right coronary artery leasion. A recently repeated echocardiogram showed his aortic valve area to be 0.62cm2. He was admitted to [Hospital6 3105] on [2193-3-22] for a cardiac catheterization to further evaluate his aortic valve and coronary artery disease. This revealed his aortic valve area to be 0.58cm2 with a mean gradient of 53mmHg. His right coronary artery had an 80% lesion, his left anterior descending artery was 50% stensosed and his circumflex had a 50% stenosis. He denies any symptoms of dyspnea, fatigue, chest pain or orthopnea. He has been transferred today from [Hospital3 12748] for surgical evaluation. Past Medical History: Aortic stenosis Coronary artery disease Hyperlipidemia Hypertension Herpes zoster with postherpatic neuralgia right ear Surgery for diverticulitis s/p TURP s/p Tonsillectomy/Adenoidectomy Social History: Lives with: Alone Occupation: Retired Tobacco: [12-9] ppd for 21 years ETOH: Denies Family History: Sister with valve replacement in her late 70's Physical Exam: PREOP EXAM: Pulse: 75 SR Resp: 18 O2 sat: 100% B/P: 121/63 Height: 64" Weight: 154lbs BSA 1.8 General: WDWN in NAD Skin: Warm, Dry and intact. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Minimal swelling in right auricular/periauricular area but tender to palpation. Edentulous Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [C] Heart: RRR, IV/VI SEM, Nl S1-S2 No S3. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Right radial and brachial cath sites noted. No Edema Varicosities: Spider varicosities bilaterally L>R. GSV appears suitable. Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 PT [Name (NI) 167]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Transmitted vs. Bruit Pertinent Results: [2193-3-27] Intraop ECHO PREBYPASS: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Diastolic function consistent with Impaired relaxation. No clot in LAA, Intact IAS. Mildly dilated coronary sinus. No [Month/Day/Year 88652], Normal EF > 55%. POSTBYPASS: normally functioning av bioprosthesis. No other changes. No disseciton seen after Cannula removed. No [Last Name (LF) 88652], [First Name3 (LF) ] > 55%. . [2193-3-27] Cardiac Catheterization 1. Selective coronary angiography of the RCA demonstrated a proximal 70 stenosis. The LCA demonstrated no significant coronary artery disease. 2. Selective venous conduit angiography demonstrated the SVG to RCA to be patent with normal flow. . [2193-3-25] CTA Mild aortic arch calcifications extending into the descending thoracic aorta with a small amount of calcification along the sinotubular junction as described above. . [2193-3-30] CXR Interval increase in small pleural effusions. The patient has been extubated and the Swan-Ganz catheter has been withdrawn. . [2193-4-1] CXR In comparison with study of [3-30], there are substantial bilateral pleural effusions with the change in appearance most likely reflecting the PA upright rather than portable semi-upright position. The pulmonary vessels are essentially within normal limits. Compressive atelectatic changes are seen at the bases. . LABS: [2193-4-2] WBC-8.1 RBC-3.29* Hgb-10.4* Hct-30.5* RDW-15.1 Plt Ct-201# [2193-3-31] WBC-7.9 RBC-3.29* Hgb-10.5* Hct-29.6* RDW-14.9 Plt Ct-87* [2193-3-30] WBC-8.6 RBC-3.36* Hgb-10.6* Hct-30.3* RDW-14.9 Plt Ct-72* [2193-3-29] WBC-13.8# RBC-3.50 Hgb-11.3* Hct-31.5* RDW-15.3 Plt Ct-79* [2193-4-2] Glucose-110* UreaN-15 Creat-0.8 Na-135 K-3.9 Cl-103 HCO3-25 [2193-4-1] Glucose-116* UreaN-14 Creat-0.2* Na-133 K-3.2* Cl-97 HCO3-29 [2193-3-31] Glucose-118* UreaN-15 Creat-0.8 Na-130* K-4.0 Cl-89* HCO3-35* [2193-3-30] Glucose-101* UreaN-14 Creat-0.8 Na-128* K-4.4 Cl-94* HCO3-31 [2193-3-29] Glucose-104* UreaN-9 Creat-0.7 Na-131* K-5.3* Cl-98 HCO3-26 [2193-4-2] 04:37AM BLOOD Mg-2.2 Brief Hospital Course: He was transferred from outside hospital and underwent preoperative workup. On [2193-3-27] he was brought to the Operating Room for coronary artery bypass graft and aortic valve replacement surgery. See operative report for further details. He received Cefazolin and Vancomycin for perioperative antibiotics. Post operatively he was transferred to the intensive care unit for post operative management. He initially required inotropes and pressors for hemodynamic instability and a TEE was obtained that revealed RV hypokinesis. After further evaluation with increased lactate and acidosis he was returned to the Operating Room and had angiogram to evaluate his right graft which was patent. He remained on pressors and inotropes receiving volume with improvement overnight. On postoperative day one he remained intubated and sedated. On postoperative day two, his pressors and inotropes were continued to be weaned to off and diuretics were started for gentle diuresis. He awoke neurologically intact and was extubated without incident. Beta blockade and statin therapy were initiated. A contraction alkalosis was noted which responded well to diamox. On postoperative day three he remained stable, and all chest tubes and temporary pacing wires were removed without complication. He was then transferred to the floor. He remained in a normal sinus rhythm. Beta blockade and ACEI were advanced as tolerated to optimize heart rate and blood pressure. Over several days, he continued to make clinical improvements with diuresis and was medically cleared for discharge to the TCU at St. Raphaels [Hospital3 ] Rehab on postoperative day six. Discharge chest x-ray was notable for bibasilar atelectasis and bilateral pleural effusions. Oxygen saturations at discharge were 100% on room air. At discharge, he remained fluid overloaded and will continue to require diuresis which should be titrated accordingly. All surgical incisions were healing well, and his pain was well controlled with Tylenol. Percocet was discontinued during his hospital stay secondary to some mild confusion. Prior to discharge, followup appts with Dr. [Last Name (STitle) ] and his cardiologist were arranged. Medications on Admission: Neurontin 300mg three times a day Lisinopril 10mg daily Toprol xl 50mg daily Nortriptyline 25mg daily Zocor 20mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day: hold if sbp < 100mmHg. 8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for HR < 55 or SBP < 90 mmHg. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks: Lasix 40mg daily x 1 week, then re-evaluate need for ongoing diuresis. 13. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 1 weeks. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts Aortic stenosis s/p aortic valve replacement Hyperlipidemia Hypertension Postop Pleural Effusions Discharge Condition: Alert and oriented x3 nonfocal Spanish speaking Ambulating with Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 2+ Edema 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: Dr [Last Name (STitle) ] ([Telephone/Fax (1) 170]) [2193-4-24] at 1:15 pm Cardiologist: Dr. [Last Name (STitle) 29070] [2193-5-7] at 1:45 pm Please call to schedule appointments with your Primary Care: Dr. [Last Name (STitle) ] in [3-12] weeks ([Telephone/Fax (1) 72895]) 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:[2193-4-2]	[ "785.51", "511.9", "272.4", "401.9", "V02.53", "276.4", "305.1", "414.01", "424.1", "E878.2", "285.1" ]	icd9cm	[ [ [] ] ]	[ "37.22", "39.61", "88.56", "35.21", "36.11" ]	icd9pcs	[ [ [] ] ]	8877, 8907	5217, 7420	286, 539	9107, 9340	2631, 5194	10181, 10737	1693, 1742		7590, 8854		8928, 9086		7446, 7567			9364, 10158								1757, 2612																						234, 248														567, 1359													1381, 1571	1587, 1677
30,552	156,268	47003	Discharge summary	report	Admission Date: [2134-6-14] Discharge Date: [2134-6-19] Date of Birth: [2071-6-8] Sex: M Service: MEDICINE Allergies: Codeine / Compazine / Vistaril Attending:[First Name3 (LF) 1253] Chief Complaint: Alcohol withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 63 y/o M with PMHx significant for EtOH abuse with history of withdrawal seizures and many admission for EtOH withdrawal (most recently in [3-/2133]), HTN, GERD, HCV, depression/anxiety, panic disorder, who is being admitted to the ICU for EtOH withdrawal. He reports that he presented to the ED today because he wanted to stop drinking and needed help. He endorses drinking 1 quart of vodka a day; last drink was 8am this morning. He endorses a lot of stress in his life recently, including an abusive relationship. . In the ED, initial vs were: T 98.0 P 125 BP 155/94 R 20 O2 sat 98%RA. He was noted to be tremulous, diaophoretic, and tachycardic. He was given a total of 30 mg IV valium (10 mg IV x 3), as well as 2L IVF and thiamine. He was noted to have NBNB emesis, for which he was given zofran. EtOH level was 121. He was admitted to the [Hospital Unit Name 153] for further management of his EtOH withdrawal. . On arrival to the ICU, the patient's VS were T: 98.6 BP: 155/103 P: 106 R: 19 O2: 98% on RA. He endorsed continued tremors and nausea. He also endorsed visual hallucinations (seeing lights in his peripheral vision). He also reported chronic palpitations that he attributed to anxiety and chronic baseline dyspnea that he attributed to smoking. He also endorsed a cough productive of white/yellow phlegm, chronic neuropathic pain in his feet. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied bloody emesis or bloody stools. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. No new skin rashes. Past Medical History: - EtOH abuse, with multiple admissions for EtOH withdrawal (most recently [3-/2134]) - Chronic HCV, genotype 2, followed by Dr. [Last Name (STitle) ]; since [2126] has had undetectable viral loads after successful treatment with interferon and ribavarin - Past admission for hematemesis, thought likely to be [Doctor First Name ]-[Doctor Last Name ] tear, endoscopy was unremarkable - Hypertension - Hepatitis B cAb positive - prior IVDU with prior methadone maintenance - depression/anxiety - reports does not tolerate SSRIs - panic disorder with agoraphobia - GERD s/p [5-19] Enteryx procedure - chronic LBP, inactive - tobacco use - prior patellofemoral syndrome R knee - s/p medial meniscectomy [10-19] R knee - s/p inguinal hernia repair [2132-6-3] Social History: Reports that he had quit smoking but then started again several weeks ago. Now smoking 1ppd. Long hx of EtOH (since age 13 per [Month/Day/Year ]). Currently drinking 1 quart of vodka a day, last drink was 8 am this morning. Remote cocaine, heroin, barbituate use ([2113]); denies current illicit drug use. Family History: Father died at age 33 from malignant hypertension, mother with depression but otherwise healthy, currently living in nursing home. One daughter died of ovarian cancer. Multiple other family members with ETOH abuse on both sides of family (cousin, sister, uncle, aunt, father). Physical Exam: Physical Exam on Admission: Vitals: T: 98.6 BP: 155/103 P: 106 R: 19 O2: 98% on RA General: Alert, Orient x 3, Mildly anxious and tremulous HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, no spider hemangiomas GU: no foley Ext: warm, well perfused, no edema noted Neuro: 5/5 strength in all four extremities, EOMI, PERRL Pertinent Results: [2134-6-14] 03:44PM BLOOD WBC-9.5# RBC-5.27 Hgb-15.9 Hct-45.5 MCV-86 MCH-30.3 MCHC-35.0 RDW-16.1* Plt Ct-247# [2134-6-17] 07:35AM BLOOD WBC-4.7 RBC-4.33* Hgb-12.9* Hct-38.1* MCV-88 MCH-29.8 MCHC-33.8 RDW-15.2 Plt Ct-134* [2134-6-18] 08:30AM BLOOD WBC-4.6 RBC-4.49* Hgb-13.5* Hct-39.8* MCV-89 MCH-30.1 MCHC-34.0 RDW-15.4 Plt Ct-147* [2134-6-14] 03:44PM BLOOD Glucose-161* UreaN-24* Creat-1.4* Na-138 K-3.6 Cl-97 HCO3-20* AnGap-25* [2134-6-18] 08:30AM BLOOD Glucose-98 UreaN-12 Creat-1.0 Na-141 K-3.6 Cl-102 HCO3-31 AnGap-12 [2134-6-14] 03:44PM BLOOD ALT-32 AST-50* CK(CPK)-386* AlkPhos-97 TotBili-1.8* [2134-6-15] 04:18AM BLOOD ALT-24 AST-35 LD(LDH)-195 CK(CPK)-288 AlkPhos-81 TotBili-2.3* DirBili-0.7* IndBili-1.6 [2134-6-17] 07:35AM BLOOD ALT-21 AST-26 AlkPhos-98 TotBili-1.4 [2134-6-14] 03:44PM BLOOD Lipase-29 [2134-6-17] 07:35AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.4* [2134-6-16] 07:08AM BLOOD HIV Ab-NEGATIVE [2134-6-14] 03:44PM BLOOD ASA-NEG Ethanol-121* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2134-6-15] 06:00AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]->1.030 [2134-6-15] 06:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-80 Bilirub-MOD Urobiln-8* pH-6.0 Leuks-NEG [2134-6-15] 06:00AM URINE RBC-2 WBC-26* Bacteri-FEW Yeast-NONE Epi-0 RenalEp-3 [2134-6-15] 06:00AM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG CHEST (PORTABLE AP) Study Date of [2134-6-15] IMPRESSION: AP chest compared to [2134-5-29]: Lung volumes are lower accounting for an apparent increase in heart size, still normal. No definite focal pulmonary abnormality. No evidence of pleural effusion or central adenopathy. As before the thoracic aorta is generally large and elongated, but not focally aneurysmal. Brief Hospital Course: 63 y/o M with PMHx significant for EtOH abuse with history of withdrawal seizures and many admission for EtOH withdrawal, HTN, GERD, HCV, depression/anxiety, panic disorder, who was intially admitted to the ICU for EtOH withdrawal. # EtOH withdrawal. Patient has significant history of EtOH abuse, history of admissions for EtOH withdrawal, as well as history of withdrawal seizures. He received valium, thiamine, and fluid while in the ED. Given his significant withdrawal symptoms (tremor, nausea, vomiting, hallucination of lights) and history of withdrawal seizure, patient was admitted to the ICU for close monitoring. Utox was negative except for benzodiazepine. He received folate, multivitamin, additional IVF, and zofran. He was continued on CIWA scale and benzodiazepines throughout the hospitalization, and his withdrawl gradually imrpoved. At the time of discharge, his [Doctor Last Name ] was due to anxiety, but he has a history of anxiety and panic disorder, and this was felt to be at his baseline. Pt knows resources in community, including AA, and plans to use these resources after discharge to maintain abstinance. # Acute renal failure. He was noted to have initial creatinine up to 1.4 from baseline 0.9-1.0. It was thought to be [2-17] pre-renal in the setting of EtOH abuse and poor po intake. He received IVF while in the ED and in the ICU. His creatinine normalized by time of discharge. # Domestic Abuse. Patient endorsed abuse from his female partner. [Name (NI) ] has excoriated marks on his arms, which he said was inflicted from her. SW was consulted, and helped patient develop plans for a safe transition back to home. Pt was able to explain his safety plan, which includes having his locks changed by a friend who is a locksmith. # Elevated bilirubin/elevated AST. This was noted on admission. Due to alcohol, and improved prior to discharge. # Chronic HCV: S/p tx with IFN/ribavirin. Most recent viral load was in [4-/2134], was negative. Followed by Dr. [Last Name (STitle) ]. AST and TBili slightly elevated on admission labs. No abdominal tenderness on exam. He should continue to follow outpatient hepatologist. # Hypertension. He was hypertensive on arrival to ICU, which was thought [2-17] EtOH withdrawal. He continued with home lisinopril and HCTZ. # Depression/Anxiety/Panic Disorder. Not on any medications at home. SW was consulted. His psychologist was contact[Name (NI) ]. [Name2 (NI) ] will follow up with his psychologist and his PCP after discharge. # GERD. He continued on home omperazole # Tobacco Abuse. He was given nicotine patch. Counseling to smoke cessation was provided. Prophylaxis: Subcutaneous heparin Access: peripherals Code: Full Communication: Patient [Name (NI) 1094] friend [Name (NI) ] [Telephone/Fax (1) 99673] or [Doctor First Name 7279] [Telephone/Fax (1) 99674] Medications on Admission: - omeprazole 20 mg daily - lisinopril-HCTZ 10-12.5 mg daily - Per [Name (NI) ], pt also taking thiamine, MVI, folate, but he does not endorse this. - Was recently given gabapentin for neuropathic pain but reports that he could not tolerate this. Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. lisinopril-hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: # Alcohol withdrawl # Domestic abuse # Transaminitis # Hypertension, benign # Depression, Anxiety, Panic disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with alcohol withdrawl, and you were intially managed in the ICU. You were managed through your alcohol withdrawl with medication. Social work was consulted to assist with your domestic issues, as well as to assist with community resources to help you abstain from alcohol. Followup Instructions: Please follow up with your primary care physician and your psychologist within one week to follow up from this hospitalization. Department: DIGESTIVE DISEASE CENTER When: MONDAY [2134-6-21] at 7:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5085], 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: ENDO SUITES When: MONDAY [2134-6-21] at 7:30 AM	[ "530.81", "584.9", "401.1", "070.30", "300.4", "300.01", "790.4", "291.0", "303.91", "070.54", "V61.8", "276.51" ]	icd9cm	[ [ [] ] ]	[ "94.62" ]	icd9pcs	[ [ [] ] ]	9881, 9887	6012, 8938	309, 315	10045, 10045	4159, 5989	10513, 11116	3243, 3523		9238, 9858		9908, 10024		8964, 9215			10196, 10490								3538, 3552																						251, 271							1750, 2087							343, 1732							3566, 4140	10060, 10172					2109, 2896	2912, 3227
79,671	186,136	37558	Discharge summary	report	Admission Date: [2111-12-7] Discharge Date: [2111-12-30] Date of Birth: [2055-3-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: Acute respiratory distress syndrome in setting of H1N1 influenza Major Surgical or Invasive Procedure: tracheostomy PEG placement bronchoscopy central line placement PICC placement History of Present Illness: 56M with Down syndrome, asthma, presenting with respiratory distress. Per patient's father, patient started to have cough on Friday after going to see eye doctor for regular checkup. Father reports that he was also producing yellow sputum. Also Saturday, febrile to approximately 101. Reports that difficulty breathing started yesterday and got progressively worse throughout day. Father reports that patient has had previous episodes of pneumonia but that this seems worse. Per father, no known sick contacts. [Name (NI) ] working up until Friday when he took the day off to go to Dr. [Last Name (STitle) ]. Father also reports that patient appeared to be having some abdominal pain, he believes on pt's left side, which they treated with a heating pad with some improvement, past 1-2 days. Also notes that he was going to the bathroom more frequently, reports loose stools, thinks that was going on prior to friday. . Initially presented to [Hospital3 ]. O2 sat 72% on RA with tachypnea to the 50s. CPAP and was then intubated. After intubation developed hypotension and a R femoral CVL was placed. Levophed started. Given vanc, zosyn, and levofloxacin. During transport required to be bagged due to low sats and SBPs in 80s. Labs at [Hospital1 ] were signicant for WBC count 12.3 and Na 120, Chloride 90, Bicarb 19. . In the [Hospital1 18] ED, initial vs were: T P BP R19, 96% O2 sat. Frothy sputum. ABG 7.26/35/84 on 100% fiO2. Patient was given: levophed on at 0.04; no further antibiotics given. Past Medical History: - Down syndrome - Asthma - DM II - Hypothyroidism - GERD - Hypercholesterolemia - HTN - ?Kidney surgery - Patient deaf right ear, requires hearing aid in left ear - History of MRSA in sputum (after admission for PNA on [2111-3-12])? if may have been contaminant -multiple abdominal surgeries per father Social History: Per father, patient works at an engineering company making copies and some work on the computer. Denies any tobacco, etoh, drug use. Denies sick contacts. Reports patient did get vaccinated against seasonal flu this year Family History: Noncontributory Physical Exam: VSS General: alert and oriented X3; sitting up in chair with PMV in place HEENT: Sclera anicteric, MMM, oropharynx clear, mucosa moist Neck: supple, JVP not elevated, no LAD Lungs: coarse b/l; no rhonchi or wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: NABS, soft, obese, appears mildly tender Ext: warm and well perfused with no pulses Pertinent Results: Labs on Admission: Blood: [2111-12-7] 12:55AM BLOOD WBC-15.2* RBC-4.11* Hgb-12.2* Hct-34.8* MCV-85 MCH-29.7 MCHC-35.0 RDW-14.7 Plt Ct-241 [2111-12-7] 12:55AM BLOOD Neuts-96.5* Lymphs-2.5* Monos-0.8* Eos-0.1 Baso-0.1 [2111-12-7] 12:55AM BLOOD PT-13.0 PTT-54.1* INR(PT)-1.1 [2111-12-7] 12:55AM BLOOD Glucose-218* UreaN-18 Creat-1.1 Na-126* K-4.0 Cl-97 HCO3-19* AnGap-14 [2111-12-7] 12:55AM BLOOD ALT-44* AST-70* LD(LDH)-461* CK(CPK)-961* AlkPhos-43 TotBili-0.7 [2111-12-7] 12:55AM BLOOD CK-MB-11* MB Indx-1.1 [2111-12-7] 12:55AM BLOOD cTropnT-0.02* [2111-12-7] 04:26PM BLOOD Calcium-9.2 Phos-3.7 Mg-1.6 [2111-12-7] 05:55AM BLOOD Type-ART pO2-134* pCO2-32* pH-7.27* calTCO2-15* Base XS--10 Urine: [2111-12-7] 01:20AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.021 [2111-12-7] 01:20AM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2111-12-7] 01:20AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 Labs at discharge: Blood: [2111-12-28] 02:47AM BLOOD WBC-6.6 RBC-2.66* Hgb-7.3* Hct-22.5* MCV-84 MCH-27.3 MCHC-32.4 RDW-15.1 Plt Ct-887* [2111-12-28] 02:47AM BLOOD Plt Ct-887* [2111-12-28] 02:47AM BLOOD Glucose-147* UreaN-23* Creat-1.0 Na-143 K-3.7 Cl-113* HCO3-23 AnGap-11 [2111-12-13] 02:05AM BLOOD ALT-31 AST-46* AlkPhos-115 TotBili-0.8 [2111-12-28] 02:47AM BLOOD Albumin-2.7* Calcium-8.2* Phos-2.5* Mg-2.6 Iron-24* [2111-12-28] 02:47AM BLOOD calTIBC-231* Ferritn-344 TRF-178* Important Radiological Studies: Admission CXR: ([2111-12-7]) IMPRESSION: 1. Bilateral patchy pulmonary opacities some of which are mass like and discrete, could be multiple nodules mass or abscesses. A CT scan is recommended if lessions due not resolve. 2. Endotracheal tube in appropriate position. 3. NG tube with its tip in the mid-to-distal esophagus. Repositioning is recommended. [2111-12-7] CT Chest, Abdomen and Pelvis IMPRESSION: 1. Diffuse airspace disease, most consistent with pneumonia or ARDS. 2. Gynecomastia, may indicate underlying liver disease. 3. Right adrenal myelolipoma. 4. Cecal bascule. Brief Hospital Course: 56M with asthma, DM, HTN presenting with respiratory distress and pneumonia/ARDS/Influenza. He was admitted to the MICU and a brief description of his MICU course is described below according to system: . # Respiratory failure: Patient presented with history of fevers, productive cough and increasing SOB consistent with PNA. Patient had chest xray and CT scan that were consistent with ARDS. He was treated with a course of vancomycin, zosyn, and levofloxacin. Sputum cultures, blood cultures were collected on admission and routinely for fever spikes or other changes. No organisms isolated. Legionella urine Ag negative. Influenza A positive, confirmed as H1N1. Patient received 5 day course of tamiflu (150mg [Hospital1 ]) and 10 day course of peramivir. He received a second course of Vanc/Cefepime/Cipro for fever spikes on HD 16. . P:F <200. Patient was intubated and ventilated per ARDSnet protocol. Esophageal balloon placed to measure thoracic pressures accurately. ABG on arrival 7.26/35/84/16. Aline placed for regular ABG checks. Patient overbreathing ventilator initially and was paralyzed with cistracurarium for 3-4 days. Patient was sedated with propofol initially. This was transitioned to fentanyl and midazolam throughout hospital course. . After hypotension resolved, patient was assessed daily for need of diuresis with lasix to remove excess fluid and treat resultant pulmonary edema so vent settings could be weaned. . Patient received tracheostomy on [2111-12-21] and was weaned from ventilator support to trach mask of 40% at time of discharge. He was evaluated by speech and swallow and fitted for passy-muir valve. . # Hypotension: Patient presented with sepsis. Given IVF boluses and levophed for pressure support. Aline placed for BP measurements. Was weaned from pressors and IVF stopped when pressures stabilized. Normal echocardiogram suggesting no cardiac component. . #Abdominal Pain: Per patient's father, patient was having abdominal pain 1-2 days and diarrhea. LFT's elevated. CT scan unrevealing of cause of acute abdominal pain. Repeated cdiff tests were negative. When patient weaned from sedation, not complaining of abdominal pain. LFT normalized at time of discharge. They were likely elevated at time of presentation from hypoperfusion of liver in setting of sepsis. . #Acidosis: Patient presented with an ABG of 7.26/35/84/16. He had a normal lactate and decreased bicarbonate. Per family has had several days of diarrhea so most likely had true losses of bicarbonate, likely cause of acidosis. He was given 150 mEq of NaBicarb in 1000 mL D5W. Bicarbonate boluses given for acidosis. Acidosis improved by time of discharge. . # Hyponatremia: Report of sodium of 120 at OSH and 126 here. Most likely hypovolemic hyponatremia, responded well to fluids . #ARF: Patient had worsening Cr in 1st week of hospitalization. A urine sediment revealed brown and fine granular casts, no dysmorphic RBCs. Renal was conulted and recommended weaning antibiotics as possible. Creatinine resolved over time. . #Chronic eye infection: patient presents with chronic eye infection of R eye. Patient followed by ophthamology at [Hospital1 2025] who recommended continuing his prescribed tobramycin and prednisolone drops until outpatient follow-up. . # Hypothyroidism: Treated with home synthroid dose. . #DM II: Insulin drip was needed to control blood sugars initially. Was changed to a sliding scale and blood sugars were well controlled at time of discharge. . #GERD: PPI was prescribed during stay FEN: IVF for hypotension, repleted electrolytes as needed, was given tube feeds for nutrition. A PEG was placed by IR on [2111-12-22] and tube feeds were tolerated well through PEG. Prophylaxis: Subutaneous heparin and pneumo boots Access: peripherals, Aline, and R IJ placement. Right IJ and A line removed before discharge. Code: Full during this admission Communication: Parents Disposition: rehabilitation center. Medications on Admission: Tobramycin Sulfate 0.3 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Glargine and insulin Discharge Medications: 1. 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. 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 4. Tobramycin Sulfate 0.3 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 6. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic Q2H;PRN () as needed for dryness. 7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for fevers. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 11. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Methadone 5 mg Tablet Sig: [1-30] Tablet PO three times a day for 3 days: Please give [1-30] tablet for 3 days starting [12-30] and then stop dose. 13. Ciprofloxacin 0.3 % Drops Sig: Two (2) Drop Ophthalmic [Hospital1 ] (2 times a day) for 7 days. 14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 15. Insulin Regular Human Subcutaneous 16. Metoprolol Tartrate 25 mg Tablet Sig: [1-30] Tablet PO BID (2 times a day): Please take 12.5 mg [Hospital1 ] and hold for SBP<100. Titrate to HR <80. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: ARDS Discharge Condition: stable, tolerating PEG feeds, trach mask of 40% FiO2 Completed by:[2112-1-7]	[ "584.9", "307.9", "E930.0", "564.00", "785.52", "276.1", "530.81", "379.99", "488.1", "276.2", "238.71", "995.92", "359.9", "518.81", "785.0", "272.0", "244.9", "693.0", "360.03", "401.9", "285.9", "250.00", "038.9", "787.91", "789.00", "758.0" ]	icd9cm	[ [ [] ] ]	[ "31.1", "88.72", "96.72", "29.11", "96.6", "38.93", "96.04", "43.19", "38.91" ]	icd9pcs	[ [ [] ] ]	11453, 11525	5216, 9210	378, 457	11573, 11655	3035, 3040		2603, 2620		9723, 11430		11546, 11552		9236, 9700											2635, 3016																						274, 340								4079, 5193						485, 2019							3055, 4059						2041, 2349	2365, 2587
43,529	194,815	16872	Discharge summary	report	Admission Date: [2115-8-20] Discharge Date: [2115-8-23] Date of Birth: [2032-12-31] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Norvasc Attending:[First Name3 (LF) 106] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 82M with CAD, chronic diastolic CHF, AFib on coumadin admitted with dyspnea. Three days ago patient notes that he was not feeling well. He was more fatigued than usual and had shortness of breath with walking. He did not have palpitations, chest pain, fevers, chills, orthopnea, pnd, worse edema than baseline (has had chronic LE edema X 5 years), syncope, or presyncope. At about 3 am on the morning of admission he awoke to turn down the AC because he was chilly. When he sat up he became acutely short of breath. His wife was able to calm him down and when he lay back down he felt better. However, over the course of the next few hours he started to feel more and more short of breath, even when lying down, and by 7am his wife was very concerned. She noticed that when she tried to stand him up to walk to the living room he was very weak and his legs were wobbly. She called 911, and they brought him to the ED. . Upon presentation to the ED initial vitals were: T 98 HR 76 BP 179/68 RR 28 SP02 98%RA. In the ED patient denied CP, fever, chills, cough, weight gain. His O2 sats declined from 98% on RA ->91% on 4L->96% on NRB. CXR showed mild fluid overload and possible PNA. Bedside TTE revealed: LA is moderately 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. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. 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. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [2112-4-11], the findings are similar. . He received the following medications: Aspirin 81mg, CeftriaXONE 1g, Azithromycin 500mg, Nitroglycerin SL 0.4mg SLX3 (for HF not for complaints of CP), and Furosemide 80mg IV X 1. He felt better after the furosemide (he put out 500mL) and his O2 requirement came down to 94% on 4L. He was transferred to the floor. . On the floor patient remained on NC and then on first set of vitals was noted to be hypoxic to the mid-80s on 5L NC. He was placed on a NRB and his O2 sat came up to 100%. He had no complaints of chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, or cough at the time. His EKG was unchanged from prior. A CXR was also unchanged. ABG showed an elevated A-a gradient with PO2 103 on the NRB. He was given another 80mg IV lasix, morphine, and started on nitro paste. Intially he improved with this regimen, however, he would occasionally dip into the high 80s and then recover spontaneously on the NRB and they were unable to wean him off the NRB. He was transferred to the CCU for his continued requirement of the NRB. . On presentation to the ccu the patient was comfortable on a NC. He denied fevers, chills, palpitations, chest pain, nausea, vomiting, diaphoresis, abdominal pain, bloating, worsening edema, weight gain, diarrhea, and dysuria. He endorsed shortness of breath as outlined above although currently less than prior, constipation off and on for several years, and chronic edema of his lower extremities for the last 5 years - treated with lasix. Past Medical History: 1. CARDIAC RISK FACTORS: hypertension, dyslipidemia. 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: s/p PTCA x1 15 years ago records not at the [Hospital1 18] -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: GASTRITIS H.pylori + (treated) GOUT SYNCOPE RENAL INSUFFICIENCY (creat ~ 1.6) VENOUS INSUFFICIENCY and lower extremity edema BENIGN PROSTATIC HYPERTROPHY ATRIAL FIBRILLATION diastolic dysfunction with volume overload treated with lasix RETINAL VASCULAR OCCLUSION in [2115-4-19] thought [1-21] plaque rupture not thrombotic event as therapeutic on coumadin at the time Social History: Originally from Poland. Worked in [Doctor First Name 533] labor camp for a few years before emmigrating. Also was in the service in the US. Lives in [Location ], MA with his wife. [Name (NI) 1139] history: Former 15 pack-year smoker, quit 60 years ago. Rare ETOH use. No recent travel. No sick contacts. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: PE on admission: V/S: Wt 89.4 kg T 99.5->102 ax BP 170/71 HR 70 RR 22 O2sat 94%6L NC GENERAL: WDWN M in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to angle of jaw CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregularly irregular with distant heart sounds. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. Scattered expiratory wheezes with poor air movement bilaterally and crackles about [12-22] of the way up bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Umbilical hernia without tenderness. EXTREMITIES: 1+ edema bilaterally to knees. Negative homans sign. NEURO: Alert and oriented X 3. Right pupil larger than left. Left arm slightly weaker than right. PE on discharge: V/S: Tmax 99, Tc 97.5, BP 154/69 (130-157/59-69) HR 65 (55-83) RR 16 O2sat 94%RA GENERAL: elderly white male in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRLA, Conjunctiva pink, OP clear with no erythema or exudate NECK: Supple with JVP to angle of jaw CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregularly irregular with distant heart sounds. No m/r/g. LUNGS: Resp unlabored, no accessory muscle use. scatttered rales at left base. ABDOMEN: + BS, Soft, NTND. No HSM. Umbilical hernia without tenderness. EXTREMITIES: Trace edema in LE b/l, no cyanosis or clubbing NEURO: Alert and oriented X 3. Right pupil larger than left. Left arm slightly weaker than right. Pertinent Results: On Admission: . [2115-8-20] 08:05AM BLOOD WBC-8.7# RBC-3.99* Hgb-10.7* Hct-34.4* MCV-86 MCH-26.8* MCHC-31.1 RDW-16.1* Plt Ct-214 [2115-8-20] 08:05AM BLOOD PT-20.1* PTT-32.0 INR(PT)-1.9* [2115-8-20] 08:05AM BLOOD Glucose-172* UreaN-45* Creat-1.7* Na-139 K-4.1 Cl-101 HCO3-23 AnGap-19 [2115-8-20] 08:05AM BLOOD CK-MB-NotDone proBNP-2736* [2115-8-20] 08:05AM BLOOD cTropnT-0.06* [2115-8-21] 05:43AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.7 [2115-8-20] 03:35PM BLOOD TSH-0.43 [2115-8-20] 05:00PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.006 [2115-8-20] 05:00PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2115-8-20] 05:00PM URINE RBC-[11-8]* WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0 . On discharge: [2115-8-23] 05:35AM BLOOD WBC-6.6 RBC-3.74* Hgb-9.9* Hct-31.6* MCV-85 MCH-26.6* MCHC-31.5 RDW-16.8* Plt Ct-265 [2115-8-23] 05:35AM BLOOD PT-27.5* PTT-41.0* INR(PT)-2.7* [2115-8-23] 05:35AM BLOOD Glucose-127* UreaN-60* Creat-1.5* Na-142 K-4.0 Cl-105 HCO3-28 AnGap-13 [2115-8-23] 05:35AM BLOOD Calcium-8.9 Phos-3.5 Mg-3.2* . Urine culture [8-20] negative Blood cultures 9/1 and [8-21] NGTD Legionella urine antigen neg [8-20] . TTE [8-20]: The left atrium is mildly dilated. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There may be inferolateral hypokinesis but views are technically suboptimal. Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, laterally directed jet of moderate to severe (3+) mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2113-11-23], mitral regurgitation is now more prominent. There may be inferolateral hypokinesis in the current study but images are technically suboptimal for assessment of regional wall motion. The left ventricular cavity is now more dilated. . Portable CXR [8-20]: Bilateral perihilar opacities may represent congestive heart failure versus pneumonia. In the setting of the patient's elevated BNP, findings more likely represent moderate congestive heart failure. . Repeat Portable CXR [8-20]: Stable appearance with bilateral perihilar airspace opacities. Mild cardiomegaly. . Portable CXR [8-21]: In comparison with the study of [8-20], there is little overall change in the bilateral lower lung and left perihilar patchy opacifications, consistent with multifocal pneumonia. . Lower extremity dopplers [8-21]: No evidence of deep vein thrombosis in either leg. [Hospital Ward Name 4675] cyst seen in the right popliteal fossa. Brief Hospital Course: ASSESSMENT AND PLAN: 82 year old man with history of CAD s/p PCTA 15 years ago, diastolic CHF with history of fluid overload on lasix, atrial fibrillation on coumadin with recent admission for retinal occlusion, admitted with dyspnea on exertion, hypoxia, and fever and transferred to the ICU due to increasing oxygen requirements. . # Hypoxia: Likely this is multifactorial in etiology, from both pulmonary and cardiac sources. He presented with evidence of volume overload on exam, on CXR, and with an elevated BNP. In addition, he had a fever likely infiltrate on CXR thought to be consistent with community acquired pneumonia. PE was also a consideration, but felt to be less likely because he was anticoagulated on coumadin and had other more likely etiologies for his hypoxia ([Doctor Last Name ] score 4). Consequently, he was treated for community acquired pneumonia with azithromycin and ceftriaxone/cefpodoxime for a total five day course to end on [2115-8-24]. In addition, TTE showed new LV dilation likely causing more severe MR [First Name (Titles) ] [Last Name (Titles) ] with preserved LVEF (although this is likely over-estimated in MR) consistent with acute exacerbation of his diastolic CHF. He was diuresed with furosemide over the course of his admission, and his noninvasive oxygen requirements declined; he was able to maintain oxygen saturation in the high 90s at room air on discharge. . # Fever: Most likely infectious with either pulmonary or urinary infection being most probable given leukocytosis, positive UA and hypoxia with CXR showing possible infiltrate. Blood and urine cultures NGTD, unable to obtain sputum culture. Treated for both UTI and CAP; initially with ceftriaxone and azithromycin, and transitioned to cefpodoxime with plan for total five day course to end [2115-8-24]. . # CORONARIES: Patient with remote history of CAD s/p PTCA at OSH and his tropinins were slightly elevated troponins with a peak of 0.19 on [2115-8-21], flat CKs and negative MBs in the setting of CRF. Cardiac enzymes were thought to be most likely elevated from fluid overload and ventricular dilatation, and not cleared secondary to renal failure. The patient denied any anginal symptoms, and serial ECGs were not suggestive of any acute ischemia. He was continued on home dose of statin, and started on aspirin 81 mg PO daily. Per history, he is unable to tolerate beta blockers and ace inhibitors. . # PUMP: Patient has history of diastolic dysfunction and has had episodes of fluid overload treated with oral lasix in the past. TTE on this admission revealed new LV dilation and worsening of his MR with pulmonary artery hypertension, likely related to his acute fluid overload. He was treated with aggressive diuresis, a salt restricted diet and continuation of home blood pressure regimen for afterload reduction with felodipine, hydralazine, clonidine and Imdur. . # RHYTHM: The patient was monitored on telemetry and was found to be intermittently in slow atrial fibrillation, with some ECGs showing sinus bradycardia with prolonged AV conduction and occasional junctional escape beats. The patient is on coumadin for atrial fibrillation at home, and was found to be subtherapeutic on admission. He also had a recent history of retinal artery occlusion while anticoagulated. For that reason, he was maintained on a heparin drip until INR was again therapeutic. In addition, his coumadin was decreased from 5 to 2.5 on [8-22], with a plan to return to home dose of 5 mg on [8-25] after he has finished his course of antibiotics. . # Hypertension: Patient's BP was 170/70 at recent PCP visit and has been dificult to control according to OMR notes for last several years. He is unable to tolerate ACE inhibitors or beta blockers. During this admission, he was maintained on his home regimen with hydralazine, clonidine, felodipine and Imdur. . # Lower extremity edema: Thought to be related to fluid overload from acute on chronic diastolic CHF. LE dopplers on [8-21] were negative for DVT. . # Chronic renal insufficiency: Patient remained at or below his baseline creatinine of 1.7 during the course of the admission. . # Hyperlipidemia: Continued home dose of statin. . # Gout: Continued home dose of allopurinol . # CODE: DNR/DNI confirmed on admission with patient and family Medications on Admission: ALLOPURINOL 300 mg daily CLONIDINE 0.1 mg twice daily FELODIPINE 10 mg daily FUROSEMIDE 80 mg daily HYDRALAZINE 150 mg TID IMDUR 60 mg daily SIMVASTATIN 40 mg daily WARFARIN 5 mg daily Discharge Medications: 1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydralazine 50 mg Tablet Sig: Three (3) Tablet PO three times a day. 4. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:1 Tablet(s) Refills:0 11. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 1 days. Disp:4 Tablet(s) Refills:0 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Outpatient Lab Work Please check INR on Sunday [2115-8-25] and call results to Dr. [Name (NI) 47530] office at [Telephone/Fax (1) 1144] 14. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: Primary Diagnosis: Community Acquired Pneumonia Secondary Diagnosis: Acute on Chronic Diastolic Chronic Congestive Heart Failure Atrial Fibrillation on coumadin Coronary Arteryu Disease Chronic Kidney Disease Discharge Condition: stable Discharge Instructions: You had a pneumonia that caused your oxygen level to be low and you were admitted to the intensive care unit. Your fevers and low oxygen resolved slowly with intravenous antibiotics. You are now on oral antibiotics and will need to take them for one more day. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet, information was given to you about this. . Medication changes: 1. Start 1 baby aspirin daily 2. Continue Azithromycin until [8-24] 3. Continue Cefpodoxime until [8-24] 4. Take 2.5 mg of coumadin on [8-24], then resume 5 mg of coumadin on [8-25]. . Please call Dr. [Last Name (STitle) ] if you have fevers, increasing cough, chest pain, trouble breathing, or any other concerning symptoms. Please check your INR on Sunday [2115-8-25]. Followup Instructions: Cardiology: Provider: [Name10 (NameIs) 1918] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2115-9-19] 3:40 Provider: [Name10 (NameIs) 1918] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2115-10-24] 2:00 Primary Care: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD Phone:[Telephone/Fax (1) 1144] Date/Time: Thursday [2115-8-29] at 11:00am. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD Phone:[Telephone/Fax (1) 1144] Date/Time:[2115-11-27] 9:00	[ "599.0", "414.01", "274.9", "600.00", "272.4", "403.90", "428.0", "427.31", "459.81", "585.9", "599.70", "486", "428.33", "V58.61" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	15651, 15714	9714, 14073	293, 300	15967, 15976	6642, 6642	16877, 17485	4866, 4980		14309, 15628		15735, 15735		14099, 14286			16000, 16437								4995, 4998		3971, 4105												7448, 9691					16457, 16854			246, 255														328, 3876			15804, 15946			15754, 15783	6656, 7434			4136, 4515			3898, 3951	4531, 4850
62,715	178,952	42421	Discharge summary	report	Admission Date: [2192-2-17] Discharge Date: [2192-2-28] Date of Birth: [2123-1-15] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain with exertion Major Surgical or Invasive Procedure: [2192-2-20] Coronary artery bypass grafting x3 with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery [2192-2-20] Mediastinal re-exploration and evacuation of a clot status post coronary artery bypass surgery History of Present Illness: This 69 year old male was seen by his primary care physician [Name Initial (PRE) ] 3-4 weeks of exertional chest pressure that radiates down left arm. He was seen at an urgent care center for evaluation and an EKG showed new deep T wave inversions in I,AVL,V1-6.Pt. was admitted and ruled out for an MI by enzymes and EKG. CXR showed no acute changes. Chest CT showed no evidence of pulmonary embolism. He was started on Plavix and ASA yesterday and transferred for cardiac catheterization with Dr. [Last Name (STitle) 66097] ti [Hospital1 18]. Past Medical History: diet controlled diabetes mellitus Hypertension Hyperlipidemia Cervical disc disease Sciatica Depression Social History: [2-15] yr hx of cig smoking in his 20's. Former cigar smoker after that. -ETOH: prior alcoholism, sober for 9 months -Illicit drugs: none Family History: Mother with cirrhosis, both parents have ETOH abuse. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse: 63 Resp:16 O2 sat:97% RA B/P Right:125/79 Left:136/78 Height: 5ft 9" Weight:210lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []crackles in bases Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]protruberant Extremities: Warm [x], well-perfused [x] Edema [] No edema____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:+1 Left:+1 DP Right: trace Left:trace PT [Name (NI) 167]:trace Left:trace Radial Right: Cath site Left:+2 Carotid Bruit Right: None Left:None Pertinent Results: [2192-2-26] 05:30AM BLOOD WBC-10.4 RBC-3.53* Hgb-10.8* Hct-32.1* MCV-91 MCH-30.5 MCHC-33.6 RDW-14.3 Plt Ct-134* [2192-2-25] 04:16AM BLOOD WBC-8.2 RBC-3.32* Hgb-10.1* Hct-29.2* MCV-88 MCH-30.5 MCHC-34.6 RDW-14.4 Plt Ct-126* [2192-2-26] 05:30AM BLOOD Glucose-94 UreaN-43* Creat-1.2 Na-139 K-4.2 Cl-101 HCO3-27 AnGap-15 [2192-2-25] 04:16AM BLOOD Glucose-81 UreaN-44* Creat-1.0 Na-140 K-3.3 Cl-102 HCO3-26 AnGap-15 [2192-2-24] 08:36PM BLOOD Glucose-162* UreaN-48* Creat-1.1 Na-138 K-3.8 Cl-101 HCO3-24 AnGap-17 TTE [2192-2-20] PRE-CPB: 1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. POST-CPB: On infusion of phentylephrine. AV pacing for slow sinus rhythm. Preserved biventricular systolic function. MR remains 1+. No AI. Aortic contour is normal post decannulation. [2192-2-20] TTE Exploration for Bleeding. 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. There is no sign of tamponade physiolo9gy. [2192-2-26] 05:30AM BLOOD WBC-10.4 RBC-3.53* Hgb-10.8* Hct-32.1* MCV-91 MCH-30.5 MCHC-33.6 RDW-14.3 Plt Ct-134* [2192-2-27] 04:30AM BLOOD UreaN-39* Creat-1.2 Na-140 K-4.8 Cl-103 Brief Hospital Course: Mr. [Known lastname 91857] was admitted under cardiology and underwent cardiac catheterization which showed total occlusion of the proximal LAD, 70% proximal LCx lesion, 40% prox RCA lesion, and 50% RPDA lesion, with right to left collaterals. He remained chest pain free after cardiac catheterization. Cardiac surgery was consulted and routine preoperative evaluation was performed. Given his recent Plavix dose, surgery was delayed for several days. On [2-20], Dr. [Last Name (STitle) ] performed three vessel coronary artery bypass with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery. She had increasing amount of chest tube drainage in the first 2 hours after surgery totaling nearly 1 liter in 2 hours and hence, he was taken back to the Operating Room for exploration. He was hemodynamically stable with no signs of tamponade. There was a large amount of old clot and blood in the mediastinum as well as in the left pleura. After this was cleared, all the surgical sites were inspected. No sign of any surgical site bleeding was found and the bleeding was thought to be due to the Plavix which he was on preoperatively. He was kept intubated on POD 1 and ventilator and vasoactive support was weaned. POD 2 found the patient extubated to BIPAP. He was aggressively diuresed with Lasix three times a day. He had several days on BIPAP and when taken off and desaturated quickly. He was weaned from BIPAP on POD 4 to nasal canula and progressed well from a respiratory standpoint. Beta blocker was initiated and the patient was gently diuresed toward his preoperative weight. He went into a rapid atrial fibrillation and was started on an Amiodarone drip. He converted to sinus rhythm and remained in sinus for the remainder of his hospital course. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD 8 the patient was ambulating freely, the wounds were healing and pain was controlled with oral analgesics. The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: Neurontin 300 mg twice daily Plavix 75 mg daily Lipitor 80 mg daily Atenolol 50 mg daily Celexa 20mg daily was taking for over 1yr but stopped taking this [Month (only) ] Motrin 600mg prn back pain Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 2 weeks. Disp:14 Tablet, ER Particles/Crystals(s) Refills:0 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg (two tablets) twice a day for two weeks, then 200mg(one tablet twice a day for two weeks then 200mg daily(one tablet) until directed to stop. Disp:120 Tablet(s) Refills:2 8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 11. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day as needed for shortness of breath or wheezing for 4 weeks. Disp:1 Refills:1 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease noninsulin dependent diabetes mellitus Hypertension Hyperlipidemia Cervical disc disease Sciatica Depression Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait and walker Incisional pain managed with oral medications Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. trace Edema 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 [Last Name (STitle) ]([Telephone/Fax (1) 170]) on [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2192-3-28] 1:00 in the [Hospital ] medical office building [Doctor First Name ] [Hospital Unit Name ] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 12997] in [5-17] weeks ([Telephone/Fax (1) 86132]) Cardiologist: Dr. [Last Name (STitle) ] will call with appointment 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:[2192-2-28]	[ "276.69", "303.93", "401.9", "411.1", "272.4", "414.01", "311", "285.1", "250.00", "427.31", "E878.2", "998.11", "721.3", "V58.61", "721.0" ]	icd9cm	[ [ [] ] ]	[ "36.15", "37.22", "36.12", "39.61", "34.03", "88.56" ]	icd9pcs	[ [ [] ] ]	8701, 8750	4661, 7042	335, 657	8927, 9167	2462, 4638	10008, 10748	1552, 1720		7296, 8678		8771, 8906		7068, 7273			9191, 9985								1735, 2443																						271, 297														685, 1245													1267, 1373	1390, 1536
15,688	190,587	13724	Discharge summary	report	Admission Date: [2159-6-14] Discharge Date: [2159-6-21] Date of Birth: [2090-2-3] Sex: F Service: GYN/ONC with transfer to Medical Intensive Care HISTORY OF THE PRESENT ILLNESS: Ms. [Known lastname 41323] is a 69-year-old woman with a history of recently-diagnosed endometrial cancer status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, on [2159-5-8]. She abdominal pain. The patient had received her usual postoperative course of Ciprofloxacin. On initial examination by the Gyn Service, the patient was noted to have greenish exudate emanating from an open 3 cm incision. There was associated mild erythema and minimal tenderness. Wound cultures were sent and the patient was started empirically on Ceftazidime and Clindamycin and admitted to the gynecology PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease. 3. Diet controlled diabetes. 4. Status post cholecystectomy. 5. Endometrial cancer, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 6. aortic stenoisis 7. Morbid obesity. 8. Chronic renal insufficiency. ALLERGIES: The patient is allergic to PENICILLIN AND SULFA. MEDICATIONS: Medications at home revealed the following: 1. Atenolol 12.5 mg p.o.q.d. 2. Mavik 1 mg p.o.q.d. 3. Multivitamin one tablet p.o.q.d. 4. Ultram 100 mg p.o.b.i.d. 5. Naprosyn 500 mg p.o.b.i.d. 6. Neurontin 800 mg p.o.b.i.d. 7. Protonix 40 mg p.o.q.d. SOCIAL HISTORY: The patient lives with her daughter and brother-in-law. She denies any alcohol or tobacco use. FAMILY HISTORY: The patient's sister has depression and lung disease. PHYSICAL EXAMINATION: Examination revealed the following: Temperature 99.1, heart rate 74, blood pressure 122/56, respiratory rate 22, oxygen saturation 94%to 96% on room air. GENERAL: The patient was an obese-appearing woman in no acute distress. NECK: Neck was supple. CHEST: Chest was clear to auscultation bilaterally. CARDIOVASCULAR: Examination indicated regular rhythm, normal S1 and S2 and a 3/6 systolic ejection murmur. ABDOMEN: Soft, nontender. The patient had an open 3 cm incision over her left lower abdomen with greenish discharge. There was mild erythema and minimal tenderness. EXTREMITIES: On extremity examination, the patient had trace edema bilaterally with palpable peripheral pulses. HOSPITAL COURSE: The following describes the [Hospital 228] hospital course while on the gynecology and Medical Intensive Care Unit Services. The patient's wound gram stain was positive for 3+ gram-negative rods. Culture later turned out to be positive for Methicillin-resistant Staphylococcus aureus, as well as rare Enterococcus and Corynebacterium. and bacteroides fragilis. On hospital day #3, the patient was continued on Ceftazidime and Clindamycin while awaiting the culture results. On hospital day #3, the patient was noted to have a low-grade temperature to 100.2, as well as decreased urine output with 90 cc over twenty-four hours. Blood pressure was noted to be 82/42. Urinalysis indicated 11 white blood cells, occasional bacteria and one subcutaneous epithelial cell. The patient was also noted to have decreased mental status with impairment in orientation and attention. Creatinine was also noted to rise to a peak of 4.0. The patient was given 1000 cc normal saline bolus and then started on fluids at 100 cc per hour. Shortly, thereafter, the patient's oxygen saturation was noted to drop to 83% on three liters. The patient was without additional complaints of dyspnea. She was noted to have diminished breath sounds at the bases and ABG indicated pH of 7.24, pCO2 of 73, pAO2 of 326. Chest x-ray did not indicate any signs of overt congestive heart failure and there were no effusions. Antihypertensives were stopped and Medicine consultation was obtained. Subsequently, the patient was transferred to the Medical Intensive Care Unit, where the patient was described as alert and oriented without complaints. Pressure at that time was 110/60 and she was saturating 100% on a nonrebreather and 93% on room air. CKs were cycled and negative, as well as the patient had a negative troponin as well. There were no EKG changes. The etiology of the patient's hypercarbia was unclear, thought secondary to body habitus versus mucous plugging versus CNS depression. Repeat blood cultures were sent and negative. On hospital day #4, as the patient was stable, she was transferred back out of the Medical Intensive Care Unit and back onto the gynecology service. On hospital day #4, to patient continued to have borderline urine output, however, the creatinine improved with hydration. Oxygen requirement remained stable on four liters nasal cannula. She was started on nightly BiPAP for possible obstructive sleep apnea. The patient tolerated this somewhat during the first night, but refused subsequent sessions. The patient was then transferred to the Medicine Service on hospital day #5 due to delirium, borderline O2 sats and eval of hypercarbia. The following summarizes the patient's initial events while on the Acove Service. Infectious Disease was consulted with the question of whether the patient might simple be colonized with Methicillin-resistant Staphylococcus aureus or whether she actually had a MRSA wound infection. The Infectious Disease Service recommended stopping all antibiotics. The patient's mental status subsequently was noted to improve over hospital days 5 and 6. Blood cultures continued to be negative. The creatinine continued to improve and on hospital day #6, it was down to 1.2. The patient's urine output also improved dramatically. On hospital day #6, the followup ABG indicated a pH of 7.44, pCO2 of 42 and PO2 of 60. Given that the patient's hypercapnia appeared to have resolved, it was decided that her transient hypercapnia might best be worked up as an outpatient in the context of pulmonary evaluation and/or a sleep study. The Department of Physical Therapy was consulted and their recommendations were still pending at the time of this dictation. It was anticipated that the patient will be discharged to an rehabilitation facility and would followup with the primary care provider. [Name10 (NameIs) ] patient's antihypertensive medications were continued to be held until her blood pressure again became problem[Name (NI) 115]. [Name2 (NI) ] low dose beta blocker was resumed on [4-21] and sbp 100-110. Her ace-Inhibitor has been stopped since hypotensive episode and ARF. Could consider readding at later date if BP rises but will need close monitor of renal function. Would avoid NSAIDs altogether due to renal insufficiency. Pt's delirium resolved markedly each day and was back to baseline mental status at the time of discahrge. It was felt that delirium was multifactorial including hypotension/acute renal failure/infection/?side effect of antibiotics/hypercarbia and hypoxemia. As all of these resolved her mental status cleared quickly. DISCHARGE DIAGNOSES: 1. Wound infection status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 2. aortic stenosis 3. Coronary artery disease. 4. Diabetes mellitus- diet controlled. 5. Status post cholecystectomy. 7. Morbid obesity. 8. Acute renal insufficiency, resolved.Creat 1.1/BUN 19 day prior to discahrge. 9. Hypercarbia, resolved-likely due to obesity hypoventilation syndrome. Hypoxemia- PO2 60 on room air abg with adquate O2 sat. 10. Delirium, resolved. 11. MRSA colonization 12. Mild hypomagnesemia MEDICATIONS ON DISCHARGE: 1. Neurontin 800 mg p.o.b.i.d. 2. Protonix 40 mg p.o.q.d. 3. Heparin 5000 units subcutaneously q.12h. 4. Lopressor 25 po bid 5. mag oxide 400 [Hospital1 ] for 3 days. 6. EC-aspirin 325 po qd Pt needs TID wet to dry dressing changes. DISPOSITION ON DISCHARGE: At the time of this dictation, it was anticipated that the patient would be discharge to an rehabilitation facility. She was to followup with her primary care provider- [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11333] in [Name (NI) ] Pt should have pulmonary eval as outpatient including f/u of oxygenation, PFTs and sleep study to eval baseline hypoxemia and possible OSA/obesity hypoventilation syndrome. CONDITION ON DISCHARGE: Stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3022], M.D. [MD Number(1) 3023] Dictated By:[Last Name (NamePattern1) 194] MEDQUIST36 D: [2159-6-19] 15:07 T: [2159-6-19] 15:14 JOB#: [Job Number 41324] Edited by Dr. [Last Name (STitle) ] on [2159-6-21]	[ "593.9", "584.9", "780.57", "276.5", "V10.42", "293.0", "998.59", "250.00", "275.2" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]							1600, 1655	7060, 7580				7606, 7860		2393, 7039																					1678, 2375			7875, 8343																																			851, 1469	1486, 1583	8367, 8713
10,916	198,322	50623	Discharge summary	report	Admission Date: [2192-2-3] Discharge Date: [2192-2-7] Date of Birth: [2105-2-5] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2610] Chief Complaint: Leg swelling/pain Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: Ms [Known lastname ] is an 87 y/o woman with multiple medical problems including [Name (NI) 2091] (b/l creatinine 2.1), CHF (EF 45% in [2189]), pAfib on pradaxa, DM, Htn, colon cancer s/p hemicolectomy [2186], who came to the ED today for progressively worsening bilateral leg edema and pain for the past two weeks. Denies trauma to the legs, medication non-compliance, or dietary indiscretions. She has been wearing her compression stockings daily, but does not typically elevate her legs. She has accompanying dyspnea on exertion, but denies chest pain, palpitations, cough, or syncope. She denies headache, abdominal pain, nausea or vomiting. . In the ED, initial VS were: 98.0, 65, 162/80, 18, 98%. She was mentating appropriately. Exam was notable for 2+ pitting edema to upper thighs, bilaterally. Her abdomen was nontender, and her lungs were clear. Labs were most notable for elevated creatinine above baseline, hyperkalemia, and metabolic acidosis. ABG was 7.14/48/65/17. BNP was > 12K. CXR showed pulmonary edema. ECG showed atrial fibrillation with slow ventricular response, and evidence of prior MI, without acute ischemic changes. Renal was consulted, and recommended giving IV diuresis and obtaining renal ultrasound. Pt was given percocet two tabs, IV insulin/dextrose, calcium gluconate, and furosemide 80 mg IV. VS prior to transfer were 98.0, 78, 16, 122/71, 100% RA. . On arrival to the MICU, Ms. [Known lastname ] is hungry and asking for food. She reports constant burning pain in her lower legs and feet. . Review of systems: As Per HPI. Denies fevers, chills, cough, headache, chest pressure, nausea, vomiting, diarrhea, constipation, dysuria or polyuria. She has not noticed a change in how much she is urinating. Past Medical History: - IDDM (dx [2175]) s/p multiple ED visits/hospitalizations [2187] for hypoglycemia - s/p fall [5-4] w/ small (4mm) R frontal lobe petechial hemorrhage - Paroxysmal atrial fibrillation on dabigatran - Osteoarthritis, cervical, left knee; status post R TKR [2184-1-1] - Chronic renal failure - baseline creatinine 2.1 and recently up to 2.4 - Breast cancer status post R mastectomy in [2167] - Hypertension - Hypercholesteremia - Hearing loss - Hypothyroidism/thyromegaly - Depression - GERD - Adenocarcinoma of the colon status post right hemicolectomy in [1-/2187] - Carpal tunnel syndrome - Recurrent C.diff infection . PAST SURGICAL HISTORY: 1. TAH/BSO [2175]. 2. Right total knee replacement [2183]. 3. Right mastectomy [2167]. 4. Right hemicolectomy [2186]. 5. Resection of cyst on left face [2188-10-14] Social History: Lives in an apartment. The patient is divorced and has a son who lives nearby. Her daughter lives in [State 9512]. Has a home health aide and daily VNA services. Daughter [Name (NI) ] lives close by and is contact ([Telephone/Fax (1) 105294]). History of using snuff, does not drink ETOH or use IV drugs. Ex-smoker quit 15 years ago per patient. Family History: Mother died of MI in 60s. Multiple family members with type 2 diabetes. Brother died of some unspecified ca. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T:98.1 BP:140/78 P:67 R:15 O2:99% RA; Wt 113.5 kg General: Awake, alert, interactive, oriented, NAD HEENT: MMM, OP clear, PERRL, no conjunctival icterus, injection or pallor Neck: supple, +JVD, no LAD CV: Irregularly irregular. Normal S1/S2. Faint systolic murmur at upper sternal borders. No S3/S4 or rubs Lungs: CTAB, no wheezes, rales, rhonchi Abdomen: soft, +mild diffuse tenderness to palpation, non-distended, no rebound tenderness or guarding. +BS throughout. no organomegaly GU: foley in place Ext: 3+ edema to bilateral thighs, most prominent above the knees. Palpable symmetric 2+ DP/PT/radial pulses bilaterally. No clubbing or cyanosis. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities proximally and distally, mild numbness in bilateral feet, which are also tender to palpation. gait deferred, finger-to-nose intact . DISCHARGE PHYSICAL EXAM VS: Temp: 99.1, BP 142/60, HR 57, RR 18, O2 sat 96% on RA HEENT: PERRL, MMM, OP clear NECK: supple, JVP ~ 10 cm, no LAD CV: irregularly irregular, normal S1, S2, no m/r/g LUNG: CTAB, no w/r/rh ABD: soft, NT/ND, +BS, no HSM EXT: bilateral hyperpigmentation of lower extremity, tender to palpation, minimal pitting edema (<1+) Neuro: CNII-XII intact, 5/5 strength upper/lower extremities proximally and distally, mild numbness in bilateral feet, which are also tender to palpation. gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS [2192-2-3] 03:40PM BLOOD WBC-6.0 RBC-3.46* Hgb-10.7* Hct-34.1* MCV-99* MCH-31.0 MCHC-31.4 RDW-18.5* Plt Ct-173 [2192-2-3] 03:40PM BLOOD Neuts-78.2* Lymphs-15.0* Monos-4.3 Eos-1.1 Baso-1.5 [2192-2-3] 04:10PM BLOOD PT-13.8* PTT-51.5* INR(PT)-1.3* [2192-2-3] 03:40PM BLOOD Glucose-123* UreaN-55* Creat-3.9* Na-142 K-5.7* Cl-118* HCO3-11* AnGap-19 [2192-2-3] 03:40PM BLOOD ALT-13 AST-20 LD(LDH)-265* AlkPhos-108* TotBili-0.3 [2192-2-3] 03:40PM BLOOD Albumin-3.8 Calcium-8.6 Phos-4.3 Mg-2.1 [2192-2-3] 08:10PM BLOOD Type-[Last Name (un) ] pO2-65* pCO2-48* pH-7.14* calTCO2-17* Base XS--12 Intubat-NOT INTUBA Comment-PERIPHERAL . DISCHARGE LABS [2192-2-7] 10:45AM BLOOD WBC-6.9 RBC-3.69* Hgb-11.1* Hct-34.4* MCV-93 MCH-30.0 MCHC-32.1 RDW-17.8* Plt Ct-179 [2192-2-7] 10:45AM BLOOD PT-13.0* PTT-37.7* INR(PT)-1.2* [2192-2-7] 10:45AM BLOOD Glucose-192* UreaN-46* Creat-3.1* Na-143 K-4.4 Cl-109* HCO3-22 AnGap-16 [2192-2-7] 10:45AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.6 . PERTINENT LABS [2192-2-3] 03:40PM BLOOD proBNP-[Numeric Identifier ]* [2192-2-3] 03:40PM BLOOD Osmolal-322* [2192-2-4] 05:04AM BLOOD TSH-3.3 [2192-2-4] 05:04AM BLOOD Cortsol-13.9 [2192-2-3] 03:40PM BLOOD ASA-NEG Acetmnp-11 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . MICROBIOLOGY [2192-2-3] 11:23 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2192-2-6] MRSA SCREEN (Final [2192-2-6]): No MRSA isolated. . RADIOLOGY CXR [2192-2-3] FINDINGS: Frontal and lateral views of the chest were obtained. The cardiac silhouette remains moderately enlarged. Mediastinal contours are stable. There is moderate pulmonary vascular congestion with interstitial edema. No large pleural effusion is seen, although trace effusions be difficult to exclude. No definite focal consolidation. IMPRESSION: Findings consistent with fluid overload. . ECHO [2192-2-3] The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 45 %). The right ventricular cavity is moderately dilated with moderate 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. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional left ventricular systolic dysfunction c/w CAD. Right ventricular dilation and dysfunction. Pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [2190-7-12], estimated pulmonary artery systolic pressure is higher. The right ventricular may be more dilated and hypokinetic, but was not well visualized on the prior study. Brief Hospital Course: 87 y/o F with CHF, [Year (4 digits) 2091], afib, T2DM, presenting with worsening lower extremity edema and pain, found to have acute on chronic kidney injury, acidosis, and hyperkalemia. . ACTIVE ISSUES # non-gap metabolic acidosis: Pt presented with predominantly non-anion gap metabolic acidosis. Her presentation is most consistent with type 4 renal tubular acidosis, likely developed in the setting of diabetic [Year (4 digits) 2091]. There was a gradual decline of HCO3 in the past two months. Pt was initially treated in the ICU and received three amps of bicarbonate. Her pH has normalized afterwards. Pt was evaluated by nephrology team, who recommended daily bicarbonate supplement. She was started on sodium bicarbonate 650 mg tid. . # AoCRF: Pt presented with Cr 3.9, with a recent baseline of 2.2-2.6. Her [Last Name (un) ] is likely [12-29] CHF exacerbation with concormitant ACEI use. There was probably a component of ATN given the presence of granular cast on urine sedimentation and prominant auto-diuresis on HD#3,4. She was maintained on low K, phos, Na diet. Her Cr on discharge is 3.1. She needs continued monitoring of electrolytes and kidney function. . # Hyperkalemia: Pt presented with hyperkalemia to 5.7. The reason for her hyperkalemia is likely multifactorial, including [Last Name (un) ], RTA, and ACEI use. There were no hyperkalemia related EKG changes during the entire hospitalization. Her enalapril was discontinued. She was initially treated with calcium, insulin and dextrose in the ICU. She required multiple dose of kayaxalate to lower the potassium. Her potassium has been stable for 48 hours prior to discharge less than 5. ACE inhibitor discontinued at this hospitalization. . # CHF exacerbation: Pt presented with 25 lbs above dry weight with significantly elevated BNP, and CXR consistent with severe fluid overload. ECHO on [2-3] showed unchanged EF with diastolic dysfunction. Pt was treated with aggressive iv lasix diuresis for two days. Her urine output increased dramatically afterwards likely in the setting of recovery from ATN. We therefore held diuresis until her urine output normalized. We discontinued her enalapril and metoprolol, and started her on a low dose 10 mg pravastatin and carvedilol 3.125 [Hospital1 ]. Pt was evaluated by the cardiologist, who also recommended aspirin for her CAD and compromised systolic function. However, the decision was deferred given the complicated medical comordities and her age. Regarding her diuretics, her home dose was increased from 20 mg qday to 40 mg qday. . # Bradycardia: Pt had episodes of bradycardia to 30s in the ED. She was monitored on telemetry throughout this hospitalization. Her average heart rate has consistently been >50, with episodes of recorded bradycardia from arhythmia. Per discussion with cardiology, the underlying rhythm was afib with slow ventricular response and occasional slow a-flutter with variable block. AV nodal disease is the underlying pathology. Patient was started on a low dose beta blocker on this hospitalization for generalized rhythm control and cardioprotective effects. No further episodes of bradycardia on carvedilol. . # Arrhythmia - Afib/Aflutter: Pt has known history of atrial fibrillation, CHADS score [3-1], on dabigatran prior to admission. We had to discontinue her dabigatran in setting of renal failure. She was started on warfarin 5 mg qd, with an initial attempt of heparin bridge. However, pt had difficult venous access, thus difficult to obtain reliable monitoring. We discontinued the heparin gtt as we felt the risk of adverse events outweighed the benefit of reducing the stroke risk while awaiting a therapeutic INR. Her metoprolol was switched to carvedilol per above (initially held in presence of bradycardia), and she was discharged on a warfarin dose of 6 mg qday as INR remained subtherepeutic at time of discharge. . # LE edema: Pt presented with chief complaint of symmetric bilateral LE edema with tenderness on palpation. This is a chronic condition likely [12-29] venous stasis and exacerbated by CHF exacerbation. We felt cellulitis or DVT is unlikely in this clinical setting. Pain symptoms improved with diuresis. . CHRONIC ISSUES # HTN: Pt's blood pressure medication was discontinued initially. We held her enalapril and metoprolol, but restarted her amlodipine during this hospitalization as well as carvedilol per above due to systolic BP's as high as 180 mmHg. Systolic BP's returned to 140's mmHg with this regimen. . # Diabetes: We continued her home dose 70/30 insulin and sliding scale. Her blood glucose was largely well controlled. . # HL: We started pravastatin 10 mg daily given her CAD. Her LDL goal should be < 70. . # Anemia: Her HCT has been stable. We continued her iron supplement . # GERD: Stable. We continued her pantoprazole 40 mg [Hospital1 ]. There is insufficient evidence that [Hospital1 ] PPI has benefit over daily PPI. . # Hypothyroidism: TSH wnl. We continued her levothyroxine. . # Osteopenia: We started pt on Calcium/ Vitamin D . TRANSITIONAL ISSUES # CODE STATUS: Full (confirmed) # PENDING STUDIES AT DISCHARGE: - none # MEDICATION CHANGES: - STOPPED dabigatran - STOPPED enalapril - STOPPED metoprolol - INCREASED furosemide to 40 mg qd (from 20 mg qd) - STARTED warfarin 6 mg qd - STARTED pravastatin 10 mg qd - STARTED sodium bicarbonate 650 mg tid - STARTED carvediolol 3.125 mg [Hospital1 ] - STARTED vitamin D/Calcium # FOLLOWUP: - Pt need close monitoring of her INR for warfarin treatment - Please monitor electrolytes closely for hyperkalemia - Pt has Nephrology followup for chronic renal insufficiency and renal tubular acidosis - Pt has cardiology followup for slow atrial flutter with variable conduction, medical management vs permanent pacemaker - Pt needs PCP followup, pending issues include: 1) aspirin for primary prevention 2) blood pressure control 3) will avoid ACEI given RTA type 4 Medications on Admission: amlodipine 10 mg daily dabigatran 75 mg [Hospital1 ] enalapril 5 mg [Hospital1 ] furosemide 40 mg daily gabapentin 100 mg TID levothyroxine 50 mcg daily metoprolol tartrate 12.5 mg [Hospital1 ] oxycodone 5 mg Q8H PRN pantoprazole 40 mg [Hospital1 ] PNV w/o calcium-iron fum-FA [MVI] 27mg-1mg tab daily acetaminophen 650 mg Q8H PRN docusate 100 mg [Hospital1 ] FeSO4 325 mg QOD NPH/regular 70/30 20u qAM, 10u qPM milk of magnesia 800 mg/5mL - 30 mL QHS PRN senna 2 tabs [Hospital1 ] Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 3. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 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 Q12H (every 12 hours). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain . 13. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: see below units Subcutaneous twice a day: Please take 20 units in AM and 10 units in PM. 14. Citracal + D 250 mg calcium- 250 unit Tablet, Chewable Sig: Four (4) Tablet, Chewable PO once a day. Disp:120 Tablet, Chewable(s) Refills:0 15. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 16. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 17. warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day: At 4 PM. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary diagnosis: - Acute on chronic kidney insufficiency - Renal tubular acidosis type 4 - Congestive heart failure (systolic and diastolic, EF 45%) Secondary diagnosis: - atrial fibrillation - hypertension - diabetes 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: Dear Ms. [Known lastname ], You came to our hospital for leg pain. However, we found that you had worsening heart function and worsening kidney function and electrolyte disturbances. You were found to have a condition called renal tubular acidosis type 4 which was responsible for your potassium changes. Your kidney function stablized. In regards to your leg swelling, we were able to remove significant amounts of fluid from you with diuretics, and your heart and kidney condition improved significantly. . You were seen by physical therapy, and it has been recommended that you receive physical therapy in a short term rehab facility. . Please note the following changes in your medication: - Please STOP taking enalapril - Please STOP taking metoprolol - Please STOP taking dabigatran (Pradaxa) - Please START to take sodium bicarbonate 650 mg tablet by mouth three times a day - Please START to take warfarin 6 mg tablet by mouth daily - Please START to take pravastatin 10 mg tablet by mouth daily - Please START to take carvediolol 3.125 mg tablet by mouth twice a day - Please INCREASE furosemide to 40 mg (from 20 mg) by mouth daily . Please weigh yourself every morning, and [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Please also note that we have made the following appointments for you listed below, including follow up with a Nephrologist (Kidney doctor) and Cardiologist (Heart doctor). . It has been a pleasure taking care of you here at [Hospital1 18]! Followup Instructions: Department: WEST [Hospital 2002] CLINIC/NEPHROLOGY When: THURSDAY [2192-3-8] at 4:00 PM With: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. [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: CARDIAC SERVICES When: MONDAY [2192-3-19] at 8:40 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2385], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please make patient has a followup appointment setup prior to leaving the rehab.	[ "428.0", "244.9", "530.81", "276.2", "428.43", "459.81", "403.90", "V10.05", "427.89", "250.00", "584.9", "733.90", "272.4", "276.7", "585.9", "427.31", "285.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	16392, 16462	8107, 13309	319, 326	16738, 16738	4976, 8084	18444, 19201	3414, 3524		14720, 16369		16483, 16483		14190, 14697			16921, 18421							2833, 3019	3539, 4957													13325, 13334					1951, 2142	13356, 14164			262, 281														382, 1932			16663, 16717			16504, 16640		16753, 16897					2164, 2810	3035, 3398
53,870	114,818	35236	Discharge summary	report	Admission Date: [2101-9-27] Discharge Date: [2101-10-6] Date of Birth: [2032-10-27] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2101-9-28] Aortic Valve Replacement (21mm [Company 1543] Mosaic Porcine Valve), Augmentation Aortoplasty with Pericardial patch History of Present Illness: 68 y/o female with known aortic stenosis with dyspnea on exertion and decreased exercise tolerance who was experiencing increased heart failure symptoms. She has known critical aortic stenosis with normal coronaries and LV function. Also was on Coumadin for paroxysmal atrial fibrillation. Being admitted prior to surgery for Heparin. Past Medical History: Aortic Stenosis, Congestive Heart Failure - Diastolic, Paroxysmal Atrial Fibrillation, Thoracic Lymphadenopathy, Hypertension, Obesity, Mild COPD, Goiter, s/p C-section x 2, s/p Hysterectomy, s/p Excision of Liver cyst Social History: Quit smoking 20yrs ago after 20pk/yrhx Social ETOH use 2 drinks/month Family History: Father died from CAD at 60 Physical Exam: At discharge: VS:T98 BP87/44 P86 SB RR20 Gen:NAD Chest:CTA Bilaterally Heart:RRR, Sternum stable Abd:S, NT, ND Ext:1+ LE Incision:distal pole MSI beefy, no drainage Pertinent Results: [9-28] Echo: Pre Bypass: No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic root. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Post Bypass: Preserved biventricular function. A bioprosthetic aortic valve is seen. (#21 [Company ] mosaic ultra per surgeons). No perivalvular leaks. Trace central AI. Peak gradient 62-65 mm Hg, mean gradient 22-25 mm Hg. Mitral regurgitation remains 1+. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [2101-10-6] 05:20AM BLOOD WBC-13.2* RBC-3.43* Hgb-10.2* Hct-30.7* MCV-90 MCH-29.8 MCHC-33.3 RDW-14.8 Plt Ct-429# [2101-10-6] 05:20AM BLOOD Plt Ct-429# [2101-10-6] 05:20AM BLOOD Glucose-107* UreaN-27* Creat-1.1 Na-134 K-4.6 Cl-100 HCO3-24 AnGap-15 Brief Hospital Course: As mentioned in the HPI, Ms. [Known lastname 80397] was admitted one day prior to surgery. She was started on Heparin and underwent usual pre-operative work-up. On [9-28] he was brought to the operating room where he underwent a aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. She was found to be in atrial fibrillation and amiodarone was started. EP was consulted and suggested medical treatment with amiodarone instead of electrical cardioversion. Her chest tubes were removed and she was transferred to the floor. Her wires were removed and she was started on coumadin. She was agressively diuresed. By post-operative day 8 she was ready for discharge to home. Medications on Admission: Cardizem 120mg qd, Lisinopril 10mg qd, MVI, Coumadin 4mg qd (stopped [9-23]) 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:0 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 4. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day): take 2.5 tablets for a total of 125mg three times per day. Disp:225 Tablet(s) Refills:0 5. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 5 days: sternal erythema. Disp:15 Capsule(s) Refills:0 6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: please take 1 mg daily or as directed by the office of Dr. [Last Name (STitle) 47403]. Disp:40 Tablet(s) Refills:0 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 9. Outpatient Lab Work INR to be drawn on Monday [2101-10-10] with results sent to the office of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 47403], fax ([Telephone/Fax (1) 80398] Discharge Disposition: Home With Service Facility: TBA Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Congestive Heart Failure - Diastolic PMH: Paroxysmal Atrial Fibrillation, Thoracic Lymphadenopathy, Hypertension, Obesity, Mild COPD, Goiter, s/p C-section x 2, s/p Hysterectomy, s/p Excision of Liver cyst 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 or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 11763] Dr. [Last Name (STitle) 3321] in [12-26] weeks Dr. [Last Name (STitle) 47403] in [11-24] weeks ([Telephone/Fax (1) 80399]. INR to be drawn on Monday with results sent to the office of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 47403], fax ([Telephone/Fax (1) 80398]. Plan confirmed with [Doctor First Name 4134]. Completed by:[2101-10-6]	[ "276.50", "599.0", "496", "241.1", "424.1", "427.31", "278.01", "428.32", "427.32", "401.9", "V58.61", "428.0" ]	icd9cm	[ [ [] ] ]	[ "35.21", "99.04", "39.61", "39.56" ]	icd9pcs	[ [ [] ] ]	5306, 5340	2859, 3727	299, 437	5634, 5640	1375, 2836	6417, 6888	1146, 1174		3858, 5283		5361, 5613		3753, 3835			5664, 6394								1189, 1189													1203, 1356									240, 261														465, 801													823, 1043	1059, 1130
28,752	124,926	11007+56200	Discharge summary	report+addendum	Admission Date: [2104-10-17] Discharge Date: [2104-10-23] Date of Birth: [2024-12-26] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 3326] Chief Complaint: respiratory decompensation, transfer from rehabilitation Major Surgical or Invasive Procedure: none History of Present Illness: 79y/o male with DMII, PVD, CAD s/p CABG and aortic valve replacement in [8-12] course complicated by left arm plegia, HIT and unable to wean off vent s/p tracheostomy and PEG. He was discharged to rehab on [2104-9-15]. He was weaned off the ventilator early in his rehab stay but within the past couple of weeks has been vent dependent. It was felt that he may have developed a vent-associated pneumonia and he was started on zosyn ([9-25] for 7 day course). He then was started on levofloxacin when his sputum grew stenotrophomonas (pan-sensitive) and felt to have persistent "right lung" consolidation. He did not have fevers during this time, but did have significant sputum/secretions. His BUN/creatinine was noted to rise and peaked at 2.6 within the past 2 weeks from unclear etiology. His diuretics were held during this period and may have contributed to congestive heart failure. (BNP 200 checked at rehab and CXR with pulm edema on [2104-10-10]). Within the past 2-3 days, his diuretics were restarted and on day of transfer, creatinine 1.8. An Echo was performed within the past couple of days showing EF 40% and moderate aortic insufficiency. Per rehab he has gained 8lbs since admission on [9-15]. Patient's family requested he be transferred to [Hospital1 18]. The wife states she was concerned that he wasn't sleeping well at night. . Of note, since his surgery, he has had a left arm plegia which was thought to be either from CVA or a brachial plexopathy. Past Medical History: CAD s/p CABG (LIMA -> LAD, SVG ->OM) CHF EF 50%, mod AI DM2 with neuropathy and retinopathy aortic stenosis s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 1291], [First Name8 (NamePattern2) ] [Initials (NamePattern4) 1525] [Last Name (NamePattern4) ] PVD s/p left bkpop-at with left cephalic vein [6-6], s/p left fem-pedal [5-6] failed ostoarthritis-back l/s spine AFib with embolic CVA catracts s/p repair bilaterally inguinal hernia s/p repair retinopathy s/p OD laser HIT positive s/p trach s/p PEG tube Social History: retired, married, living in [Hospital ] [Hospital ] rehab since CABG/[Hospital 1291] Family History: NC Physical Exam: V: 96.2F HR 101 BP 149/48 RR 22 99% 550x 12/40%/5PEEP Gen: awake, opens eyes to command, OP clear, MMM HEENT: OS with catract Neck: JVP 8-9 cm, trach collar CV: irreg irregular 2-3/6 systolic murmur at apex Pulm: coarse breath sounds bilaterally with bibasilar crackles ABd: Normoactive BS, soft, ND/NT, feeding tube in place without erythema at site Ext: warm, dopplerable DP/PT pulses bilaterally, left 2nd toe with dry ulceration, right heel with dry pressure ulcer. Left arm with swelling and well-healed surgical scar Neuro: awake, able to open eyes and tracks but does not follow other commands, able to move both legs and right arm, responds to pain on left arm. Pertinent Results: [2104-10-17] 10:14PM BLOOD WBC-9.5 RBC-3.25* Hgb-10.0* Hct-31.2* MCV-96 MCH-30.8 MCHC-32.1 RDW-17.3* Plt Ct-124# [2104-10-17] 10:14PM BLOOD Neuts-60.2 Lymphs-24.1 Monos-8.8 Eos-6.3 Baso-0.5 [2104-10-17] 10:14PM BLOOD PT-15.0* PTT-31.3 INR(PT)-1.3* [2104-10-17] 10:14PM BLOOD Glucose-40* UreaN-65* Creat-1.6* Na-145 K-5.0 Cl-115* HCO3-22 AnGap-13 [2104-10-20] 12:29PM BLOOD CK(CPK)-65 [2104-10-21] 04:47AM BLOOD CK(CPK)-24* [2104-10-20] 12:29PM BLOOD CK-MB-2 cTropnT-0.01 [2104-10-21] 04:47AM BLOOD CK-MB-3 cTropnT-0.02* [2104-10-17] 10:14PM BLOOD proBNP-4050* [2104-10-17] 10:14PM BLOOD Calcium-8.7 Phos-4.8* Mg-2.8* [2104-10-18] 01:10AM BLOOD Type-ART Tidal V-550 FiO2-40 pO2-87 pCO2-37 pH-7.38 calTCO2-23 Base XS--2 -ASSIST/CON Intubat-INTUBATED [2104-10-19] 08:49AM BLOOD Type-ART pO2-94 pCO2-36 pH-7.39 calTCO2-23 Base XS--2 [2104-10-20] 12:37PM BLOOD Type-ART Temp-36.2 Rates-/23 Tidal V-350 PEEP-5 FiO2-40 pO2-102 pCO2-41 pH-7.40 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOUS . GRAM STAIN (Final [2104-10-18]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. Trimethoprim/Sulfa sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. Levofloxacin PENDING . KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA \| KLEBSIELLA PNEUMONIAE \| \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S IMIPENEM-------------- <=1 S MEROPENEM------------- <=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- 2 S . Studies: EKG: Atrial fibrillation with controlled ventricular response. Right bundle-branch block. Left anterior fascicular block. Low limb lead voltage. Compared to the prior tracing of [2104-8-24] no diagnostic change. . ECHO: No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild global left ventricular hypokinesis (LVEF = 50 %). There is no ventricular septal defect. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The prosthetic aortic valve leaflets appear normal The transaortic gradient is normal for this prosthesis. A paravalvular aortic valve leak is probably present. At least mild to moderate ([1-8]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([1-8]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. No valvular vegetations are seen.The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2104-8-14], an [Year (4 digits) 1291] is now present with a mild to moderate paravalvular leak. If clinically indicated,a TEE may better assess the basis and severity of the aortic valve prosthesis regurgitation. . CXR ([10-17]): Comparison made to the prior chest x-ray of [9-9]. The heart is enlarged. Bilateral pulmonary edema with alveolar opacification and bilateral effusions is present. Tracheostomy tube remains in a good position. . LABS ON DISCHARGE [2104-10-23] 04:35AM BLOOD WBC-12.5* RBC-3.56* Hgb-10.8* Hct-33.7* MCV-95 MCH-30.4 MCHC-32.1 RDW-17.0* Plt Ct-169 [2104-10-22] 05:41AM BLOOD PT-24.5* PTT-40.8* INR(PT)-2.5* [2104-10-23] 04:35AM BLOOD Glucose-210* UreaN-51* Creat-1.3* Na-146* K-4.0 Cl-113* HCO3-24 AnGap-13 [2104-10-20] 12:29PM BLOOD CK(CPK)-65 [2104-10-20] 12:29PM BLOOD CK-MB-2 cTropnT-0.01 [2104-10-21] 04:47AM BLOOD CK-MB-3 cTropnT-0.02* [2104-10-17] 10:14PM BLOOD proBNP-4050* [2104-10-23] 04:35AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.3 [2104-10-20] 12:37PM BLOOD Type-ART Temp-36.2 Rates-/23 Tidal V-350 PEEP-5 FiO2-40 pO2-102 pCO2-41 pH-7.40 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOU Brief Hospital Course: A/P [10-21]: 79 year old male DMII, PVD, CAD s/p CABG and [Month/Year (2) 1291] in [8-12], trach/PEG and recent vent dependence. . 1) Vent dependence/ Congestive Heart Failure - The patient was admitted with dependence on vent which may have been due to recent stenotrophomonas PNA (started levoflox on [10-13]) vs. CHF exacerbation. He initially required mechanical ventilation but tolerated short periods of time off of the ventilator on trach mask with high O2. He was started on levofloxacin for empiric treatment of community acquired pneumonia and completed a 10 day course. His sputum culture grew Stenotrophamonas which may have been infectious vs. colonizer due to tracheostomy and long-term mechanical ventilation. Sputum cx also showed rare growth of Klebsiella resistant to ciprofloxacin. However at the time of these sensitivity results he had already had significant clinical improvement with abx and diuresis. He was last mechanically ventilated on [10-21] and then tolerated being off of the ventilator with trach mask only on an FiO2 of 50%. He did require diuresis of approximately 500cc - 1.0L daily which contributed to improvement of respiratory status. Likewise, his chest X-ray cleared significantly upon discharge. He did however continue to have the need for frequent suctioning for thick secretions from tracheostomy. A passymuir valve was placed and he subsequently was able to talk with tracheostomy in place. [Hospital 35664] rehabilitation, continue to monitor patient's intake/output patient should be even to slightly negative every day. Continue albuterol nebulizers as needed for shortness of breath. . 2) Atrial Fibrillation - The patient was increased on his dose of Metoprolol to 100 mg po tid with improved rate control. He was increased to Coumadin 2.5mg daily with therapeutic INRs. ---- AT rehabilitation, continue to monitor INR at least twice a week . 3) Hypernatremia - He did have a free water deficit with elevated serum sodium to 147. This was treated with increased free water boluses to make up a deficit of 2.5L, which was transitioned to PEG tube flushes q3-4 hours of 200cc free water. ---- AT rehabilitation, please check at least twice weekly chemistry to ensure patient is receiving adequate free water. . 4) Hypertension - The patient's metoprolol dose was increased as above, also hydralazine was started as well as isosorbide dinitrate which he tolerated with good blood pressure control with SBPs 110s-130s. . 5) s/p [Hospital 1291] - bioprosthetic valve. ECHO showed [1-8]+ AR, [1-8]+ MR. CT [Doctor First Name ]. was consulted and felt that there was no indication for additional surgery. His anticoagulation was maintained. . 6) Hyperkalemia - Resolved shortly after discontinuing captopril that was recently started. Responded to Kayexalate. Feel this indicates a contraindication to starting an ACE-I in the future. . 7) Mental status - Is at baseline, pt. continued on standing Seroquel at bedtime for restlessness. Patient did have several episodes of somnolence and confusion which were attributed to his Ativan, daytime Seroquel doses, and Ambien. Maintained evening Seroquel dose with no change to mental status, all other medications discontinued. . 8) Diabetes Mellitus - Patient was maintained on Lantus and SSI. . 9) Anemia: Patient on iron. Darbepoetin held while in hospital and was not needed to maintain hematocrit. Defer restarting to rehabilitation facility. . 10) Coronary Artery Disease: Not active, maintained on simvastatin, ASA, metoprolol, and Lasix. Added isosorbide dinitrate, hydralazine. . 11) Acute Renal Failure in patient with Chronic Kidney Disease - Baseline Cr 1- 1.2, patient now near baseline. Peak Cr 2.7, unclear etiology. Continue to monitor as an outpatient. . 11) FEN - Tube feeds continued, passymuir valve placed . 12) Discharged to Rehabilitation Medications on Admission: Aspirin 81 mg po daily esomeprazole 20mg daily Simvastatin 10 mg po daily coumadin 1mg po daily tylenol prn Miconazole Nitrate 2 % Powder qid prn. lidocaine patch 5% to back aranesp 0.06/0.3ml qMon ferrous sulfate 300mg/5ml daily Metoprolol Tartrate 25 mg po tid Glargine 50 units sc daily + novolog sliding scale levAlbuterol: 2 Puffs Inh Q4H prn Furosemide 20 mg PO daily seroquel 50mg po qhs + 25mg po tid prn agitation ativan 0.5mg po q12hrs prn lasix levofloxacin 250mg daily (start [2104-10-13]) ambien 10mg po qhs Discharge Medications: 1. Acetaminophen 325 mg Tablet [Month/Day/Year ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. Aspirin 81 mg Tablet, Chewable [Month/Day/Year ]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 10 mg Tablet [Month/Day/Year ]: One (1) Tablet PO DAILY (Daily). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Month/Day/Year ]: One (1) Adhesive Patch, Medicated Topical 12 HOURS ON AND 12 HOURS OFF () as needed for to back. 5. Ferrous Sulfate 300 mg/5 mL Liquid [Month/Day/Year ]: Five (5) mL PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol [Month/Day/Year ]: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath. 7. Miconazole Nitrate 2 % Powder [Month/Day/Year ]: One (1) Appl Topical TID (3 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Insulin Glargine 100 unit/mL Solution [Last Name (STitle) ]: Fifty (50) units Subcutaneous once a day. 10. Novolog insulin sliding scale as directed by rehab physican 11. Warfarin 2.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime). 12. Hydralazine 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours). 13. Quetiapine 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QHS (once a day (at bedtime)). 14. Metoprolol Tartrate 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO three times a day. 15. Isosorbide Dinitrate 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 16. Furosemide 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day: please adjust as needed to maintain patient euvolemic status. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: 1.) Congestive heart failure exacerbation 2.) Possible community acquired pneumonia 3.) Renal Failure 4.) Atrial Fibrillation 5.) Mental Status Changes Secondary diagnosis: 3.) Hyperkalemia 4.) Hypertension 5.) Diabetes Mellitus Discharge Condition: afebrile, displaying normal vital signs, tolerating trach mask for >24 hours without need for mechanical ventilation. Discharge Instructions: You were admitted to the hospital because of worsening of your breathing. You were found to have a possible infection in your lungs and were treated with 10 days of antibiotics. You were also treated for excess fluid in your lungs called pulmonary edema which can also worsen breathing. Initially you needed mechanical ventilation but gradually you were able to breathe comfortably with just oxygen mask for your tracheostomy. A special valve was placed on your tracheostomy tube so that you would be able to talk. . The following changes were made to your medication regimen: 1.) Coumadin dose was increased to 2.5mg po qhs 2.) Metoprolol increased to 100mg po tid 3.) Lasix dose - increased to 40mg po daily or as instructed by your rehab physician 4.) Seroquel - reduced frequency to 25mg po once daily at bedtime 5.) Discontinued Ambien 6.) Discontinued Ativan 7.) Started new medicine called hydralazine for blood pressure 8.) Started new medicine called isosorbide dinitrate Followup Instructions: Please follow-up as instructed by your rehab physician or as previously scheduled. Name: [Known lastname ],[Known firstname ] F. Unit No: [Numeric Identifier 6355] Admission Date: [2104-10-17] Discharge Date: [2104-10-23] Date of Birth: [2024-12-26] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 2097] Addendum: Patient's Stenotrophomonas from sputum culture was sensitive to Levofloxacin and he received a 10 day course. . [2104-10-17] 10:19 pm SPUTUM Source: Endotracheal. FINAL REPORT [2104-10-23] GRAM STAIN (Final [2104-10-18]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2104-10-23]): OROPHARYNGEAL FLORA ABSENT. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. Trimethoprim/Sulfa sensitivity testing confirmed by [First Name8 (NamePattern2) 5260] [Last Name (NamePattern1) ]. Levofloxacin Sensitivity testing per DR [Last Name (STitle) 6356] #[Numeric Identifier 6357]. In [Last Name (un) 6358] sensitive results may not predict clinical efficacy; interpret results with caution. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ . STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA LEVOFLOXACIN---------- 2 S TRIMETHOPRIM/SULFA---- 2 S . . KLEBSIELLA PNEUMONIAE AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S IMIPENEM-------------- <=1 S MEROPENEM------------- <=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - MACU [First Name11 (Name Pattern1) 126] [Last Name (NamePattern4) 2098] MD [MD Number(1) 2099] Completed by:[2104-10-23]	[ "V42.2", "999.9", "276.7", "V45.81", "250.60", "250.50", "428.0", "276.0", "707.15", "518.84", "V44.1", "357.2", "482.0", "428.23", "362.01", "427.31", "585.9", "707.07", "584.9" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.71" ]	icd9pcs	[ [ [] ] ]	18460, 18687	8340, 12245	335, 341	15003, 15123	3291, 4490	16157, 18437	2576, 2580		12820, 14622		14732, 14732		12271, 12797			15147, 16134								2595, 3272								4531, 8317														239, 297														369, 1880			14924, 14982			14751, 14903							1902, 2446	2462, 2560
188	123,860	20259	Discharge summary	report	Admission Date: [2160-12-31] Discharge Date: [2161-1-8] Date of Birth: [2105-5-18] Sex: M Service: MEDICINE Allergies: Codeine / Ambien / Shellfish Derived Attending:[First Name3 (LF) 1493] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: [12-31] Diagnostic paracentesis [12-31] intubation, mechanical ventilation History of Present Illness: Mr. [Known lastname 54381] is a 55 y.o M with HCV cirrhosis, HCC s/p RFA, s/p [Known lastname ], now with recurrent Hep C, HTN, adrenal insufficiency, Type II DM who presented to OSH on [12-31] with AMS. He was found to be hypoglycemic along with combative and altered. He was intubated, sedated and transfered to the [Hospital1 ] for further evaluation. At the time of transfer, he was admitted to MICU [Location (un) 2452] at which time he remained intubated but became more interactive. The MICU team was alerted that [3-12] [Month/Day (4) ] cultures from the OSH grew GPCs in pairs and chains which ended up being Strep mitis. The patient was initially treated with vancomycin and then coverage was narrowed to cefazolin. He was extubated without difficulty and has been stable from a respiratory standpoint for 24 hours. His mental status was attributed to hepatic encephalopathy in the setting of sepsis and he has been treated with lactulose and rifaximin. . Upon arrival to the floor vitals were 97.0 155/88 66 20 100RA glucose 188. The patient was able to respond to simple questions. He did not follow instructions. He was AOx2 (date [12-31]). Past Medical History: - Hepatitis C cirrhosis and hepatocellular carcinoma s/p radiofrequency ablation x 3, s/p liver transplantation [1-10], recurrent Hep C after transpant, now with decompensated liver failure with ascites and encephalopathy, listed. Last EGD in [2158] showed 1 cords of grade I varices. - Recurrent Hep C after Transpant- last viral load 69 on [2158-7-11]. - HTN - Hx of Type II DM - Adrenal Insufficiency: [2158-11-6]. After Cortisal Stimulation test. - s/p appendectomy - s/p tonsillectomy - s/p cervical laminectomy - s/p right forearm ORIF - s/p bone graft from right hip to elbow - s/p knee surgery Social History: Former fireman and barowner; positive tobacco history; 2 packs per day x 30 years, quit prior to liver [Year (4 digits) ]. He is not using IV drugs. Family History: His father has renal failure. His mother has hypothyroidism. Physical Exam: Vitals: BP 167/78 HR 67 RR 16 SaO2 100%RA General: somnolent male, NAD HEENT: NG tube in place, mild scleral icterus, no oral lesions, dry MM Neck: JVP not elevated Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes or crackles CV: Regular rhythm, normal rate, S1, S2, II/VI systolic murmur LLSB Abdomen: soft, mild destension, nontender, +BS, scar from prior surgery inplace. GU/Rectal: foley and flexiseal in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no splinter hemorrhages or lesions Pertinent Results: Micro: OSH [Year (4 digits) ] culture: S. mitis [2160-12-31] Peritoneal fluid: negative [2161-1-1] [Month/Day/Year ] cultures: negative [2161-1-2] Urine culture: pending . Images: [2160-12-31] ABDOMINAL ULTRASOUND: There is moderate amount of ascites in the perihepatic and perisplenic region. The macronodular [Month/Day/Year ] liver is echogenic in echotexture but without focal lesions, compatible with cirrhosis. The right, mid and left portal veins are widely patent with normal hepatopetal flow. A 3-cm focal dilation of the main portal vein is similar in appearance compared to prior CT study. Slight turbulent flow is noted around the focal dilation. The hepatic veins and arteries are patent and normal in Doppler waveforms. The spleen measures 14.8 cm. The right kidney measures 11.3 cm. The left kidney measures 12.0 cm. There is no hydronephrosis, hydroureter or stone. IMPRESSION: Patent hepatic vasculature. Cirrhotic liver with moderate ascites. Normal kidneys. Splenomegaly. [2161-1-2] CXR: FINDINGS: The NG tube has its tip projected over the stomach. There is blunting of the costophrenic angles bilaterally. The heart remains enlarged. There is no significant change in the bibasilar atelectasis. IMPRESSION: 1. Bibasal atelectasis and bibasal effusions along with cardiomegaly, overall appearances are suggestive of CHF. 2. The nasogastric tube terminates in the proximal stomach, recommended advancing up to 5 cm Brief Hospital Course: Mr. [Known lastname 54381] is a 55-year old male with HCC s/p RFA, HCV cirrhosis, s/p OLT [2156], with HCV recurrence and cirrhosis complicated by encephalopathy, ascites, varices who was admitted with altered mental status and Streptococcal bacteremia. 1. BACTEREMIA- Original cultures from [Hospital6 33] showed Strep mitis, but subsequent speciation showed Strep sanguinus and salivarius species, all of which are consistent with oral flora, as patient has poor dentition. We obtained a panorex dental X-ray to better evaluate infectious foci in his oropharynx. He was treated with a 7-day course of cefazolin which was changed to IV ceftriaxone for ease of dosing upon discharge, for a total treatment duration of 14 days. Infectious Disease service was consulted regarding the treatment of this microorganism. A TTE was obtained to rule out endocarditis, and there were no obvious vegetations. A TEE was not pursued due to low clinical probability of endocarditis given lack of adequate Duke's criteria. He was discharged with antibiotic course to be administered through PICC line. 2. HEPATIC ENCEPHALOPATHY- Mr. [Known lastname 54381] was quite encephalopathic on admission, and his mental status improved slowly each day on lactulose and rifaxamin. At the time of discharge, he was mentating at his baseline. 3. METABOLIC ACIDOSIS- chronic metabolic acidosis with partially compensated respiratory alkalosis as per [Known lastname ] gas and daily labs. Could be partially due to volume depletion from greatly increased stool output from lactulose, as patient was hypokalemica and bicarb depleted. Renal was consulted and recommended fluid challenge. He was also given albumin and bicarbonate with some improvement in lab values, but this derangement appears chronic. Medications on Admission: 1. Hydrocortisone 10 mg PO QAM 2. Hydrocortisone 5 mg PO QPM 3. Metoprolol Tartrate 50 mg PO BID 4. Pantoprazole EC 40 mg PO BID 5. Paroxetine HCl 20 mg PO DAILY 6. Rifaximin 600 mg PO TID 7. Sucralfate Oral 8. Ferrous Sulfate 325 mg PO DAILY 9. Magnesium Oxide Oral 10. Doxazosin 1 mg PO HS 11. Trimethoprim-Sulfamethoxazole 80-400 mg PO MWF ([Known lastname 766]-Wednesday-Friday). 12. Ciprofloxacin 250 mg Tablet PO qsunday. 13. Lactulose 60 gram PO every 4-6 hours (titrate to 3BM) 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY PRN 15. Tacrolimus 0.5 mg PO Q12H 16. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Subcutaneous Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Ceftriaxone 2 gram Recon Soln Sig: Two (2) grams Intravenous once a day for 8 days: to end [2161-1-16]. Disp:16 grams Refills:0 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF ([Month/Day/Year 766]-Wednesday-Friday). 6. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 7. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO QSUN (every [Month/Day/Year 1017]). 8. Tacrolimus 0.5 mg Capsule Sig: [2-8] Capsule PO Q12H (every 12 hours). 9. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl Topical PRN (as needed) as needed for pain. 10. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO QID (4 times a day). 11. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 13. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. 16. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Sixty (60) units Subcutaneous twice a day: 60 units NPH in AM and 48 units in afternoon . Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: PRIMARY: Strep sanguis and Strep salivarium bacteremia, hepatic encephalopathy SECONDARY: HCC s/p RFA, HCV s/p OLT '[56], c/b recurrence HCV w/ ascites, varices and PSE Discharge Condition: Activity Status:Ambulatory - requires assistance or aid (walker or cane) Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Discharge Instructions: It was a pleasure being involved in your care, Mr. [Known lastname 54381]. You were admitted to the hospital because of a bacterial infection in your [Known lastname ], for which you were treated with antibiotics. The likely source of this bacteria is from your mouth, so it is important to follow-up with good dental care. You also were confused which is due to your hepatic encephalopathy. You cleared up with lactulose by the time you were sent home. Your medications have CHANGED as follows: 1. We ADDED CEFTRIAXONE 2g IV q24h (antibiotic) for a total 14 day course to end on [2161-1-16] The rest of your medications are the same, please continue to take them as you have been. Please keep your follow-up appointments below. Call your doctor or 911 you experience crushing chest pain, difficulty breathing, intractable nausea or vomiting, [Year (4 digits) ] in your urine vomit or stool or any other concerning medical problem. Followup Instructions: 1. Please see your liver doctor, [Name6 (MD) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2161-1-12] 8:00 2. please make an appointment to see your primary care doctor, Dr. [Last Name (STitle) 54392]. Phone [Telephone/Fax (1) 54393] for a post-hospital stay follow-up visit Completed by:[2161-1-9]	[ "518.81", "996.82", "V49.83", "789.59", "E878.0", "255.41", "790.7", "456.21", "276.0", "276.8", "276.3", "585.9", "V10.07", "070.44", "571.5", "403.90", "584.9", "041.09", "250.80", "276.2" ]	icd9cm	[ [ [] ] ]	[ "96.71", "54.91", "38.93" ]	icd9pcs	[ [ [] ] ]	8669, 8720	4577, 6377	319, 403	8937, 9055	3087, 4554	10090, 10435	2449, 2511		7080, 8646		8741, 8916		6403, 7057			9114, 10067								2526, 3068																						258, 281														431, 1619								9069, 9090					1641, 2262	2278, 2433
16,698	151,269	51640	Discharge summary	report	Admission Date: [2126-2-19] Discharge Date: [2126-2-21] Date of Birth: [2045-6-8] Sex: M Service: SURGERY Allergies: A.C.E Inhibitors / Beta-Adrenergic Blocking Agents Attending:[First Name3 (LF) 668] Chief Complaint: Bleeding from the liver s/p biopsy of the liver Major Surgical or Invasive Procedure: Exploratory laparotomy, cauterization of right hepatic lobe biopsy site. History of Present Illness: This is an 80 year old male who is status post percutaneous U/S guided liver biopsy ([2126-2-19]) of Seg VI with a moderate hematoma after the biopsy. The patient presented to [Hospital1 18] SICU for observation and then taken to the OR once this was not controlled. Past Medical History: PMHx: 1. Hypertension 2. Hypercholesterolemia 3. Cataract, left eye. 4. Macular hole, left eye. PSHx: 1. Total knee replacement. 2. Prostatectomy 3. Cataract extraction Stent to RCA after circulatory collapse Social History: He currently lives with his girlfriend. [Name (NI) ] is a retired laboratory technician and was exposed to significant amounts of beryllium over his professional career. He denies any exposure to asbestos. He currently smokes about two packs a week and has a 30 pack-year smoking history. Family History: He denies any family history of lung disease. Pertinent Results: [2126-2-21] 05:37AM BLOOD WBC-8.7 RBC-3.46* Hgb-9.4* Hct-26.9* MCV-78* MCH-27.1 MCHC-34.9 RDW-19.0* Plt Ct-187 [2126-2-20] 03:40PM BLOOD Hct-29.1* [2126-2-20] 08:45AM BLOOD Hct-30.9* [2126-2-20] 12:50AM BLOOD Hct-28.5* [2126-2-19] 09:54PM BLOOD Hct-29.7* [2126-2-19] 05:16PM BLOOD WBC-6.1 RBC-3.17* Hgb-8.0* Hct-23.8* MCV-75* MCH-25.2* MCHC-33.5 RDW-18.4* Plt Ct-243 [2126-2-19] 10:50AM BLOOD WBC-4.9 RBC-3.10* Hgb-7.3* Hct-22.1* MCV-71* MCH-23.5* MCHC-32.9 RDW-17.6* Plt Ct-277 [2126-2-19] 10:50AM BLOOD Neuts-68 Bands-0 Lymphs-17* Monos-9 Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-0 [2126-2-19] 10:30AM BLOOD Neuts-49* Bands-0 Lymphs-38 Monos-10 Eos-1 Baso-1 Atyps-0 Metas-1* Myelos-0 [2126-2-19] 10:50AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-2+ [2126-2-19] 05:16PM BLOOD PT-13.1 PTT-27.1 INR(PT)-1.1 [2126-2-19] 05:16PM BLOOD Plt Ct-243 [2126-2-20] 12:50AM BLOOD Glucose-158* UreaN-15 Creat-0.9 Na-138 K-4.2 Cl-107 HCO3-23 AnGap-12 [2126-2-19] 05:16PM BLOOD Glucose-128* UreaN-13 Creat-0.9 Na-139 K-4.1 Cl-106 HCO3-22 AnGap-15 [2126-2-19] 05:16PM BLOOD ALT-62* AST-91* CK(CPK)-66 AlkPhos-132* Amylase-87 TotBili-0.8 [2126-2-19] 10:50AM BLOOD ALT-19 AST-19 CK(CPK)-30* AlkPhos-144* Amylase-98 TotBili-0.3 [2126-2-19] 05:16PM BLOOD Lipase-13 [2126-2-19] 05:16PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2126-2-19] 10:50AM BLOOD cTropnT-<0.01 [2126-2-20] 12:50AM BLOOD Calcium-8.7 Phos-5.3* Mg-1.6 [2126-2-19] 05:16PM BLOOD Albumin-2.4* Calcium-8.7 Phos-4.9* Mg-1.7 [2126-2-19] 04:05PM BLOOD Type-ART pO2-277* pCO2-43 pH-7.36 calTCO2-25 Base XS--1 [2126-2-19] 10:35AM BLOOD Type-ART pO2-312* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 [2126-2-19] 04:05PM BLOOD Glucose-113* Lactate-1.4 Na-136 K-5.1 Cl-108 [2126-2-19] 04:05PM BLOOD Hgb-8.5* calcHCT-26 [2126-2-19] 03:03PM BLOOD Hgb-7.6* calcHCT-23 [2126-2-19] 04:05PM BLOOD freeCa-1.16 . . Cardiology Report ECG Study Date of [2126-2-19] 10:27:38 AM Baseline artifact. Leads VI and V5-V6 were not recorded. Sinus rhythm. Borderline left axis deviation. Cannot exclude prior inferior wall myocardial infarction. Probable left ventricular hypertrophy. Anterior T wave inversions raise consideration of ischemia, etc. Compared to the previous tracing of [2126-1-10] atrial ectopy is not seen without overall diagnostic change in the leads recorded. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 79 162 102 426/460.42 71 -20 63 . . BX-NEEDLE LIVER BY RADIOLOGIST [2126-2-19] 7:54 AM IMPRESSION: Ultrasound-guided biopsy of a heterogenous lesion in segment 6 previously seen on ultrasound and MRI. A total of three core biopsies were obtained. No immediate post-procedure complications were observed; however, the patient experienced hypotension while being monitored after the procedure in the daycare unit and was sent to the emergency room after a Code was called . There is evidence of a subcapsular hematoma on fast scan and CT scan of the abdomen was then performed to evaluate the amount of hemorrhage. . . CHEST (PORTABLE AP) [2126-2-19] 11:06 AM IMPRESSION: Right-sided pleural densities and atelectasis in right lower lobe area, stable in comparison with the previous examination of [2126-2-1]. No new acute findings. No pneumothorax. . . CTA ABD W&W/O C & RECONS [2126-2-19] 11:07 AM IMPRESSION: 1. Moderate-sized perihepatic extracapsular hematoma with posterior area of active extravasation. This extravasation appears to be arising from vessels associated with hypervascular lesion at the inferior right lobe of the liver (biopsied earlier today) with clot formation adjacent to this lesion. 2. Four rim-enhancing hepatic lesions, which are likely metastases. 3. Left lower pole renal cell carcinoma. 4. New 18 x 18 mm left lower lobe pleural-based mass, which is concerning for metastasis given that it was not present on prior chest CT from [2125-10-12]. Recommend dedicated chest CT to evaluate for additional lesions. 5. Right-sided pleural effusions including a loculated anterior effusion and layering posterior effusion with compressive atelectasis. Status post right- sided pleurodesis. 6. Adrenal adenoma. 7. Sclerotic and mottled appearance of right iliac [Doctor First Name 362], which may represent early Paget's disease or less likely a focus of metastasis. . . Brief Hospital Course: This patient was admitted to [Hospital1 1388] Transplant surgery service after a liver hemorrhage status post a liver biopsy. The patient was initially admitted to the S-ICU where he had imaging (please see reports as above). He had a major drop in his hematocrit from 28 to 22 and underwent a CT scan that demonstrated active extravasation of contrast from the liver bed. The patient was taken to the operating room for exploration (ex-lap and cauterization of liver bleed). The patient had no intra or post-operative complications. He was brought to the PACU in a stable condition. Cardiac enzymes were drawn for chest discomfort and the drop in Hct - they were negative and his EKG was unremarkable. The patient did well overnight. The following morning, he was started on a clear diet, which was tolerated. He had no new issues and only complained of a sore throat. The following day on POD2, the patient was discharged after he was ambulating and tolerating a regular diet. He had no new issues and his labwork was stable and within normal limits. Medications on Admission: Norvasc 7.5', cozaar 50', Lipitor 40', Lopresor 50", Amlodipine 2.5''', colace, Foltex T', ASA 81' Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:30 Capsule(s) Refills:0 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for Temp above 101F. Disp:25 Tablet(s) Refills:1 Discharge Disposition: Home Discharge Diagnosis: Hemoperitoneum s/p liver biopsy (percutaneous liver biopsy) Discharge Condition: Stable. Discharge Instructions: You should not resume your aspirin until follow-up with your transplant surgeon, Dr [First Name (STitle) ]. You should see your PCP [Last Name (NamePattern4) ] 1 weeks time. Please follow-up with your cardiologist and schedule an outpatient TTE (echo) as they indicated when you were in hospital with us. Light activity only. You may take Tylenol for pain as you need it, and Colace for constipation as you need it. 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 vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, 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 skin, or the whites of your eyes become yellow. * 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. Followup Instructions: -- Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2334], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2126-5-20] 9:30 -- Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD Phone:[Telephone/Fax (1) 4022] Date/Time:[2126-8-19] 12:40 -- Please call to see Dr [First Name (STitle) ] in 2 weeks time: ([Telephone/Fax (1) 3618] Completed by:[2126-2-21]	[ "998.11", "496", "272.0", "568.81", "V64.41", "163.9", "401.9", "189.0" ]	icd9cm	[ [ [] ] ]	[ "39.98", "50.11" ]	icd9pcs	[ [ [] ] ]	7328, 7334	5833, 6891	356, 431	7438, 7447	1363, 5810	8837, 9282	1297, 1344		7040, 7305		7355, 7417		6917, 7017			7471, 8814																														269, 318														459, 735													757, 970	986, 1281
49,773	176,317	4261	Discharge summary	report	Admission Date: [2105-1-20] Discharge Date: [2105-1-23] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Confusion and Word finding difficulty Major Surgical or Invasive Procedure: none History of Present Illness: Healthy [Age over 90 ]M with multiple falls over past few months; etiology of the falls is unclear. Also reported to have progressive confusion and difficulty finding words. Referred to OSH for evaluation where on CT scan of brain, pt was found to have an acute on chronic SDH. Pt was then transferred to [Hospital1 18] for continued neurosurgical evaluation and treatment. Mr. [Known lastname 18497] also complained of mid/low thoracic back pain, worsened since last fall; denies any H/A,N/V, weakness, numbness or paresthesias or radiculopathy. Past Medical History: None Social History: Resides with son and daughter in law; retired professor [First Name (Titles) ] [Last Name (Titles) 18498]y. Non smoker. Daily ETOH use. Family History: Noncontributory Physical Exam: VSS: 97.6- 141/65-77-20. O2Sat 98% 16 98% RA Mental status: Awake. Somewhat drowsy. Arouses fully with light stimulation, cooperative, normal affect. NAD. Resting comfortably in bed. Orientation: Oriented to person, partially to place, and date. Language: Speech is slow and fluent with good comprehension. Conversational with intermittent naming and word finding difficulties. No dysarthria or paraphasic errors. II: Pupils equally round and reactive to light, 3mm to 2mm bilaterally. III, IV, VI: Extraocular movements full bilaterally without nystagmus.Conjugate gaze V, VII: Facial strength and sensation intact and symmetric. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Occasional fine hand tremors. Strength full power [4-14] throughout. Sensation: Intact to light touch bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Pertinent Results: [2105-1-21] WBC-6.9 RBC-4.40* Hgb-13.3* Hct-37.9* MCV-86 MCH-30.2 MCHC-35.1* RDW-13.9 Plt Ct-168 [2105-1-21] Glucose-90 UreaN-21* Creat-0.8 Na-140 K-3.9 Cl-104 HCO3-26 AnGap-14 [2105-1-21] Phenyto-13.4 Brief Hospital Course: Pt was admitted to the neurosurgical service for ongoing observation and treatment. Serial CT imaging of brain has not demonstrated any increase in th subdural hematoma. CT's of brain were performed on [2-25] and [1-21]. On [1-21] there is no significant change in the size and appearance of the acute on chronic subdural hematoma in the left side of the head, in the frontal, temporal and parietal regions, with a maximum transverse dimension of 1.6 cm with mass effect unchanged as described above. The patient has remained stable. The physical exam is as decribed in this summary. He has had episodic agitation for which he was placed on Ativan with excellent results. PT was consulted and following pt during this hospitalization. The patient would benefit from ongoing therapies upon discharge to improve strength and endurance, in an effort to reach his baseline potential. Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for temp>101.5. Discharge Disposition: Extended Care Facility: [Location (un) ] Discharge Diagnosis: Subdural Hematoma Discharge Condition: Neurologically stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in 4 weeks with a non-contrast head CT. Call [Telephone/Fax (1) 1669] to make an appointment. Completed by:[2105-1-23]	[ "E888.9", "852.20", "293.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	3772, 3819	2336, 3235	304, 311	3881, 3905	2092, 2308	5149, 5323	1107, 1124		3258, 3749		3840, 3860					3929, 5126								1139, 1187																						227, 266														339, 902								1202, 2073					924, 930	946, 1091
70,622	141,292	859	Discharge summary	report	Admission Date: [2141-9-27] Discharge Date: [2141-9-28] Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1556] Chief Complaint: RUQ pain. Major Surgical or Invasive Procedure: None. History of Present Illness: [Age over 90 ]M with multiple medical co-morbitities including Afib, BPH s/p TURP x 3, CRI who presented to the ED this morning after being found short of breath in his nursing home with RUQ pain. On arrival at [Hospital1 18] ED, patient was found have RR in the 50's and SBP in the 60s. Patient was emergently intubated and started on neo gtt and levophed gtt. ED ordered a CT scan which showed likely gangrenous cholecystitis with intrabdominal free air. Surgery was emergently consulted for further management. Past Medical History: Dementia, Hypertension, Chronic kidney disease, BPH with overflow incontinence, Urinary retention, Prostate cancer, Inguinal hernia, Iron deficiency anemia, UGI bleed, Glaucoma, Stasis dermatitis and superficial ulcerations, Lymphedema, AFib PSH: TURP [3-21] Social History: Lives at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ]. They provide meals. Denies smoking, social drinking. Used to be a designer of clothes, had his own company. Per reports from [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ], unable to walk on his own and requires assistance for the majority of his other ADL's (but is able to use the bedpan and feed himself). Family History: Patient unsure age parents passed away. Has many siblings (7 or 8), four of whom are still alive. Physical Exam: T 99.8 P 90 BP 120/70 ACV 450 x 20 .50 FIO2 on neo gtt @250 and levophed gtt @ 2 Gen: Intubated and sedated R: decreased at bases CV: irregularly irregular Abd: ND, bilateral reducible inguinal hernias with bowel, TTP in RUQ Rectum: Rectal good tone guiac pos Pertinent Results: [2141-9-27] 08:45AM PT-19.8* PTT-63.8* INR(PT)-1.8* [2141-9-27] 08:45AM PLT SMR-NORMAL PLT COUNT-329 [2141-9-27] 08:45AM WBC-2.1# RBC-2.75 HGB-6.9# HCT-23.1 MCV-84 MCH-25.0* MCHC-29.7* RDW-19.2* [2141-9-27] 08:45AM NEUTS-26* BANDS-36* LYMPHS-14* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-14* MYELOS-2* [2141-9-27] 08:45AM CK-MB-2 [2141-9-27] 08:45AM cTropnT-0.04* [2141-9-27] 08:45AM LIPASE-19 [2141-9-27] 08:45AM ALT(SGPT)-6 AST(SGOT)-8 LD(LDH)-117 CK(CPK)-18* ALK PHOS-29* TOT BILI-0.2 [2141-9-27] 08:45AM GLUCOSE-73 UREA N-29* CREAT-1.0 SODIUM-151* POTASSIUM-3.0* CHLORIDE-126* TOTAL CO2-13* ANION GAP-15 [2141-9-27]: CT abd/pelvis showed 1. Significant free air within the abdomen. 2. Gangrenous-appearing gallbladder with large internal stone and intraluminal gas, with erosive encroachment of the neighboring [Name2 (NI) 499], which would provide a mechanism for the pneumoperitoneum. Brief Hospital Course: On [2141-9-27], the patient was admitted to the trauma surgical ICU on the general surgery service in critical condition with perforated gangrenous cholecystitis as demonstrated on CT. He was hemodynamically unstable, requiring two pressors and intubation. Vancomycin, ciprofloxacin, and metronidazole were started. His family was contact[Name (NI) ] and fully informed, and they expressed their full undertstanding of the risks of attempting surgical intervention. The family was also informed of the high mortality rate from the patient's illness. Subsequently, the family (through the patient's son and health care proxy, [Name (NI) ] [Name (NI) 5922]) elected not to pursue any surgical options for care, but prior discussions with the patient himself included a wish to be full code. Social work was consulted, and after the family arrived on the night of admission, the risks and low benefits of resuscitation were discussed. Antibiotics were switched to linezolid and zosyn. On [2141-9-28], the family decided to render the patient DNR and "do not reintubate" status considering the high morbidity and mortality of cardiopulmonary resuscitation and the high risks of surgical intervention. They wished to maintain the same level of medical intervention, and the patient continued to receive copious IVF, with occasional blood transfusion. A third pressor was added. However, in the evening of [2141-9-28], the patient became asystolic and expired. Medications on Admission: Fexofenadine 60 mg", Tamsulosin 0.4 mg', Brimonidine 0.15 % Drops", Finasteride 5 mg', Docusate Sodium 100 mg", Senna 8.6 mg", Acetaminophen 325 mg Q6H PRN, Bisacodyl 5 mg", Pantoprazole 40, mg', Ipratropium Bromide 0.02 % Inhalation Q6H, Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Q6H, Ferrous Sulfate 325 mg', Diltiazem HCl 240 mg', Nystatin 100,000 unit/g', Sodium Chloride 0.65 % Aerosol"" Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Perforated gangrenous cholecystitis. Discharge Condition: Expired. Discharge Instructions: He who has gone, so we but cherish his memory. Followup Instructions: None. Completed by:[2141-9-28]	[ "V10.46", "574.00", "575.4", "995.92", "427.31", "038.9", "600.00", "567.29", "585.9", "403.90", "365.9", "427.5" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	4863, 4872	2901, 4392	228, 235	4952, 4962	1925, 2878	5057, 5093	1523, 1623		4834, 4840		4893, 4931		4418, 4811			4986, 5034								1638, 1906																						179, 190														263, 789													811, 1076	1092, 1507
64,280	130,154	22021	Discharge summary	report	Admission Date: [2201-3-1] Discharge Date: [2201-3-25] Date of Birth: [2123-7-20] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 5831] Chief Complaint: Upper/lower Extremity Weakness, Parasthesias Major Surgical or Invasive Procedure: Lumbar Puncture Exploratory laparotomy, lysis of adhesions, small bowel resection Exploratory laparotomy, small bowel resection x2 with primary anastomosis History of Present Illness: 77 yo Female with hx of HTN, HLD presents with upper/lower extremity weakness, numbness and shortness of breath. . Patient notes that she was in her normal state of health until approx one month ago when she notes migratory joint pain. She notes that it involved the knees, shoulders. The pain wouldn't involve multiple joints at once but would migrate between them. She denies associated swelling. She saw her PCP in [Name9 (PRE) 108] who ordered a shoulder film which he thought was concerning for mild dislocation. After several weeks these arthralgias resolved. No associated fevers, chills, or rash. . Approx 2 days ago the patient noted the sudden onset of weakness in the feet, legs and hands. The weakness has been progressive and profound to the point that she cannot even stand. She has difficulty doing things with her hands. Associated with this is some parasthesias. She denies any recent change in thinking, difficulty speaking, trauma, neck or back pain. She has been ambulatory and active up until this occurance two days ago. She denies bug bites. She spends time on Long Boat Key in [State 108] during the winter. She did get a flu shot approx 1 month ago however has been otherwise well without viral syndrome. No new medications or change in meds. no heavy metal exposure. . The night prior to presentation while in bed she developed worsening shortness of breath and anxiety. She was unable to sleep. Denies associated chest pain. Shortness of breath led her to come to the hospital. In the ED, initial vitals: 98.5 100 163/115 30 97% 2L. CXR without acute process. D- Dimer checked and elevated so CTA performed which was negative for PE but did reveal mild pulmonary edema. ABG revealed a respiratory alkalosis which fit with the patients increased respiratory rate. UA negative, however 80 ketones noted. BMP with anion gap, hyponatremia. CBC with leukocytosis and left shift. Aspirin level was negative. LFTS with AST/ALT 54/63, mild elevation in alk phos. NIF performed with respiratory -25mmHg. Given 1 liter normal saline. Given Ceftriaxone, Azithromycin, Lorazepam in ED. Vitals prior to transfer: 97.3 22 98 124/78 100%ra. . Currently, patients breathing comfortably. Complains of lower extremity and hand weakness Past Medical History: --HTN --HLD --Appendectomy six years ago. --Squamous cell carcinoma of the left leg [2197] Social History: She is a former smoker who has not smoked for more than ten years. She is widowed and works part-time as a hostess at the [Company 49705] Long Wharf. Prior History of etoh use, nothing for years Family History: Father died at 74 years of age due to Parkinson's disease and diabetes. Mother died at 94. Both of her siblings have diabetes. Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp F 97.7, BP 136/80 , HR 93, R 16, O2-sat 96% RA GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, 2/6 SEM LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use 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, extremely tan, dry skin in the peripherally NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [4-4] in deltoids, biceps, triceps, 4/5 strength in interosseous, intrinsic muscle of hand, 4/5 strength with plantar/dorsiflexion, illiopsoas, gait not test, sensation subjectively decreased to light touch in hands, feet in stocking glove distribution, DTRs 2+ on left and 1+ on right, cerebellar exam intact DISCHARGE PHYSICAL EXAM: VS - T 97.9, BP 140-160/80's, HR 70-80's, RR 18, 98% on RA GEN - elderly tanned woman lying in bed in NAD HEENT - OP clear CV - RRR PULM - CTA-B ABD - soft, NT, ND, large midline abdominal scar with staples, well healing, no erythema or exudates EXT: no edema NEURO EXAM: MS - AAOx3 CN - PERRL 4->3mm, EOMI, face symmetrical, tongue midline MOTOR - deltoids, biceps, triceps and wrist extensors [4-4] bilaterally, Finger Ext 5-/5 bilaterally, Finger Flex 4+/5 on R and [3-5] on L, IP [4-4] bilaterally, TA 0/5 bilaterally, gastroc [12-4] bilaterally, [Last Name (un) 938] 0/5 bilaterally REFLEXES - 0 bilaterally at achilles, 1 at patella bilaterally SENSATION - decreased vibratory and proprioception below ankles bilaterally GAIT - deferred Pertinent Results: ADMISSION LABS: [2201-3-1] 07:38AM BLOOD WBC-15.7# RBC-3.84 Hgb-12.2 Hct-36.7 MCV-96 MCH-31.7 MCHC-33.2 RDW-12.7 Plt Ct-482* [2201-3-1] 07:38AM BLOOD Neuts-92.0* Lymphs-4.5* Monos-2.8 Eos-0.5 Baso-0.2 [2201-3-1] 07:38AM BLOOD PT-15.1* PTT-26.5 INR(PT)-1.4* [2201-3-2] 05:45AM BLOOD Fibrino-613* [2201-3-1] 07:10PM BLOOD ESR-120* [2201-3-1] 07:38AM BLOOD Glucose-156* UreaN-9 Creat-0.6 Na-132* K-3.5 Cl-96 HCO3-16* AnGap-24* [2201-3-1] 07:38AM BLOOD ALT-54* AST-63* LD(LDH)-283* CK(CPK)-1328* AlkPhos-230* TotBili-1.2 [2201-3-1] 07:38AM BLOOD proBNP-709* [2201-3-1] 07:38AM BLOOD cTropnT-<0.01 [2201-3-1] 07:38AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.2 Mg-1.9 [2201-3-1] 07:38AM BLOOD D-Dimer-5605* [2201-3-1] 07:38AM BLOOD Osmolal-273* [2201-3-1] 07:38AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [2201-3-1] 07:10PM BLOOD RheuFac-12 CRP-222.6* [2201-3-2] 07:18PM BLOOD IgA-625* [2201-3-1] 07:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2201-3-1] 07:38AM BLOOD HCV Ab-NEGATIVE [2201-3-1] 08:32AM BLOOD Lactate-2.4* [2201-3-1] 11:58AM BLOOD Lactate-1.7 DISCHARGE LABS: [2201-3-25] 05:39AM BLOOD WBC-9.0 RBC-2.67* Hgb-8.4* Hct-26.4* MCV-99* MCH-31.4 MCHC-31.7 RDW-18.4* Plt Ct-257 [2201-3-25] 05:39AM BLOOD Glucose-76 UreaN-14 Creat-0.3* Na-135 K-4.1 Cl-101 HCO3-28 AnGap-10 [2201-3-25] 05:39AM BLOOD ALT-88* AST-33 LD(LDH)-245 AlkPhos-142* TotBili-0.5 [2201-3-25] 05:39AM BLOOD Albumin-2.6* Calcium-8.1* Phos-1.7* Mg-1.9 REPORTS: CXR [2201-3-1]: FINDINGS: Single portable chest radiograph demonstrates unremarkable mediastinal and cardiac contours. Aorta is calcified. There is mild pulmonary vascular congestion. Mild left base atelectasis is seen without definite focal consolidation. No pleural effusion or pneumothorax evident. CTA CHEST [2201-3-1]: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Multiple pulmonary nodules measuring up to 5 mm. Per guidelines, follow up CT may be performed in 6 months in a high risk patient and 12 months in a low-risk patient. EMG [2201-3-2]: IMPRESSION: Abnormal study. The electrophysiologic findings are consistent with an acute (<7 days) demyelinating polyradiculoneuropathy, as in [Month/Day/Year 7816]-[Location (un) ] syndrome (GBS) . The absence of slowing of conduction velocity or conduction block, however, prevent a definitive electrodiagnosis of GBS. ECHO [2201-3-2]: Conclusions The left atrium is mildly elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with abnormal contraction of the basal half of the anterior septum. The remaining segments contract normally (LVEF = 55 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with mild regional systolic dysfunction suggetive of CAD (or IVCD if present). LENI [2201-3-2]: IMPRESSION: No evidence of DVT. CXR [2201-3-4]: FINDINGS: As compared to the previous radiograph, there is a newly occurred right basal opacity that could represent either atelectasis or aspiration. Overall, the lung volumes have decreased. There is no pleural effusion, but mild fluid overload might be present. Moderate cardiomegaly and mild tortuosity of the thoracic aorta. MRI SPINE [2201-3-4]: IMPRESSION: 1. No evidence of abnormal signal within the spinal cord to suggest [First Name9 (NamePattern2) 7816] [Location (un) ]. No evidence of abnormal enhancement of the nerve roots. 2. Multilevel degenerative changes of the cervical spine and lumbar spine as described in detail above. 3. 1.1-cm hyperintense lesion in the right thyroid gland. Ultrasound is suggested if clinically warranted. 4. Abnormal signal in the right apex and lower lobes which is limited evaluated by MR. CT/XR is suggested if clinically warranted. CT ABDOMEN AND PELVIS [2201-3-6]: IMPRESSION: 1. No evidence of intra-abdominal or pelvic malignancy. 2. Bibasilar atelectasis has worsened since [2201-3-1]. Tiny bilateral pleural effusions. 3. Diverticulosis without diverticulitis. 4. Atherosclerotic calcifications throughout the normal-caliber aorta. Stenosis at the origin of the celiac artery with post-stenotic dilation. Calcific densities of the SMA origin with associated stenosis. 5. Dense coronary calcifications noted. MR HEAD [2201-3-7]: CONCLUSION: Scattered white matter hyperintensities on FLAIR. These are often attributed to chronic small vessel ischemia, but a demyelinating process could produce a similar appearance. . CT ABD & PELVIS WITH CONTRAST [2201-3-13] IMPRESSION: Findings concerning for bowel ischemia of several loops in the pelvis. There is likely an internal hernia in the right lower quadrant with secondary small-bowel obstruction upstream from the hernia. . ART DUP EXT UP UNI OR LMTD [2201-3-15] Limited arterial Duplex ultrasound from elbow to wrist. IMPRESSION: Wall thickening of the radial wall and decreased vascular flow. Given the ring-like area of echogenicity a dissection flap is not entirely excluded. Angiography would be helpful to further characterize these findings . Portable TTE [2201-3-15] No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). A left ventricular mass/thrombus cannot be excluded. The aortic valve leaflets are mildly thickened (?#). The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Poor quality study. No source of embolism identified. No evidence of endocarditis. If clinically indicated, a TEE would better exclude valvular vegetations. . ART DUP EXT [2201-3-23]: IMPRESSION: Occluded right radial artery. Patent proximal inflow. Brief Hospital Course: # Presumed [First Name9 (NamePattern2) 57635] [Location (un) ]: Mrs. [Known lastname 57636] initially presented with distal weakness most pronounced in the lower extremities as well as proprioceptive/vibratory sensory loss, and with the prior report of dyspnea, this provoked concern for [Known lastname 7816]-[Location (un) ] syndrome. NIF was initially -25 but was -80 on repeat. A lumbar puncture performed ~5 days after onset of symptoms did not show albuminocytologic dissociation (however this is not seen in [12-2] of patients when LP is performed within 7 days of onset). MRI of the cervical and thoracic spine showed no evidence of abnormal signal within the spinal cord to suggest [First Name9 (NamePattern2) 7816] [Location (un) ]. However, EMG was consistent with GBS with dropped F and H waves. A history of migratory arthralgias was thought to be a viral syndrome and a possible trigger for GBS. Stool culture was negative for Campyloabacter. (EBV and CMV serologies were negative for acute infection.) The patient received IVIg x 5 days and did show some improvement, greater in the upper extremities. The patient was found to have urinary retention and a Foley was placed. She was also given ~5 days of erythromycin as a promotility [Doctor Last Name 360] given concern for dysautonomia secondary to GBS. The patient did report pain and was started on gabapentin. She was transferred from Medicine to Neurology on HD5. Given that the presentation and lab abnormalities (particularly very high inflammatory markers, e.g., ESR 120, CRP 222) were not entirely consistent with GBS, a sural nerve biopsy was obtained early on HD12. Steroids were considered but deferred in the setting of small bowel infarction (see below). The sural nerve biopsy and bowel pathology did then return positive for ANCA vasculitis and the pt was started on steroids and rituximab as below. . # Polyneuropathy/ANCA vasculitis: The patient was treated for presumed GBS as above. She was also evaluated for vasculitides, hepatitides, Lyme, syphilis, B12 deficiency, heavy metal intoxication, poly/dermatomyositis, monoclonal gammopathy, EBV/CMV as above, sarcoid, and paraneoplastic syndromes. All this workup was negative, with the exception of + [Doctor First Name ] at 1:80, a weakly positive c-ANCA, and positive SS-A, the significance of which was initially unclear but not thought to be significant enough to explain the clinical presentation. Rheumatology was consulted and provided ongoing input. However, when pt then had an SBO, and the pathology of that surgical specimen as well as the sural nerve biopsy returned positive for ANCA vasculitis, she was then treated with solumedrol 1gram x3 days, then started on steroids, initially prednisone 60mg x1 day, but this was then increased to 80mg QD thereafter. Pt will remain on this dose for the forseeable future, and will need a very very slow taper over many months to complete treatment. In addition, pt was started on rituximab 675mg IV weekly, with first dose given on [3-23]. The current plan is to continue this for 4 weeks, but rheumatology will consider a longer treatment after 4 weeks pending clinical improvement, and this follow-up appointment is made. The patient will go to the infusion clinic on a weekly basis for 4 weeks here at [Hospital1 18] and will be transported from rehab to this appointment to get her rituximab. . #. Shortness of Breath: At presentation, the patient was worked up for pulmonary embolus given a report of dyspnea and recent air travel. ABG on admission with respiratory alkalosis. CTA was negative for PE. Oxygen saturation remained stable. Echo and lenis were both unrevealing. Per the patient, dyspnea resolved with 0.25 mg IV lorazepam. Oxygen saturation remained normal throughout admission. . # Tachycardia: While on the Medicine service on HD2, the patient had a very brief episode of atrial fibrillation with RVR following a likely aspiration event with correlate on CXR. She was subsequently restarted on metoprolol 37.5 mg QID. She remained normocardic thereafter until she developed small bowel ischemia (below). We stopped the metoprolol once she remained in NSR thereafter. . # Small bowel obstruction with ischemia: On HD11, the patient developed persistent abdominal pain greater on the right side. On HD12, the patient had WBC 32.4 and appeared ill. A CT abdomen/pelvis showed small bowel obstruction in the ileum with ischemia. The ACS team was called to evaluate the patient and was found to have peritoneal signs on exam. She was taken to the OR for exploratory laparotomy and small bowel resection. She was left indiscontinuity until POD 1 when she was returned to the OR for washout and stapled anastamosis of her remaining small bowel. Post operatively the patient did well. She was closely monitored in the ICU where she was kept NPO and administered IVF. An NGT was left in place and her leukocytosis and hyponatremia slowly improved. Zosyn was started empirically and discontinued on POD 3. She was moved to the floor and kept NPO with NGT in place and on mIVF until return of bowel function. Patient started passing flatus and her diet was advanced to regular on POD5 after anastomosis. She has continued to have BM's throughout her admission after the SBO repair. Given that she is now on high dose steroids, surgery decided to leave her staples in for 4 weeks rather than the usual 2 to encourage wound healing. She will have them removed on [4-9] at her surgery follow-up appointment. . # Right ring finger cyanosis: On HD15 patient was noticed to have cyanosis of R ring finger and decreased radial pulse. Patient had had a prior radial A-line. An doppler ultrasound showed ring-like area of echogenicity in radial artery thought to represent a focal occlusion of radial artery at site of prior a-line. Ulnar artery was patent and there was a palmar arch signal. She was treated with a heparin gtt and nitropaste over the finger and wrist and serial hand exams followed. HD18 hep gtt and nitropaste was discontinued and there was no residual deficit. HD19 reevaluation showed R hand and finger were warm and well perfused. However, the next day she again had cyanosis of her R hand and nitropaste was used again with good effect. She had a repeat ultrasound of her R radial and ulnar artery. Her radial artery had a thrombus in it, however, she was still getting good flow through her ulnar artery. After discussion with vascular surgery, her general surgery team, rheumatology and her primary neurological team, it was decided to not anticoagulate her at this time given her recent bowel surgery and complicated hospital course. This should be reevaluated at a later date when she is more stable. . # Hyponatremia: The patient's sodium was initially 130 but began to downtrend on HD7. Urine electrolytes were checked on HD9 and found to be consistent with intravascular volume depletion, which was consistent with poor PO intake, and gentle IV fluids were started. However, sodium continued to downtrend on HD11, and rechecked urine lytes were more consistent with SIADH. Sodium continued to downtrend despite strict fluid restriction and two salt tabs on HD12, so on HD13 a PICC was placed and 3% NS started at 20cc/hr x 36 hours. Renal was consulted and agreed with this plan. Etiology of SIADH unclear but could theoretically be related to [Month (only) 7816]-[Location (un) ] syndrome vs. other polyneuropathic process. She improved with 3% NS and then even when taken off of this and allowed as much fluid as she wanted, the SIADH did not recur. . # Urinary tract infection: On HD12, the patient had a rise in WBC and was found on urinalysis to have UTI. Ceftriaxone 1 g IV daily x 3 days was started. . # Anemia: The patient's hematocrit fell slowly from 37 at admission to 24 on HD12, likely due to repeated phlebotomy with IV fluids and poor PO intake. Hemolysis labs were negative. Reticulocytosis was appropriate. No evidence on exam or imaging of retroperitoneal or thigh hematoma. She remained at this HCT without further dropping. She did not receive any pRBCs for her HCT. . # Elevated liver function tests: The patient had mildly elevated ALT, AST, and ALP throughout her admission. Anti-mitochondiral antibodies were negative; anti-smooth muscle Ab was positive at 1:20. Hepatology was consulted re: the signifiance of this result, and IgG/IgM levels were sent. However, it became clear shortly after this that she had an SBO and then when she was diagnosed with vasculitis her elevated transaminases were better explained. These will need to be monitored while at rehab. . # HTN: Antihypertensives were initially held during the hospital course, but the patient was restarted on Metoprolol 37.5 mg PO four times per day as above. This was then stopped when she remained in NSR. She was started on amlodipine 5mg QD for her SBP which kept her normotensive. . # HLD: Simvastatin was held in the setting of muscle weakness. PENDING LABS: ACA IgG, ACA IgM TRANSITIONAL CARE ISSUES: Patient will need her abdominal exam closely monitored given her recent bowel surgery and current need for high dose steroids and rituximab. In addition, she will need her R hand circulation monitored and nitropaste applied as needed. She should have it reevaluated in the future once she is more stable to determine if she will need anticoagulation for her R radial thrombus. Medications on Admission: --Amlodipine/Benzapril 5-20mg --Simvastatin 20mg Daily Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: sliding scale units Injection ASDIR (AS DIRECTED). 2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for fever or pain. 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection TID (3 times a day). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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). 9. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 10. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 11. nitroglycerin 2 % Ointment Sig: One (1) application Transdermal Q6H (every 6 hours) as needed for decreased perfusion of R hand. 12. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 13. prednisone 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 17. rituximab 10 mg/mL Concentrate Sig: Six [Age over 90 12887]y Five (675) mg Intravenous once a week for 3 doses: Patient will receive 675mg IV on [5-12] and [4-13] at [Hospital1 18] infusion clinic. 18. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: ANCA vasculitis SBO s/p surgical repair x2 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 57636], You were seen in the hospital for weakness and numbness in your hands and feet. You were initially treated for [Last Name (un) 4584]-[Location (un) ] Syndrome. Your hospital course was complicated by a development of a small bowel obstruction, which was surgically repaired. You had a sural nerve biopsy and with this and your bowel pathology you were able to be diagnosed with ANCA vasculitis. You were then treated with steroids and rituximab. We made the following changes to your medications: 1) We STARTED you on an INSULIN SLIDING SCALE while you are on steroids. 2) We STOPPED your BENAZEPRIL. 3) We STOPPED your SIMVASTATIN. 4) We STARTED you on LISINOPRIL 10mg once a day. 5) We STARTED you on SUBCUTANEOUS HEPARIN 5,000 units three times a day to prevent DVTs while you cannot walk. 6) We STARTED you on DOCUSATE 100mg twice a day. 7) We STARTED you on SENNA 8.6mg twice a day as needed for constipation. 8) We STARTED you on PANTOPRAZOLE 40mg once a day while you are on steroids. 9) We STARTED you on CALCIUM 500mg twice a day while you are on steroids. 10) We STARTED you on VITAMIN D3 1,000mg once a day while you are on steroids. 11) We STARTED you on NITROPASTE every 6 hours as needed for circulation issues in your right hand. 12) We STARTED you on GABAPENTIN 600mg every 8 hours. 13) We STARTED you on PREDNISONE 80mg once a day. Your Rheumatologist will tell you when you can decrease this medication. 14) We STARTED you on BISACODYL 10mg as needed per day for constipation. 15) We STARTED you on POLYETHYLENE GLYCOL 17 grams per day. You can stop this medication if you are having adequate bowel movements. 16) We STARTED you on ATOVAQUONE SUSPENSION 1500mg once a day while you are on steroids to help prevent infections. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleausure taking care of you on this hospitalization. Followup Instructions: Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2201-4-9] at 2:45 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RHEUMATOLOGY When: MONDAY [2201-4-13] at 9:30 AM With: [First Name8 (NamePattern2) 674] [Last Name (NamePattern1) ], 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: NEUROLOGY When: FRIDAY [2201-4-24] at 4:00 PM With: DRS. [Name5 (PTitle) ]/LAGANIERE [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ADULT MEDICINE When: THURSDAY [2201-5-7] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12175], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "357.1", "560.81", "788.20", "511.9", "997.2", "557.0", "446.0", "E878.2", "276.1", "444.21", "427.31", "599.0", "276.3", "507.0", "518.0" ]	icd9cm	[ [ [] ] ]	[ "54.59", "03.31", "45.61", "99.28", "04.12", "45.62" ]	icd9pcs	[ [ [] ] ]	22956, 23022	11526, 20599	337, 495	23109, 23109	5027, 5027	25362, 26621	3131, 3261		21111, 22933		23043, 23088		21032, 21088			23285, 23801		6235, 11503						3301, 4218																	23830, 25339					253, 299			20625, 21006											524, 2780					5044, 6218			23124, 23261					2802, 2898	2914, 3115			4243, 5008
52,146	185,508	42179	Discharge summary	report	Admission Date: [2150-11-14] Discharge Date: [2150-11-18] Service: SURGERY Allergies: Haldol Attending:[First Name3 (LF) 1390] Chief Complaint: right shoulder pain Major Surgical or Invasive Procedure: [2150-11-15] Closed reduction right shoulder with manipulation under anesthesia History of Present Illness: This is an [Age over 90 ] yof who was at her PCP today, to be evaluated for nausea, vomiting and constipation. When trying to transfer from car to wheelchair she suffered a fall. She was taken to [Hospital3 15516] Hospital where she was found to have a right anterior, inferior shoulder dislocation as well as superior and inferior pubic rami fractures. While in the ED at [Hospital3 ], she also had a large melanotic stool. Reduction was attempted of her shoulder by ortho/ed at CC, but was unsuccessful, it was felt that the humeral head is stuck in between the clavicle and the 1st rib. Patient poor historian secondary to demenita. Additional history obtained from her daughter via phone. Past Medical History: Past Medical History: hyperlipidemia, hypercholesterolemia, htn, arthritis, CVA, diabetes, multiple shoulder dislocations Social History: Lives with daughter [Name (NI) ], no ETOH, no tobacco Family History: non contributory Physical Exam: Temp: 98.6 HR: 67 BP: 125/63 Resp: 20 O(2)Sat: 100 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender, Nondistended Rectal: Heme Positive per resident Extr/Back: Right shoulder clearly dislocated Skin: No lacerations or ecchymosis Neuro: Speech fluent, neurovascularly intact Pertinent Results: [2150-11-14] 02:50AM WBC-10.6 RBC-2.19* HGB-6.4* HCT-19.1* MCV-87 MCH-29.1 MCHC-33.4 RDW-14.7 [2150-11-14] 02:50AM NEUTS-78.4* LYMPHS-15.8* MONOS-5.1 EOS-0.6 BASOS-0.1 [2150-11-14] 02:50AM PLT COUNT-649* [2150-11-14] 02:50AM PT-12.2 PTT-24.1 INR(PT)-1.0 [2150-11-14] 02:50AM GLUCOSE-171* UREA N-28* CREAT-1.7* SODIUM-130* POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-18* ANION GAP-20 [2150-11-14] KUB : Frontal view of the abdomen shows nasogastric tube well into a nondistended stomach. Mildly air-filled bowel loops clustering in the mid abdomen raise the possibility of intraperitoneal fluid. There is insufficient dilatation to raise concern about obstruction. Incidental note is made that reference study performed at an outside hospital on [11-13] shows multiple pelvic fractures in various stages of healing, some of which may not be fused. [2150-11-15] EGD ; Ulcers in the lower third of the esophagus Erythema and congestion in the whole stomach compatible with gastritis Ulcer in the duodenal bulb Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mrs [Known lastname 51405] was admitted to the ACS service on [2150-11-14] after sustaining a fall while stepping out of the car. She was transferred to [Hospital1 18] from an OSH. Her injuries at presentation were: -bilateral superior pubic rami fractures -R anteroinferior glenohumeral dislocation s/p attempted reduction at OSH, unsuccessful. The patient also reported constipation and melanotic stool for 1 week. She was admitted to the trauma ICU for close monitoring. The patient was transfused a total of 3U of PRBC and her Hct increased appropriately. Her UA was positive on admission and she was started on IV CIpro. She was taken to the operating room by orthopedics on HD2 to attempt close reduction of her R shoulder dislocation but this second attempt was unsuccessful as well. An EGD was performed by the GI service while the patient was under sedation for the shoulder reduction and a duodenal bulb ulcer was found. No bleeding vessel was identified. Recommendations were made to continue the PPI drip for 48 hours and monitor Hct. and check an H Pylori. The patient was stable to be transferred to the surgical floor on [2150-11-16]. Following transfer she remained with a stable hematocrit in the 30-33 range. Her oral intake was modest but she was able to tolerate a regular diabetic diet. She also had a swallowing evaluation for clearance. Unfortunately she is right handed and needs help with meals. She has not had any more melanotic stools. The Physical Therapy service evaluated her on many occasions to try to increase her mobility but she is well below her baseline and will therefore need rehab prior to returning home. Her weight bearing status is weight bearing as tolerated for both lower extremities and her right arm is non weight bearing. Her IV Cipro was discontinued after her urine culture grew > 100K yeast and the treatment was Foley catheter removal. She remains afebrile with a normal WBC. Her pre admission medications were resumed with the exception of aspirin and her atenolol was started on half her normal dose as her heart rate and blood pressure were well controlled. As she is beginning to progress she will be transferred to rehab with the hopes of eventually increasing her mobility so that she may return home. Medications on Admission: ASA 325', celexa 20', atenolol 100', protonix 40', amlodipine 10', cozaar 100'', metformin 500'', atenolol 100', tylenol #3 q 4 hrs prn Discharge Medications: 1. sucralfate 1 gram Tablet [Date Range ]: Two (2) Tablet PO BID (2 times a day). 2. insulin regular human 100 unit/mL Solution [Date Range ]: 0-10 units Injection ASDIR (AS DIRECTED). 3. atenolol 25 mg Tablet [Date Range ]: Two (2) Tablet PO DAILY (Daily). 4. losartan 100 mg Tablet [Date Range ]: One (1) Tablet PO BID (2 times a day). 5. metformin 500 mg Tablet [Date Range ]: One (1) Tablet PO BID (2 times a day). 6. citalopram 20 mg Tablet [Date Range ]: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule [Date Range ]: One (1) Capsule PO BID (2 times a day). 8. amlodipine 5 mg Tablet [Date Range ]: Two (2) Tablet PO DAILY (Daily). 9. senna 8.6 mg Tablet [Date Range ]: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 10. codeine sulfate 30 mg Tablet [Date Range ]: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 12. tramadol 50 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 13. acetaminophen 325 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 14. heparin, porcine (PF) 5,000 unit/0.5 mL Solution [Last Name (STitle) ]: 5000 (5000) units Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Last Name (un) ] Bay Nursing and Rehabilitation Center Discharge Diagnosis: S/P Fall 1. Right shoulder dislocation. 2. Bilateral superior rami fractures 3. Duodenal ulcer 4. Acute blood loss anemia 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: * You were admitted to the hospital after falling and you sustained a dislocated right shoulder and a fractured pelvis. Unfortunately these injuries and be both painful and limit your ability to get around. For that reason we are sending you to rehab to help increase your strength and mobility. * You can wear a sling on your right arm for comfort and you should elevate your right arm on pillows when in bed to help decrease the swelling. * Your pelvic bones will heal in time. You can stand and bear weight as long as the pain is bearable. The Physical therapist will get you up and walking as soon as you can tolerate it. Take enough pain medication to be comfortable. * You also had a duodenal ulcer which is healing. Do NOT take any ibuprofen, motrin, advil, aleve or any other non steroidal anti inflammatory drugs. Do NOT resume your aspirin. * Continue to try to eat more and take protein shakes to help heal your broken bones. * If you have any increased pain or any new symptoms that concern you please call your doctor [First Name (Titles) ] [Last Name (Titles) 91471] to the Emergency Room. Followup Instructions: Call the [Hospital ] Clinic at [Telephone/Fax (1) 1228] for a follow up appointment in 2 weeks. Call Dr. [Last Name (STitle) 7730] after you return home from rehab for a full evaluation Completed by:[2150-11-18]	[ "831.01", "532.40", "403.90", "272.0", "585.9", "530.20", "V12.54", "250.00", "564.09", "E817.1", "733.90", "584.9", "808.2", "535.50", "285.9", "599.0", "V49.86", "294.20" ]	icd9cm	[ [ [] ] ]	[ "38.97", "79.71", "38.91", "45.13" ]	icd9pcs	[ [ [] ] ]	6757, 6843	2888, 5177	235, 321	7009, 7009	1769, 2865	8332, 8563	1293, 1311		5363, 6734		6864, 6988		5203, 5340			7187, 8309								1326, 1750																						176, 197														349, 1056								7024, 7163					1100, 1202	1218, 1277
40,632	132,920	37624	Discharge summary	report	Admission Date: [2167-12-15] Discharge Date: [2167-12-23] Date of Birth: [2098-6-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 1257] Chief Complaint: anemia/CP Major Surgical or Invasive Procedure: Placement of percutaneous nephrostomy tube, placement of stent in right ureter. History of Present Illness: 69 year-old gentleman with Bladder cancer (dx in [10-20], s/p radical cystectomy, left nephrectomy, currently with right urostomy tube), who was scheduled to receive a nephrostomy tube placed at IR yesterday as an outpatient for worsening obstructive uropathy and renal failure, but was found to be too anemic (22) and instead was sent for an elective transfusion today at IR daycare unit. Today, about 15 minutes into the transfusion, he felt nauseated and experienced chest discomfort , and so was referred to the ED. The CP was [2-21], lasted for a few minutes, and did not radiate. No SOB, rash, or fever. In the ED, intial VS: 98.5 56 147/77 16 99%. He was CP free in the ER. Also c/o RLQ pain above urostomy site. On exam found to have a palpable mass in that area. EKG showed sinus brady at 55bpm with no ischemic changes with possible peaked T waves. Labs were significant for acute on chronic renal failure (cr 5.2), hyperkalemia to 5.6, and bicarb of 14, with AG of 15. First set of cardiac enzymes negative. HCT noted to be 22.5. Guaiac negative on exam. INR expectedly subtherapeutic at 1.4 (had been off coumadin for last week in anticipation of nephrostomy placement). CXR was clear. A CT abdomen/pelvis was performed to evaluate his palpable abdominal mass. There was no hernia or evidence of SBO. He received kayexylate, calcium gluconate, and insulin/D50. Access is 1 PIV. Most recent VS: 96.9 56 166/81 15 98%RA. Renal was consulted and will see in the ICU. Currently, he feels well. Review of systems reveals that he was a performance status 0 until the past month when he has been experiencing a cough, weakness, fatigue, and night sweats. He has not had any nausea, vomiting, fever, or chills, but has noted a decreased appetite over the past four to six weeks. His ileostomy stoma was working well, draining clear urine. He has noted some intermittent right flank discomfort this prompted an outpatient workup where he was diagnosed with a soft tissue obstruction of his mid ureter consistent with possible ureteral mass or TCC, with his baseline creatinine 1.2 becoming elevated to 3.3 as of last week. He has also noted a cough for the past month, which has been nonproductive and a chest x-ray last week by history was negative. Past Medical History: 1. Bladder Cancer dx [2166] - s/p radical cystectomy, left nephrectomy, R urostomy placement. Has T4 N1 M1 disease with left humerus and pelvic mets found in [3-23]. Had Chemo/XRT with Gem/[Doctor Last Name ]: [6-20]. #. Right hydro, progressive renal failure, creatinine 1.2-->3.2 in [11-20], CT scan [10-21]; 8 mm soft tissue obstruction in the mid right ureter. # PE with IVC filter/on coumadin # Hypertension # bronchitis Social History: Lives in [Location (un) 3844]. He has two children, ages 29 and 27. His daughter is getting married in 06/[2168]. He is a nonsmoker, no alcohol, no drug use. They spend [Doctor Last Name 6165] in [State 15946] where he received his radiation and chemo. Family History: Father died at 73 from MI. Negative for prostate, kidney, or bladder cancer. Physical Exam: [Hospital Unit Name 153] exam T= BP= 175/85 HR= 63 RR= 16 O2= 100% GENERAL: Pleasant, pale but well appearing gentleman in NAD HEENT: Normocephalic, atraumatic. + conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Urostomy pick with foley in place and gold urine drianing into stoma bag. Palpable mass lateral to stoma. Soft, NT, ND. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. Pertinent Results: [2167-12-15] 09:08PM URINE HOURS-RANDOM CREAT-45 SODIUM-27 [2167-12-15] 09:08PM URINE OSMOLAL-258 [2167-12-15] 09:08PM URINE COLOR-Straw APPEAR-Hazy SP [Last Name (un) 155]-1.007 [2167-12-15] 09:08PM URINE RBC-12* WBC-7* BACTERIA-FEW YEAST-NONE EPI-0 [2167-12-15] 09:08PM URINE MUCOUS-RARE [2167-12-15] 09:08PM URINE EOS-POSITIVE [2167-12-15] 04:00PM LD(LDH)-157 CK(CPK)-39 TOT BILI-0.2 [2167-12-15] 04:00PM CK-MB-NotDone cTropnT-<0.01 [2167-12-15] 04:00PM calTIBC-200* HAPTOGLOB-580* FERRITIN-1068* TRF-154* [2167-12-15] 12:12PM LACTATE-1.0 [2167-12-15] 12:05PM PT-15.5* PTT-26.1 INR(PT)-1.4* [2167-12-15] 11:00AM GLUCOSE-144* UREA N-75* CREAT-5.2* SODIUM-139 POTASSIUM-5.6* CHLORIDE-110* TOTAL CO2-14* ANION GAP-21* [2167-12-15] 10:09AM CK(CPK)-44 [2167-12-15] 10:09AM CK-MB-NotDone cTropnT-<0.01 [2167-12-14] 11:40AM PT-16.5* INR(PT)-1.5* Bone Scan ([2167-12-17]): Whole body images of the skeleton were obtained in anterior and posterior projections including static dedicated views of the upper extremities and thorax. Multiple foci of increased radiotracer uptake is demonstrated with the largest region at the pubic symphysis right greater than left and right inferior pubic ramus. Increased radiotracer uptake is present in a left anterior rib, probably 5th, uncertain if post traumatic or metastatic in nature. Increased tracer uptake also projecting over the medial right scapula and lateral upper thoracic ribs which is indeterminant. Increased tracer activity is noted midline in the L2-L3 region concerning for metastatic involvement. Multiple regions of increased radiotracer uptake as described above some indeterminant and others consistent with metastatic disease. CT Abdomen ([2167-12-18]): IMPRESSION: 1. Small-bowel obstruction secondary to parastomal small-bowel herniation within the right lower quadrant. This is worse compared to [2167-12-15]. The dilated ileal conduit has been decompressed seconary to Fioley catheter. Right nephrosotomy and ureteral stent are also new. 2. Sclerotic changes of the right pubic symphysis, right ischium and right ischial tuberosity concerning for metastatic disease. Additional sclerotic densities within the spine. CT Chest ([2167-12-22]): IMPRESSION: No evidence of lung metastasis. No hilar or mediastinal lymphadenopathy. Brief Hospital Course: Given that the patient had many complex issues that were all interrelated, this discharge summary is written in a narrative form as opposed to a list form by problem. Also included is a brief history that led patient to this hospitilization. . In [2167-10-13], patient was diagnosed with cystic cancer; his left kidney, left ureter, entire bladder, and prostate were removed, and an ileal conduit was created and connected to right ureter. At this time, the patient did not undergo chemoradiation. In [2167-3-15], mets were found in his left humerous and left pelvis; patient then underwent chemotherapy through [2167-6-12] and also had radiation therapy. In [Month (only) ] of [2167], the patient had a negative PET scan. . Since [7-21], ~ once per month, the patient noticed urostomy wouldn't put out urine for an hour or so. In [2167-10-13], he told his urologist about this decrease in output; his urologist then sent him for IVP and loopogram, which demonstrated an obstruction at the right mid-ureter. In this context, the patient's creatinine had risen to 3.3 from 1.2. The patient was subsequently referred to Dr. [Last Name (STitle) 3748] at [Hospital1 18]. . At the [Hospital1 18], the patient saw Dr. [Last Name (STitle) 3748] as an outpatient, who recommended that given the above imaging, the patient should undergo restaging of his disease with Bone Scan and CT Chest. He also recommended that the patient undergo percutaneous nephrostomy tube placement to relieve the ureteral obstruction. . The patient was set to undergo percutaneous nephrostomy tube placement on [2167-12-15]; however, patient was noted to be anemic at 24.7. He underwent a PRBC tranfusion and then developed chest pain. He was sent to ED then admitted to the ICU. He was ruled out for MI (CE negative X 3, normal EKG); however, he was noted to have creatinine of 5.2 during this event and consequently extended his stay in the ICU for management of ARF. A CT without contrast of abdomen suggested that his ileal conduit was dilated and also contributing to a peristomal hernia (thought to be contributing to the cause of the ARF); hydronephrosis of right kidney was also noted. Thus, his ARF was felt to be secondary to obstruction. On [12-16], patient had placement by IR of percutaneous nephrostomy tube, along with placement of stent in right ureter to dilate a 2 cm proximal ureteral stricture. The patient passed urine through his nephrostomy tube with consequent downtrending of creatinine. . The same day of his nephrostomy tube placement ([2167-12-16]), the patient noted some vague periumbilical abdominal pain. Furthermore, he noted that his ileal conduit ostomy (NOT his percutaneous nephrostomy) was not putting out any urine, even through the proximal ureteral stent had been placed. He also vomited and noted that he hadn't passed stool or flatus in 4 days. A KUB and subsequent CT scan with contrast on [2167-12-18] demonstrated a true small-bowel obstruction secondary to a peristomal hernia (with the consequent inference that the original CT on [12-15] was demonstrating a true SBO as opposed to the ileal conduit contributing to the parastomal hernia). Surgery also placed an NG tube which put out 800 cc of bilious fluid. . The patient's ileal conduit was felt to be obstructed (and consequently, the urine ostomy output was obstructed) by proximal dilated loops of small bowel. A foley was placed through the ileal conduit ostomy with subsequent drainage of urine. After these maneuvers, the patient's creatinine paradoxically bumped to 4.9 from 4.2 on [12-18]; this was subsequently found to be secondary to obstruction of percutaneous nephrostomy. The tube was cleared and the patient started passing urine through the percutaneous nephrostomy tube. The patient's creatinine continued to trend down throughout the rest of his admission (4.9 -> 1.7). . For his SBO, the patient was placed NPO with agressive IVF (200 cc NS/hr -> 200 cc D5 1/2NS -> 200 cc D5 water) for adequate bowel rest X 4 days. The patient's abdominal distension and pain markedly improved, and the patient began to pass flatus and bowel movements. The patient tolerated advancing his diet on day 5 of SBO without issue (no nausea/vomiting). On the day of discharge, the patient's exam had markedly improved, he was tolerating a regular diet, and the patient was passing stool and without abdominal pain. . The patient was hypernatremic for 2 days (Max Na of 148); this was felt to be secondary to giving patient NS initially while he was NPO. We corrected his hypernatremia by giving the patient freewater with D5 water. . Concerning the patient's metastatic disease, a bone scan on [2167-12-17] noted radiotracer uptake was concerning for new metastases. The patient was seen by Dr. [Last Name (STitle) ] (GU Oncology) to discuss outpatient treatment options. Medications on Admission: Metoprolol 50mg [Hospital1 ] Coumadin (d/c'ed) calcium Iron. Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: Seventy Five (75) mg PO twice a day. 2. Iron Oral 3. Calcium Oral Discharge Disposition: Home With Service Facility: Community health and hospice Discharge Diagnosis: Primary: Small Bowel Obstruction Secondary: 1) Acute Renal Failure 2) Atypical Chest Pain 3) Prior PE s/p IVF placement, on anticoagulation 4) Hypertension Discharge Condition: Good. Patient was tolerating POs, passing flatus, without abdominal pain, with stable vital signs, stable creatinine, and without chest pain. Discharge Instructions: You were admitted to [Hospital1 18] with chest pain during a blood transfusion; we ruled out the possibility you were having a heart attack. However, we also discovered that you had kidney failure due to a blockage between your kidney and new bladder. This was dilated and a tube was placed from your kidney to the skin; your renal function subsequently improved. Your ostomy, however, was not putting out any urine. It was determined that your small intestine had bulged into your ostomy and formed a hernia; this caused a small-bowel obstruction which blocked your ostomy output. We then treated you for small-bowel obstruction with decompression of your GI system through a tube in your nose. We also gave you IV fluids and withheld food to protect your bowels during the recovery process. It is important you continue to take it easy with your diet avoiding high fiber foods, and focus on soft foods and small amounts at a time. . Please continue to take your home medications, with the following changes: 1) Do not take Coumadin until instructed by your doctor. You should have an INR checked on Friday ([12-25]) and should talk to Dr. [Last Name (STitle) 84403] about your Coumadin dose then. 2) Your metoprolol dose was increased to 50mg three times daily, you may take 75mg twice daily. . If you experience severe abdominal pain, inability to pass stool or gas, severe nausea/vomiting, fever > 102, chest pain, shortness of breath, no urine output from your ostomy, or any other concerning symptoms, then please contact your PCP or report to the closest ED. Followup Instructions: Be sure to talk to Dr.[Name (NI) 84404] office on Friday [12-25] regarding your Coumadin dosing Follow-up with Dr. [Last Name (STitle) 84403] or your new primary care doctor in the next 1-2 weeks Please schedule a follow-up appointment with Dr. [Last Name (STitle) 3748] in 2 weeks or per his recommendations You will also need to follow-up with Dr. [Last Name (STitle) ] after your repeat bone scan.	[ "786.59", "560.89", "V45.73", "188.8", "V12.51", "V15.3", "490", "V45.74", "403.90", "198.5", "276.7", "585.9", "285.22", "V58.61", "584.9", "198.1", "997.5", "553.20", "V87.41", "591", "276.0", "593.3", "790.92" ]	icd9cm	[ [ [] ] ]	[ "59.8", "55.03", "87.75" ]	icd9pcs	[ [ [] ] ]	11856, 11915	6687, 11607	325, 407	12115, 12259	4268, 6664	13886, 14313	3475, 3553		11722, 11833		11936, 12094		11633, 11699			12283, 13863								3568, 4249																						276, 287														435, 2700													2722, 3173	3189, 3459
17,746	131,077	27666	Discharge summary	report	Admission Date: [2142-5-24] Discharge Date: [2142-6-6] Date of Birth: [2142-5-24] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname 67570] was born at 36 and 4/7 weeks gestation, weighing 3390 grams to a 37 year- old, Gravida II, Para 0 now I mother, with prenatal screens of blood type AB positive, antibody negative, HBSAG negative, RPR nonreactive, Rubella immune, GBS unknown. This pregnancy was notable for placenta previa, fibroids in the first trimester and spotting. The maternal past medical history was non contributory. Prenatal sepsis risk factors were unknown GBS colonization, no maternal fever, rupture of membranes less than 24 hours, no maternal intrapartum antibiotics. The infant was delivered by Cesarean section under epidural and spinal anesthesia. Apgars were 7 and 7. At birth, the infant presented with some respiratory distress and neonatology was called to delivery. Due to the respiratory distress in the delivery room, the infant was admitted to the Neonatal Intensive Care Unit for further management. PHYSICAL EXAMINATION: On admission, robust infant who was active, required oxygen, occasionally was crying with desaturations. Non dysmorphic. Anterior fontanel soft and flat. Ears were normal set. Neck supple. Clavicles intact. Lungs: Poorly aerated but equal breath sounds bilaterally. There was grunting, flaring and retracting present. Cardiovascular: Normal rate and rhythm, soft murmur, 2+ femoral pulses. Abdomen was soft with positive bowel sounds, no hepatosplenomegaly. Genitourinary: Normal male. Testes descended bilaterally. Patent anus. Hips stable, no clicks or clunks, no sacral anomalies. Extremities showed acrocyanosis distally but was centrally pink on oxygen. The infant's weight was 3390 grams which is 90th percentile. Length 19 inches or 48.5 cm which is 50th to 75th percentile. Head circumference is 34 cm which is 75th to 90th percentile. HOSPITAL COURSE: The infant presented with mild to moderate RDS initially. He was started on nasal cannula oxygen. The infant had a dusky episode shortly after admission to the NICU. Chest x-ray was done initially which was consistent with transient tachypnea of the newborn. An ABG was done on admission with oxygen at 100% to rule out any cardiac anomalies. The pH was 7.35, C02 of 38 and P02 of 192. The infant was transferred to nasal prong C-Pap due to worsening respiratory distress on the newborn day. Respiratory symptoms continued to worsen over the next couple of days and on day of life 1, the infant was intubated and received 2 doses of surfactant therapy for respiratory distress syndrome. The chest x-ray at that time had worsened to atelectasis and surfactant deficiency. The infant extubated from the ventilator on day of life 3 to nasal cannula. The nasal cannula was subsequently weaned off on day of life 7 and the infant weaned to room air for a brief period of time but required reinitiation of nasal cannula shortly thereafter for desaturations. The infant again slowly weaned off nasal cannula and most recent need for nasal cannula was on [2142-6-4] at 11 a.m. for a brief period of time with feeds. The infant has been on room air since that time, with a normal respiratory rate, no increased work of breathing and oxygen saturations in the range. The infant has had no issues with apnea or bradycardia and no methylxanthines were started. Cardiovascular: The infant was given normal saline bolus x1 on admission to the NICU for poor peripheral perfusion which improved. The blood pressure remained stable. The infant was noted to have a 2/6 systolic murmur on the day of discharge, but is well perfused with normal pulses, normal blood pressure, normal heart rate and rhythm. Screening cardiac investigations including hyperoxia test, EKG, chest radiograph and 4-extremity blood pressure were negative and cardiology consultation suggested that this was likely a benign finding. Follow-up consultation and echo are scheduled for one week following discharge. Fluids, electrolytes and nutrition: The infant was made n.p.o. on admission to the NICU. IV fluids were initiated. Enteral feedings were initiated on day of life 3 and advanced quickly by ad lib p.o. feedings. Infant had been p.o. feeding well, breast milk or Similac 20 with iron or breast feeding, taking all feedings by mouth and showing steady weight gain. The most recent weight was 3270 grams. The most recent set of electrolytes were drawn on [2142-5-27] with a sodium of 134; potassium of 4.2; chloride of 108; C02 24. Gastrointestinal: Gastrointestinal exam is normal. The peak bilirubin level was 5.9 over 0.4 on day of life 3. The infant has required no phototherapy treatment. Hematology: No blood typing has been done on this infant. There have been no needs for blood product transfusions. Infant remains hematologically stable. The hematocrit at birth was 45. Most recent hematocrit was 42 on day of life 2. Infectious disease: CBC and blood culture were done on admission to the NICU to rule out sepsis. The CBC was benign. The blood culture remained sterile. The infant received a total of 72 hours of Ampicillin and Gentamycin which were discontinued on day of life 3 when the clinical status normalized and the blood culture had remained stable up to that point in time. There have been no further issues with sepsis. Neurology: The infant has maintained a normal neurologic exam. The only abnormalities were the initial dusky episode on admission to the NICU but no further issues have been noted. No further neurologic evaluations were needed. Sensory: A hearing screen was performed on [2142-6-6]. The infant passed a car seat test on [2142-6-6]. State newborn screen was sent on day of life 3, [2142-5-27], which showed an elevated 17OH. The study was repeated on [2142-6-5]. Results are pending. Psychosocial: A [Hospital1 18] social worker has been in contact with this family. There are no active ongoing psychosocial issues at this time but if there are any questions or concerns, social worker can be reached at [Telephone/Fax (1) 8717]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. NAME OF PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) 1692] [Last Name (NamePattern1) 45269], MD, telephone number [Telephone/Fax (1) 37802] from [Hospital 1426] Pediatrics. CARE RECOMMENDATIONS: Ad lib p.o. feedings of breast feeding or breast milk with supplemental Similac 20 with iron as needed. MEDICATIONS: Tri-Vi-[Male First Name (un) ] 1 cc p.o. once a day. IMMUNIZATIONS RECEIVED: The infant received hepatitis B vaccine on [2142-5-28]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW UP: Follow-up appointment is recommended with the pediatrician within 48 hours of discharge. VNA referral has been done. Cardioloogy follow-up as above. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Rule out sepsis. 3. Respiratory distress syndrome, resolved. 4. Initial hypotension, resolved. 5. Initial hypoglycemia, resolved. 6. Cardiac murmur Reviewed by: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[Name8 (MD) 62299] MEDQUIST36 D: [2142-6-5] 21:27:49 T: [2142-6-6] 05:49:38 Job#: [Job Number 67571]	[ "V05.3", "769", "779.89", "765.19", "775.6", "V29.0", "765.28", "796.3", "V30.01" ]	icd9cm	[ [ [] ] ]	[ "93.90", "96.71", "99.15", "96.04", "96.6", "99.55" ]	icd9pcs	[ [ [] ] ]	6253, 6469							7647, 8066						2006, 6197	6492, 6755																7476, 7626				1134, 1988																				6783, 7464					163, 1111															6222, 6229
14,313	170,669	1957	Discharge summary	report	Admission Date: [2139-12-5] Discharge Date: [2139-12-10] Date of Birth: [2072-6-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1055] Chief Complaint: transfer from OSH for worsening renal failure Major Surgical or Invasive Procedure: Central line placement PICC line placement Renal Biopsy History of Present Illness: Mr. [Known lastname 6330] is a 67 year-old African American male with a past medical history of hypertension, diabetes mellitus type II, h/o heroin abuse, and end-stage renal disease s/p cadaveric transplant in [2134], who presented to [Hospital3 ]??????s Medical Center on [2139-12-3] with complaint of dyspnea on exertion over the two days PTA. He denied associated chest pain, palpitations, cough, nausea, vomiting, fevers, and chills. He also denied change in urine output, hematuria, dysuria, and recent NSAID use. In the Emergency Department at the OSH, he was noted to be hypertensive (169/78), and his physical exam was consistent with CHF. He was given 40 mg IV Lasix with good response (1 L urine output). Lab data on admission was notable for a BUN/ Cr of 36/3.3 and HCT = 28.4. Urinalysis showed 1+ protein, and sediment was remarkable for an occasional RBC and WBC, with no evidence of dysmorphic RBCs, muddy brown casts, or red cell casts. * At the OSH, the patient was evaluated by the Nephrology staff. The patient was administered all of his medications except his enalapril. He was monitored for signs of heroin withdrawal. His cardiac enzymes were notable for a CK of 93, MB of 3.3, and troponin value of 0.2. The patient underwent an ECHO which disclosed an EF of 70% and mild LVH. * On the day of admission to [Hospital1 18], the patient was noted to have persistently elevated blood pressures (220/106) at the OSH. Per report, the patient remained asymptomatic. He was given his usual blood pressure medications, as well as does of Labetalol (20 mg IV, 600 mg PO), Hydralazine (20 mg IV, 50 mg PO), Clonidine (0.2 mg/24 hr patch, 0.1 mg PO), and Nitropaste (3 inches). Despite administration of these medications, the patient??????s SBP remained >200. Given patient??????s persistent hypertension and acute renal failure, the patient was transferred to [Hospital1 18] for further work-up and management, including renal biopsy in the setting a post-transplant patient. * The patient was admitted to the [Hospital1 18] MICU for acute care and evaluation of his renal failure. A renal ultrasound was obtained which showed no evidence of hydronephrosis, as well as patent vasculature. The Renal service was also consulted. On transfer to the floor, the patient reported doing well. He denied CP/SOB, N/V, diarrhea, abdominal pain, HA, or dizziness. Past Medical History: PCP: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ESRD, dialysis [2127]-99, cadaveric transplant [2134]. Patient has not been seen by a nephrologist in many months. Cervical radiculitis Hepatitis C Tobacco abuse IVDU, previously on methadone maintenance. The patient has been off methadone for six months. He reports intermittent use of heroin since then. Mitral valve annuloplasty in [2131] Diabetes mellitus II, diagnosed [2136] Hypertension, poorly controlled (190/110 at 8-04 office visit) Positive PPD, no INH given due to Hepatitis C and transplant medications Pneumothoraces. s/p left thoracotomy in [2121] S/p left eye loss secondary to an accident Social History: Mr. [Known lastname 6330] is a retired water meter reader. He is now disabled. He is single without children and sexually active with women only. He drinks alcohol in moderation at the present time and smokes [1-17] PPD. Six months ago, he completed his methadone program, but states that he uses heroin intermittently. Family History: Father -- CVA (50's) Mother -- CAD Sister -- SLE (deceased @ 60 due to renal/cardiac complications) Physical Exam: VS: T = 98.7; P = 76; BP = 152-184/69-84; RR = 19; O2 Sat = 98% RA GEN: elderly AA man, NAD, lying in bed, appears comfortable. HEENT: EOMI OD, prothesis OS; PERRL OD; MMM, OP clear, anicteric NECK: no elevation of JVD appreciated, no cervical LAD, no carotid bruits CHEST: CTA bilaterally; no w/r/r CV: RRR, +2/6 systolic M @ apex; no R/G ABD: NABS, soft, ND, NT, no masses, no rebound/guarding EXT: 1+ DP/PT pulses, no C/C/E SKIN: no rashes appreciated Pertinent Results: [2139-12-6] 01:01PM BLOOD WBC-6.7 RBC-3.20* Hgb-9.8* Hct-28.7* MCV-90 MCH-30.5 MCHC-34.0 RDW-15.0 Plt Ct-202 [2139-12-6] 01:01PM BLOOD Neuts-85.1* Lymphs-10.4* Monos-3.9 Eos-0.2 Baso-0.3 [2139-12-6] 01:01PM BLOOD Plt Ct-202 [2139-12-6] 03:56AM BLOOD Glucose-117* UreaN-47* Creat-3.5* Na-137 K-3.7 Cl-109* HCO3-16* AnGap-16 [2139-12-6] 03:56AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.5* [2139-12-5] 08:47PM BLOOD CK(CPK)-173 [2139-12-5] 08:47PM BLOOD CK-MB-6 cTropnT-0.01 [2139-12-6] 03:56AM BLOOD LD(LDH)-278* CK(CPK)-184* TotBili-0.6 [2139-12-6] 03:56AM BLOOD CK-MB-6 cTropnT-0.02* [2139-12-6] 01:01PM BLOOD CK(CPK)-156 [2139-12-6] 01:01PM BLOOD CK-MB-5 cTropnT-0.03* [2139-12-6] 03:56AM BLOOD Hapto-<20* [2139-12-6] 03:56AM BLOOD Cyclspr-27* [2139-12-5] 08:47PM BLOOD Fibrino-367 [2139-12-6] 03:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2139-12-6] 01:01PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG [2139-12-6] 01:01PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.019 [2139-12-6] 01:01PM URINE Blood-MOD Nitrite-NEG Protein-500 Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2139-12-6] 01:01PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [2139-12-5] 11:00PM URINE Eos-POSITIVE [2139-12-6] 01:01PM URINE Hours-RANDOM Creat-104 Na-56 TotProt-557 Prot/Cr-5.4* [2139-12-6] 01:01PM URINE Osmolal-490 * CT HEAD W/O CONTRAST [2139-12-5] 9:59 PM 1. No acute intracranial hemorrhage or mass effect. 2. Encephalomalacia change in the left cerebellar hemisphere, likely consistent with old infarct. 3. Soft tissue density with osseous thickening in the left sphenoid air cell, likely consistent with chronic sinus infection or mucocele. * RENAL TRANSPLANT U.S. [2139-12-6] 8:03 AM 1. No hydronephrosis or stones. 2. Patent renal transplant vasculature with unchanged resistive indices. * CXR [2139-12-5] heart slightly enlarged, slight pulm vascular redistribution; mild CHF Brief Hospital Course: 67 yo man w/ h/o HTN, DM2, ESRD s/p cadaveric renal transplant [2134], who presented to OSH w/ DOE x 2 days. At the OSH, he was found to have CHF, ARF, and refractory HTN. He was transferred to [Hospital1 18] for further eval and managment. * 1) ACUTE RENAL FAILURE: ARF in this patient raised concern for late allograft dysfunction. Diff diagnosis of late acute dysfunction included prerenal azotemia due to volume depletion, cyclosporine nephrotoxicity, acute rejection (possibly due to non-compliance with immunosuppressive medications), urinary tract obstruction, and renal transplant artery stenosis (which is associated with hypertension). Other etiologies possible included acute tubular necrosis due to sepsis or nephrotoxins or drug- or infection-induced interstitial nephritis. Given this patient??????s poorly controlled blood pressure, there is also the possibility that he has hypertensive nephrosclerosis from poorly controlled hypertension. Normal renal ultrasound makes obstruction and renal transplant stenosis less likely. The renal service was consulted, and performed a renal biopsy shortly after admission. His cyclosporin was continued, but his serum levels were followed on a daily basis. He was also continued on CellCept. Renal recommended starting Solu-Medrol 500 mg IV daily. Over the course of his hospitalization, his renal function worsened. A renal U/S was repeated, but unchanged. He was discharged in stable condition with close follow-up scheduled to see his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 1860] (nephrology), and Urology. * 2) HYPERTENSIVE CRISIS: On admission, Mr. [Known lastname 10793] blood pressure were poorly controlled, and had been high at the OSH as well. He was given IV anti-hypertensives in the MICU, and then maintained on Diltiazem PO after transfer to the medicine service. His recent refractory hypertension was thought to be secondary to non-compliance with his outpatient medication. Another possibility could have been renal transplant artery stenosis. He had no evidence of end-organ hypertensive damage. His EKG was without acute changes. * 3) ANEMIA: Mr. [Known lastname 6330] is chronically anemic, which is likely secondary to renal disease. The patient also had a low haptoglobin on this admission which with his anemia was concerning for hemolysis. Hematology was consulted. They thought that this was unlikely to be TTP due to lack of schistocytes and lack of thrombocytopenia. Hematology reported that the low haptoglobin was more consistent with either liver dysfunction or cyclosporin effect. * 3) CHF: A TTE obtained was obtained on this admission showing: EF=55%; mild LVH; mild MS (consistent with rheumatic heart disease). Strict I/Os and daily weights were followed. He was diuresed to a goal of ~500 cc daily. He was maintained on a 2 gram sodium diet. He was continued on his betablocker, but his ACEI was held due to worsening renal function. * 4) HYPERCHOLESTEROLEMIA: He was continued on a statin. * 5) DIABETES (TYPE 2): The patient's Glyburide was held in setting of acute renal failure. He was maintained on a RISS. * 6) FEN: He was given a low sodium, renal, diabetic diet. * 7) PROPHYLAXIS: He was maintained on Heparin SC TID for DVT prophylaxis. * 8) COMM: Health care proxy: [Name (NI) ], [Name (NI) 449] [Name (NI) 10794] ([Telephone/Fax (1) 10795]. * 9) FULL CODE. Medications on Admission: Transfer medications from OSH: Lasix 40 mg PO daily Colace 100 mg PO daily Bentyl 20 mg PO q6hrs prn abdominal cramps Vistaril 25 mg PO q4hrs prn nausea Diltiazem 180 mg PO BID Atenolol 50 mg PO BID Neoral 75 mg PO BID CellCept [Pager number ] mg PO BID Prednisone 5 mg PO daily Glyburide 5 mg PO daily Lipitor 10 mg PO daily Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QOD (). Disp:15 Tablet(s) Refills:2 5. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:2 9. Ativan 2 mg Tablet Sig: One (1) Tablet PO ONCE as needed for anxiety for 1 doses: Please take just prior to MRI, do not drive after taking. Disp:1 Tablet(s) Refills:0 10. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:15 Tablet(s) Refills:2 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Acute on chronic renal failure Chronic rejection Hypertension anemia hemolysis hypertension diastolic dysfunction right brachiocephalic thrombus Discharge Condition: Good, making good urine output Discharge Instructions: Please call or come in if have an increase in swelling or pain. Please keep all follow up appointments and continue to take all medicines as prescribed. Followup Instructions: Please call [Telephone/Fax (1) 250] to make an appt to follow up with Dr [Last Name (STitle) ] within next 2 weeks. Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D., PH.D.[MD Number(3) ]: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 435] Date/Time:[2140-1-7] 3:30--> they will call you on Friday to make an appointment sooner. Please call ([Telephone/Fax (1) 10796] to schedule your MRI, which has been ordered. Please call ([Telephone/Fax (1) 10797] to chedule follow up with urology for possible re-testing of urodynamics.	[ "E878.0", "996.81", "305.52", "070.70", "428.0", "584.9", "428.31", "250.00", "285.9", "401.0" ]	icd9cm	[ [ [] ] ]	[ "55.23", "38.93" ]	icd9pcs	[ [ [] ] ]	11653, 11659	6630, 10073	362, 420	11848, 11880	4536, 6607	12081, 12710	3944, 4045		10454, 11630		11680, 11827		10099, 10431			11904, 12058								4060, 4517																						277, 324														448, 2857													2879, 3580	3596, 3928
14,616	142,992	29252	Discharge summary	report	Admission Date: [2149-12-23] Discharge Date: [2150-1-6] Date of Birth: [2089-5-10] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 301] Chief Complaint: Complex recurrent incisional hernias of the abdomen. Recurrent colon cancer Major Surgical or Invasive Procedure: 1. Incisional hernia repair with SurgiSIS. 2. Completion colectomy by Dr. [Last Name (STitle) 1120]. 3. Aspiration right renal cyst. 4. PICC line placement Open total colectomy, ventral hernia repair with mesh History of Present Illness: Mr. [Known lastname ] is a 60-year-old white male status post colorectal cancer both in [2134] for which he underwent a left colon cancer resection for stage III colon cancer. He recieved chemotherapy 5-FU and leucovorin. In [2141], he also underwent additional resection, a low anterior resection, for rectal cancer per the patient's report. He was in his usual state of health until [12-3] and he underwent his routine interval colonoscopy which was noted to have a right colon mass in the cecum as well as a polyp at the rectosigmoid junction. Pathology noted from outside hospital, the right cecal mass to be consistent with adenocarcinoma and the polypectomy specimen to be consistent with dysplasia. Recent CEA notes range anywhere from 4.2-4.9. The patient was referred from his primary care provider to Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 1120] for evaluation of possible laparoscopic intervention of his right-sided colon cancer. Past Medical History: [2134] colon cancer, stage III. Treated with chemo and surgery in [2141], low anterior resection for rectal cancer. History of urinary retention, as a result of nerve injury secondary to his low anterior resection. NIDDM Impotence. A left hemicolectomy in [2134], ventral hernia repair with mesh in [2135], low anterior resection in [2141]. Borderline hypertension. Social History: A heavy smoker, 2-3 packs per day for 20 years, quit in [Month (only) 547] of 06. Denies heavy alcohol use. He reports approximately two drinks per week. Denied illicit drugs or any other drug abuse. He is employed as an insurance [Doctor Last Name 360]. He is divorced. He has a one biological daughter. Family History: NC Physical Exam: VSS: T: 96.7 P: 84, RR 16, spo2 100% on RA, BP 112/62 5 feet 10 inches, his weight is 194 pounds General Appearance: No apparent distress. A well-appearing 60-year-old man. Psychiatric history: is AO x3. Eyes: Pupils equal, round, reactive to light. Extraocular muscles intact. His sclerae anicteric. ENT exam with normal. Neck: No mass. Lymph System: Negative. Respiratory System: Clear to auscultation bilaterally. Cardiac Exam: Regular rate and rhythm. No murmurs, rubs, or gallops. He had no bruits per his carotid exam, normal pulsations in his upper and lower extremities. GI system: soft, nontender, no masses palpable. On Valsalva, he has a large ventral hernia in the midline, multiple well-healed scars. Again, no masses palpated. Rectal exam has poor tone, heme negative. No mass. Neuro: Cranial nerves II through XII grossly intact. Musculoskeletal: good strength and range of motion in all four extremities. Skin: Within normal limits. Pertinent Results: [2150-1-6] 04:22AM BLOOD PT-12.8 INR(PT)-1.1 ECHO results: IMPRESSION: Normal global and regional LV systolic function. Mild mitral regurgitation. . CLINICAL IMPLICATIONS: The patient has mild mitral regurgitation. Based on [2140] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . Cytology Report RT RENAL CYST Procedure Date of [2149-12-23] . SPECIMEN DESCRIPTION: Received 25ml clear yellow fluid. Prepared 1 ThinPrep slide. CLINICAL DATA: Colon cancer. REPORT TO: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] . DIAGNOSIS: FNA, right renal cyst, aspiration: . NEGATIVE FOR MALIGNANT CELLS. . Hypocellular specimen. . Few scattered macrophages (see Note). . Note: The findings are compatible with cyst contents; however, epithelial elements are not represented. Clinical correlation is recommended . [Hospital 93] MEDICAL CONDITION: 60 year old man s/p total colectomy, POD 8 now with nausea and vomiting. REASON FOR THIS EXAMINATION: evaluate for obstruction INDICATION: Status post total colectomy, postop day 8, now with nausea and vomiting. Evaluate for obstruction. . ABDOMEN, SUPINE AND ERECT: There are multiple loops of dilated small bowel with air-fluid levels. An NG tube is in place in the stomach. Surgical clips are visualized in the lower midline. . There are areas of calcification overlying the region of the pubic symphysis which may represent calcification in the prostate gland or stones in the bladder. . IMPRESSION: Multiple dilated small bowel loops which may represent ileus or small bowel obstruction. . [2150-1-3] 9:05 am URINE Site: CATHETER FINAL REPORT [2150-1-5] URINE CULTURE (Final [2150-1-5]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ 8 I IMIPENEM-------------- 8 I MEROPENEM------------- 2 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Brief Hospital Course: Mr. [Known lastname ] was admitted on [2149-12-23] for scheduled open total colectomy and ventral hernia repair with mesh, see Op note for details. He was transferred to PACU post-op and was extubated. He recovered well and was transferred to [Hospital Ward Name 121] 9. . Abdomen: POD #1 Abdominal binder was in place with clean dry dressings intact. An intact JP #1 drained adequate output from the RLQ and JP #2 drained serosainguinous fluid from the LLQ. The incision remained well approximated with staples and no drainage. NGT was in place post-op, and removed on POD#1. Flatus was noted on POD #4. Bowel movement occurred on POD#5. JP #1 was removed on POD #6. POD#8, first small loose bowel movement. Frequent loose stools developed over the next 24 hours, he was treated with immodium prn with fair results. On POD #8, NGT was reinserted due to development of ileus, when 1000 cc of green drainage was rapidly evacuated. C. Diff was negative x3. He was held NPO, and KUB obtained, see pertinent results. On POD #13, NGT was removed, patient tolerated well. Bowel function resumed on POD#13 with Staples were removed on POD#12, incision remained C/D/I, abdomen soft and nontender. JP #2 was removed on POD#15. . Pain: Epidural PCA was used with fair effect from HD#1 until POD #4. He was then transitioned to percocet po for pain control, with IV morphine injections for breakthrough pain until POD#7. Patient reported minimal post-op pain, and required no po narcotics after POD#8. . Cardiovascular: Pt was stable in NSR until POD #5 when he developed atrial fibrillation. A cardiology consult was obtained. He was transferred to SICU for amiodarone drip. He converted to normal sinus rhythm, was transferred to CC6 and started on oral amiodarone. A TTE was performed, see pertinent results. He was monitored on telemetry, with intervals of afib, converting back to NSR over the next few POD days. He recieved lopressor IV until POD# 12, which he initially refused when he was immediately post-op. Coumadin was initiated and recommended by cardiology for 1 month. Amiodarone was continued po, and recommended for 3 months. He remained in NSR at the time of discharge. . Genitourinary: Foley catheter was in place until POD#7, when it was initially dc'd. The patient triggered on POD#7, related to low urine output of 45 cc over 4 hours. Foley was replaced, and output improved with fluid boluses. On POD#13, urine culture revealed pseudomonas, and cefipime IV was initiated, and continued at home after DC x 7 days total. Foley was left in place to leg bag for discharge home. . Respiratory: Patient was on 2L nasal cannula O2 immediately post-op and weaned by POD#7. Upon development of ileus, O2 sats dropped and he was replaced on O2 4L to keep sats> 92%. On POD#10, patient was weaned to RA. . Activity: Pt was up to the chair on POD#1 and ambulating halls POD#2. He remained active throughout his admission. . Nutrition: TPN was started due to prolonged NPO status as a result of ileus. He recieved TPN from POD#10 until POD#12. His diet was advanced and he tolerated a regular diet on POD#13. . He was discharged to home on POD#14 with appropriate follow up appointments and VNA service for IV antibiotics. Medications on Admission: Flomax 0.4 mg po BID Aspirin 81 mg po qd Avandia 8 mg po qd Metformin 1000 mg po qam, 15oo mg po qpm Lipitor 5 mg po qhs Lisinopril 5 mg po qd Androgel applied daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): until [2150-1-17] (then take 200mg once daily). Disp:20 Tablet(s) Refills:0 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): take until directed to stop by primary care physician (~3 month course). Disp:90 Tablet(s) Refills:0 10. Cefepime 1 g Recon Soln Sig: One (1) gram Intravenous Q12H (every 12 hours) for 5 days. Disp:10 gram Refills:0 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:QS x 5 days mL Refills:0 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Right colon cancer S/P Open total colectomy, ventral hernia repair with mesh Atrial Fibrillation Urinary Tract Infection Ileus Discharge Condition: good Discharge Instructions: Please call your doctor or return to the emergency room if you develop a fever greater than 101.5, shortness of breath, rapid heart rate, chest pain, foul smelling drainage from your incision, pain unrelieved by your pain medications, any problems with the Foley catheter, more than 3 loose stools per day, persistent nausea/vomiting or inability to pass gas/stool, or any other symptoms concerning to you. . No driving while on pain medications. . No tub baths or swimming, you may shower, keep incision open to air, clean and dry, keep PICC line clean and dry. Keep PICC line covered with plastic wrap while showering. Cover your abodminal incision with a dressing if you notice clear drainage. . Resume your prior home medications, as directed by your primary care physician. [Name10 (NameIs) ] your physician's office this week to have your blood drawn for INR level and Coumadin dosed accordingly. You may require Immodium if you have more than 4 loose, watery stools per day. If so, please call Dr.[Name (NI) 3377] office (number below) for instructions on dosing. Followup Instructions: See your primary care physician's office this week to have your blood drawn (INR level) and Coumadin dose adjusted. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], MD Phone:[Telephone/Fax (1) 68191] Date/Time:[2149-1-16] 3:00, at [Hospital Ward Name 23] [Location (un) 470] Surgical Specialties. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1120] (colorectal surgery) will see you when you have your appointment with Dr. [Last Name (STitle) ]. Her telephone # is [Telephone/Fax (1) 17489]. You have an appointment with Dr. [Last Name (STitle) 63370] in Winsockett on Thursday [2150-1-8] at 10:00 am. The office is located at [Apartment Address(1) 70324]. Completed by:[2150-1-6]	[ "788.20", "041.7", "401.9", "V10.00", "V15.82", "250.00", "568.0", "530.81", "427.31", "996.64", "560.1", "599.0", "285.9", "553.21", "153.4" ]	icd9cm	[ [ [] ] ]	[ "99.04", "03.90", "99.77", "53.61", "45.93", "55.92", "54.59", "45.8", "38.93", "99.15", "96.07", "45.24" ]	icd9pcs	[ [ [] ] ]	10480, 10532	5937, 9173	389, 610	10703, 10710	3370, 3524	11838, 12619	2379, 2383		9390, 10457	4479, 4552	10553, 10682		9199, 9367			10734, 11815								2398, 3351						3547, 4442																274, 351	4581, 5914													638, 1621													1643, 2032	2048, 2363
9,417	190,742	48373	Discharge summary	report	Admission Date: [2105-11-23] Discharge Date: [2105-11-26] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: Abdominal pain, melena. Major Surgical or Invasive Procedure: Nasogastric lavage. Esophagogastroduodenoscopy (EGD). History of Present Illness: [Age over 90 ] yo woman with h/o A fib (not on coumadin) and HTN who presents c/o abdominal pain, black stools, and coffee-ground emesis x 1 day. She was in USOH until [11-18] when she fell off a chair onto her bottom. She was brought to hospital and after ambulating without difficulty was sent home (no head trauma). Since the fall, her appetite has been very poor. She has eaten almost nothing, but fluid intake has been good (milk and water, primarily). Except for her appetite, she had no specific complaints. Then on [11-22] pm, she had an episode of coffee-ground emesis (large amount). She went to sleep and upon wakening had another episode of coffee-ground emesis. This morning, she also had a black tarry BM. Called son who is [Name8 (MD) ] MD and followed his recommendation of going to the hospital (she didn't want to come in). She denies feeling lightheaded or short of breath at any time. No chest pain or diarrhea. Denies taking NSAIDs. . In the emergency room, patient has been hemodynamically stable (BP 130/50, HR 80s) and initial Hct was 46 (Hct from outside records recently was 45). NGL done with about 500 cc coffee-grounds, no bright red blood. Cleared with about 700 cc lavage. She initially complained of abdominal pain and tenderness, but after po contrast given for CT abd, her pain disappeared. Past Medical History: HTN Atrial fibrillation Gout Osteoarthritis Hypothyroidism (diagnosed [6-7]) s/p hysterectomy 30 years ago ?CRI (creat 1.4 on [6-7]) Social History: Lives at home alone. Ambulates with walker. Does not cook (has meals brought to her). Raised in [Country 3399]. Moved to US in [2060]. Denies alcohol, tobacco, or caffeine use. HCP is daughter. PCP is [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 172] (APG). Family History: non-contributory. Physical Exam: PE: 147/62 - 74 - RR 21 - 94% GEN - NAD, A&Ox3 (hard of hearing), HEENT - oral mucosa dry, PERRL, EOMI, sclerae anicteric NECK - no JVD, no LAD LUNGS - CTAB HEART - nl s1s2, RRR, no mrg ABD - soft, NT/ND, NABS, no rebound or guarding EXT - no edema Pertinent Results: [2105-11-23] 12:50PM BLOOD WBC-9.8 RBC-5.27 Hgb-15.7 Hct-46.6 MCV-88 MCH-29.7 MCHC-33.6 RDW-18.5* Plt Ct-153 [2105-11-26] 04:35AM BLOOD WBC-11.6* RBC-4.85 Hgb-14.0 Hct-47.6 MCV-98# MCH-29.0 MCHC-29.5# RDW-20.2 Plt Ct-125* [2105-11-23] 12:50PM BLOOD Neuts-87.0* Bands-0 Lymphs-10.1* Monos-2.7 Eos-0.1 Baso-0.1 [2105-11-26] 04:35AM BLOOD Plt Ct-125* [2105-11-26] 04:35AM BLOOD PT-100* PTT-86.9* INR(PT)-88.6 [2105-11-26] 04:35AM BLOOD Glucose-96 UreaN-80* Creat-2.5* Na-137 K-6.0* Cl-105 HCO3-8* AnGap-30* [2105-11-23] 12:50PM BLOOD Glucose-115* UreaN-74* Creat-1.7* Na-135 K-6.5* Cl-97 HCO3-20* AnGap-25* [2105-11-26] 04:35AM BLOOD ALT-77* AST-457* LD(LDH)-2855* AlkPhos-194* Amylase-155* TotBili-3.3* [2105-11-23] 12:50PM BLOOD ALT-82* AST-505* CK(CPK)-186* AlkPhos-289* Amylase-36 TotBili-2.2* [2105-11-26] 04:35AM BLOOD Lipase-264* [2105-11-25] 04:40AM BLOOD Lipase-503* [2105-11-23] 12:50PM BLOOD Lipase-80* [2105-11-24] 03:25AM BLOOD CK-MB-5 cTropnT-0.04* [2105-11-23] 09:27PM BLOOD CK-MB-6 cTropnT-0.03* [2105-11-23] 12:50PM BLOOD CK-MB-7 cTropnT-0.03* [2105-11-26] 04:35AM BLOOD Albumin-3.2* Calcium-9.8 Phos-6.2# Mg-2.1 [2105-11-25] 04:40AM BLOOD Mg-2.0 Iron-43 [2105-11-25] 04:40AM BLOOD calTIBC-221 TRF-170* [2105-11-24] 03:25AM BLOOD Ferritn-421* . CT abd/pelvis [2105-11-23]: 1. No intra-abdominal free air. Although the stomach lining is unremarkable, CT is not sensitive in evaluating luminal irregularities or the presence/absence of ulcers. There is no evidence of oral contrast extravasation into the mesentery. 2. Moderate/large sliding hiatal hernia. 3. Differential attenuation of the liver. Ultrasound, multiphasic CT or MRI is recommended for further evaluation. 4. Left adrenal adenoma. 5. 2.8 x 2.5 cm splenic cyst. 6. 1.5 cm fat-containing periumbilical hernia. 7. Sigmoid diverticulosis without evidence of acute diverticulitis. . CXR [2105-11-23]: There is elevation of the left hemidiaphragm. There is some discoid atelectasis in the lingula. There is no free air under the diaphragms. There is some degenerative disease of the glenohumeral joint on the left. Otherwise, the lungs are clear with no consolidations, effusions, or pneumothoraces. IMPRESSION: No free air. . Abd L lat. decub. [2105-11-23]: Single left decubitus films demonstrate no air-fluid levels and no free air in the abdomen. Bowel loops are normal in caliber. There is no evidence for obstruction. . ECG [2105-11-23]: Atrial fibrillation. Left ventricular hypertrophy with ST-T wave abnormalities. The ST-T wave changes are diffuse and non-specific. . EGD tissue path: pending. . RUQ/liver u/s [2105-11-25]: The liver parenchyma is punctuated by innumerable discrete target like lesions measuring up to 3 cm consistent with metastases. The target-like appearance does suggest a GI primary, although other primary malignancies can cause this appearance. The gallbladder contains gallstones, but there is no evidence of cholecystitis nor of gallbladder carcinoma. There is no intra- or extra- hepatic biliary dilatation. Trace pleural effusion is seen on the right side. CONCLUSION: Liver metastases. These could be biopsied under ultrasound guidance if required. Brief Hospital Course: [Age over 90 ] yo woman with h/o AFib and HTN on ASA presents with coffee-ground emesis and melena x 2 days. . 1) Upper GI bleed: Initial Hct drop from 46 to 38. Pt. underwent NG lavage which cleared after 700cc, and her Hct was stable during the entire hospitalization. GI was consulted and an EGD was performed which revealed a medium-sized sliding hiatal hernia, and gastritis, esophagitis, and duodenitis with gastric and esophageal ulcers and ?[Female First Name (un) ]. Tissue samples were obtained and sent for pathologic evaluation. The Pt. was treated with protonix. The Pt. was also noted to have an elevated lipase and mild transaminitis, but exhibited no signs of active pancreatitis or gallstone/gall bladder disease. Iron studies were normal with a slightly depressed TIBC. A RUQ U/S was obtained which showed multiple liver lesions, likely metastases with unknown primary but suspicious for GI. GI recommended an abdominal MRI and possible biopsy. . At approximately 6:30am on [2105-11-26], the Pt. was found by nurse to be without pulse, and a code blue was initiated. The Pt. was unable to be resuscitated. It is not known exactly when this terminal event began, but the nurse did not believe that more than 30 minutes had passed before the Pt's cardiac arrest was noted. The Pt's family was notified, and a post-mortem examination was offered and declined. Medications on Admission: Atenolol 25 mg daily Ecotrin 81 mg daily Levoxyl Allopurinol 300 mg Triamterene/HCTZ 25 mg Discharge Medications: not applicable. Discharge Disposition: Expired Discharge Diagnosis: probable metastatic disease. cardiac arrest. Discharge Condition: expired. Discharge Instructions: not applicable. Followup Instructions: not applicable. [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2105-11-26]	[ "585.9", "530.89", "577.0", "401.9", "427.5", "197.7", "199.1", "244.9", "535.41", "427.31", "599.0", "553.3", "285.1", "274.9", "584.9" ]	icd9cm	[ [ [] ] ]	[ "99.60", "96.53", "45.16" ]	icd9pcs	[ [ [] ] ]	7395, 7404	5814, 7214	287, 342	7492, 7502	2530, 5791	7566, 7707	2227, 2246		7355, 7372		7425, 7471		7240, 7332			7526, 7543								2261, 2511																						224, 249														370, 1712													1734, 1876	1892, 2211
42,366	183,525	47425	Discharge summary	report	Admission Date: [2168-5-5] Discharge Date: [2168-5-18] Date of Birth: [2097-10-23] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 896] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: IR guided doboff placement X 2 History of Present Illness: 70 yo female with a past history of DM, CHF, PVD, CAD s/p CABG who p/w abd pain on [4-27] to [Location (un) 1459]. She presented to [Hospital1 18] as a transfer for further management of acute pancreatitis. On presentation at the OSH patient was found to have an elevated lipase 14,510 and amylase 4290 with a CT abdomen consistent with pancreatitis. She does not have a history of abominal pain on pancreatitis. Ultrasound confirmed the presence of gallstones and there was some mild CBD dilitation. She was managed supportively with pain medication, IVFs and TPN. Fluid resusication was complicated by thirdspacing and new pleural effusions on CXR. On [4-30], patient developed bradycardia, so she received epi/atropine/calcium with compressions, and was intubated and transferred to the ICU. EKG showed transient lateral STDs which improved without intervention, and enzymes remained flat. The following day she was started on vanco/clinda and later cipro for presumed aspiration pneumonia. CXR showed volume overloaded, so she was diuresed and extubated on [5-2]. She was transitioned to bipap. Amylase, lipase and LFTs normalized on [5-3]. A repeat CT scan was performed on [5-3] to evaluate for pseudocyst given rising WBC and fevers to 102.2, but this was negative. patient had some anemia with a nadir hct of 24.9 and received 2 u PRBC. Patient also developed [Last Name (un) ] while in the hospital, but this improved to 1.2 prior to transfer, which was felt to be secondary to ATN per renal consultation. In addition to renal, surgery, GI and critical care were involved with the patient's care. . On transfer, patient is sedated but responds to verbal stimuli. She is denying abdominal pain. . 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 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: -uncontrolled DM c/b retinopathy, nephropathy, neuropathy-refuses insulin -CAD s/p MI and s/p CABG 2-3yrs ago; [2167] persantine stress showed no large WMAs -CHF (borderline LVEF, mod diastolic dysfxn) with mult exacerbations -CKD [3-9] DM (Baseline Cr=2.0) -Legally blind -COPD -Gout -PVD -HTN -HL -severe OA -Hemorrhoids -h/o tubular villous adenoma on [2-/2167] [Last Name (un) ] -s/p hip replacement Social History: Single, support from brother and his children, no tobacco or EtOH Family History: DM, HTN Physical Exam: Admission Exam: Vitals: T: 99.5 BP: 135/51 P: 74 R: 31 O2: 97% bipap 15/5 FiO2 0.5 General: arouses to verbal stimuli and follows general commands HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: rhonchi bilaterally louder on expiration CV: Regular rate and rhythm, 3/6 SEM, normal S1 + S2, no rubs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ LE edema, warm, well perfused, 2+ pulses, no clubbing, cyanosis DISCHARGE: VS: Tm100.4 at 10pm, Tc97.2 HR80s-90s, BP140s/60s, RR 32, O2sat 95% on 2L NC GEN: Elderly F tachypneic but denies pain or SOB in NAD, not diaphoretic HEENT: Anicteric sclera, MMM, doboff in place LUNGS: crackles at bases worse on right, clear anteriorly HEART: RRR 3/6 SEM at RUSB ABD: Obese, soft, non-tender, non-distended Rectal: Flexiseal in place GU: Foley in place Extrem: 2+ Sacral edema Neuro: Alert, oriented X 3. Legally blind and HOH but answers questions appropriately when prompted. Pertinent Results: Admission Labs: [2168-5-6] 12:16AM BLOOD WBC-30.4* RBC-3.24* Hgb-9.2* Hct-27.6* MCV-85 MCH-28.6 MCHC-33.5 RDW-15.5 Plt Ct-200 [2168-5-6] 12:16AM BLOOD Neuts-87* Bands-7* Lymphs-1* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [2168-5-6] 12:16AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [2168-5-6] 12:16AM BLOOD PT-15.1* PTT-23.9 INR(PT)-1.3* [2168-5-6] 12:16AM BLOOD Glucose-178* UreaN-81* Creat-1.4* Na-136 K-4.3 Cl-103 HCO3-25 AnGap-12 [2168-5-6] 12:16AM BLOOD ALT-84* AST-64* LD(LDH)-330* AlkPhos-272* Amylase-24 TotBili-1.6* [2168-5-6] 12:16AM BLOOD Lipase-24 [2168-5-6] 12:16AM BLOOD Calcium-7.4* Phos-4.1 Mg-2.0 [2168-5-6] 05:46AM BLOOD calTIBC-155* Ferritn-1033* TRF-119* [2168-5-6] 02:07AM BLOOD Type-ART Temp-37 pO2-82* pCO2-34* pH-7.46* calTCO2-25 Base XS-0 Intubat-NOT INTUBA [2168-5-6] 02:07AM BLOOD Lactate-1.5 [2168-5-7] 03:53AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 [2168-5-7] 03:53AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2168-5-10] 12:48PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1 TransE-1 [2168-5-10] 12:48PM URINE CastHy-1* [2168-5-10] 12:49PM URINE Hours-RANDOM UreaN-336 Creat-23 Na-68 K-37 Cl-96 [2168-5-10] 12:49PM URINE Osmolal-373 MICRO: [2168-5-6] 12:16 am BLOOD CULTURE Source: Line- right Picc line. FINAL REPORT [2168-5-12] Blood Culture, Routine (Final [2168-5-12]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [2168-5-7]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by AMBER [Doctor Last Name 8021] #[Numeric Identifier 53651] [2168-5-7] 0800. . IMAGING: RUQ US: Tiny [Doctor Last Name 5691]-like stones seen within the gallbladder and there also is a layer of sludge. There are no signs of cholecystitis. No biliary dilatation. Small right pleural effusion. . CT Torso: 1. Acute pancreatitis, with extensive inflammation and free fluid tracking through mesentery and into thorax. Findings concerning for necrosis of the pancreatic neck and proximal body. 2. Cholelithiasis. 3. Pulmonary hypertension. 4. Age-indeterminate L3 compression deformity. . NCHCT: 1. Diffuse cerebral atrophy, without acute intracranial process. 2. Under-pneumatized mastoids, with fluid opacification. Please correlate clinically for evidence of mastoiditis. . Video Swallow: FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration. Multiple episodes of penetration were noted with thin and thick consistency barium. For details, please refer to speech and swallow division note in OMR. IMPRESSION: No evidence of aspiration. Multiple episodes of penetration with thin and thick consistency barium. . MRCP: FINDINGS: Extensive high signal intensity is present within the pancreas consistent with acute inflammation. The pancreas also has reduced signal intensity on T1-weighted imaging. There is a focal area of non-enhancement within the neck of the pancreas with an adjacent intrapancreatic fluid collection. These findings are suggestive of necrosis. The remainder of the pancreas enhances normally post-contrast. The pancreatic duct is nondilated. A number of fluid collections are noted in the lesser sac, the largest measuring 5.4 x 3.6 cm. A further 4.5 x 3.5 cm collection is present adjacent to the head of the pancreas, this collection extends cranially to the level of the caudate lobe of the liver. A fluid collection is also noted tracking over the right lobe of liver. There is layering of fluid in the neck of the gallbladder likely a composite of small stones and sludge. No common bile duct dilatation is present and no filling defects are identified. No focal liver lesions. The kidneys, adrenal glands are normal. The spleen is normal measuring 12 cm. The portal vein, splenic vein and SMV are patent. The celiac and SMA are also patent. There are bilateral pleural effusions with associated atelectasis. IMPRESSION: 1. There is evidence of acute pancreatitis with multiple peripancreatic fluid collections. 2. A focal area of non-enhancement is present in the neck of the pancreas suggestive of necrosis. 3. No common bile duct stone / dilatation. Cholelithiasis. 4. Pleural effusions, atelectasis. Brief Hospital Course: 70 yo female with a past history of DM, CHF, PVD, CAD s/p CABG who presents with abdominal pain to an OSH and found to have gallstone pancreatitis, with a course complicated by bradycardic arrest, pulmonary edema, fevers and leukocytosis, required 11 day MICU stay. # Pancreatitis: Presumed secondary to gallstones. RUQ U/S showed gallstones but no cholecystitis. CT abdomen shows possible pancreatic necrosis but no fluid collection. She was continued on Vanco, Cefepime, Flagyl until [5-11] and had no fevers after abx were stopped. Surgery was consulted and recommended ERCP and post-pyloric feeds, plan for cholecystectomy once stabilized, inpt vs outpt. ERCP said no indication given no cholestatic picture. She will follow up with dr. [Last Name (STitle) ] of general surgery in [2-7] weeks to plan her cholecystectomy. She was continued on bowel rest and Dobhoff was placed for post-pyloric feeds, eventually transitioned to NG tube with feeds tolerated without abdominal pain. Leukocytosis trended down. Swallow evaluated and diet advanced to clears prior to transfer out of MICU. On floor she continued on nectar thick liquids and ground solids. A doboff tube was placed on [2168-5-16] for continued tube feeds as she had poor po intake for many days. This can be weaned as she starts to eat more by mouth and she may no longer need the TFs after some weeks. She should be evaluated by nutrition to measure her changing caloric needs to adjust her TFs accordingly. Speech and swallow was reconsulted and felt she could tolerate a nectar-thick liquid and pureed solid diet. She had a video swallow that did not reveal any silent aspiration. She should be re-evaluated by speech and swallow at the ltac to ascertain whether her swallowing function has improved and she can advance her diet. Their recommendations were the following: 1. puree solids and nectar thick liquids 2. medications crushed in applesauce or via NG tube for a more reliable means 3. TID oral care 4. 1:1 supervision with meals a. self-feeding and meal set-up b. swallow 2-3 times per bites/sip c. alternate consistences d. only feed when awake/alert/attentive 5. Recommend using NG for supplemental nutrition, hydration, and medication until Pt able to meet these needs on a full PO diet. 6. Follow up Fri as overall status improves # Cholelithiasis: Thought to be the cause of her pancreatitis. Surgery was consulted in the MICU and recommended open ccy and an ERCP-guided sphincterotomy. ERCP was consulted and recommended MRCP prior to sphincterotomy. MRCP showed peripancreatic collections and necrotizing pancreatitis. Surgery and ERCP felt the best option was to have her follow up with Dr. [Last Name (STitle) 853] in [2-7] weeks to discuss her CCY and that because she did not have cholangitis she would not need a sphincterotomy. # Fevers/Leukocytosis: Multiple possible etilogies including recovering pancreatitis and suspected pneumonia in the setting of recent code. C. diff was negative X2 although the patient does have diarrhea it is thought [3-9] pancreatic insufficiency. She has a flexiseal for this that can be discontinued when able. Shee was continued on broad spectrum abx as above and completed >8 days for HCAP. After this treatment she continued to have low grade fevers (around 100.4) on most nights accompanied sometimes by tachypnea. This was felt initially to be aspiration but as above she was evaluated by S+S and had a video swallow that did not reveal aspiration. Therefore, the fevers have been attributed to her resolving pancreatitis and fluid collections. There is no surgical intervention for these and most likely she will continue to have low grade fevers until this completely resolves. The fevers and her tachypnea have resolved with tylenol. Cultures are pending at time of discharge and we will call if they return positive. # Respiratory failure: Presumed secondary to pulmonary edema in a patient with underlying CHF who received aggressive volume at OSH for pancreatitis. ABG at admission and subsequently with relative hypoxia without hypercarbia and respiratory alkalosis consistent with tachypnea. Continued abx as above with little improvement in O2 requirement, but responded well to 100mg IV lasix boluses with rapid decline in O2 requirement to 2.5L at time of MICU transfer. On the floor she continued to remain at about 94-96% on 2.5L NC with tachypnea to the mid-30s. She had a repeat CXR the day after transfer to the floor that showed persistent fluid overload and more aggressive diuresis with 100mg lasix IV 100mg TID and metolazone was started. It was felt the tachypnea was likely multifactorial and not only related to volume overload but also deconditioning. On discharge she was on lasix 100mg IV TID with 5mg metolazone prior to the lasix dose and was satting 95% on 2L NC. She will need further diuresis at LTAC with goal to have her off O2 and her peripheral edema improved. Her lytes should be checked and repleted daily while she is on IV diuretics. Foley is in place to help with UOP monitoring but should be discontinued when able. # Altered mental status: Patient altered at admission, quiet at baseline per family. Oriented to person, time at time of MICU transfer. Remained alternately confused at times and at other times A+OX 3 throughout stay on floor. Of note patient is legally blind and speaks Italian as her first language (although understands and speaks english as well) and per family is not altered. She is A+OX3 at discharge. # CAD/CHF: EKG without ischemic changes. Continued betablocker but held ace-i, statin, nitrate. Lasix as above. # DM: Insulin drip early in admission but transitioned to ISS with glargine, dose was 15 units QPM at time of MICU transfer. She continued to have high ISS requirements and lantus was uptitrated to 35units QHS. # Hypernatremia: Na elevated, likely [3-9] dehydration from diuresis and no PO intake. Free water flushes via Dobhoff adjusted prn and Na still elevated at time of MICU transfer. On floor the Na started to trend down with free water flushes. on discharge it was 147. Her sodium should be checked daily and her free water flushes should continue to be titrated to keep her sodium level wnl. # Family Communication: HCP = [Name (NI) ] H:[Telephone/Fax (1) 100327], C:[Telephone/Fax (1) 100328]. She has a large family that visits daily and would like updates. # Diarrhea: PAtient developed diarrhea in the MICU. CDiff was negative. Initially thought [3-9] antibiotic adverse effect but continued after antibiotics discontinued. Possibly [3-9] pancreatic insufficiency. Flexiseal is in place to prevent skin breakdown and should be discontinued when able. # Compression fractures: The patient was noted to have compression fractures on CT imaging and was started on calcium and vitamin D. She should follow up with her PCP [Last Name (NamePattern4) ]: bisphosphonate therapy when she is less ill. # Anemia: This is likely anemia of chronic disease. Guaiac negative so GIB less likely. Will need to f/u with pcp for further workup. # Transitions of care: - Blood cultures are pending and we will call LTAC with results - Sodium checks daily with titration of free water flushes as appropriate - lytes check daily and replete PRN - Flexiseal and foley in place and when can tolerate can remove Medications on Admission: 1. Januvia 100mg daily 2. Amlodipine 5mg daily 3. Isosorbide Mononitrate ER 60mg daily 4. Furosemide 80mg daily alt with 60mg daily 5. Carvedlil 25mg [Hospital1 ] 6. Captopril 25mg TID 7. Glizide 10mg [Hospital1 ] 8. Simvastatin 80mg QHS 9. Citalopram 20mg daily 10. Allopurinol 100mg daily 11. Colchicine 0.6mg PRN gout 12. Tramadol prn gout pain 13. Omeprazole 20mg daily 14. Miralax prn Discharge Medications: 1. latanoprost 0.005 % Drops [Hospital1 ]: One (1) Drop Ophthalmic HS (at bedtime). 2. heparin (porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) injection Injection TID (3 times a day). 3. glucagon (human recombinant) 1 mg Recon Soln [Hospital1 ]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. carvedilol 12.5 mg Tablet [Hospital1 ]: Two (2) Tablet PO BID (2 times a day): hold for SBP<100 HR<60. 5. allopurinol 100 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day): hold for loose stool. 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: hold for loose stool. 8. acetaminophen 650 mg/20.3 mL Solution [Hospital1 ]: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for pain, fever. 9. trazodone 50 mg Tablet [Age over 90 ]: 0.5 Tablet PO HS (at bedtime) as needed for anxiety.insomnia. 10. senna 8.6 mg Tablet [Age over 90 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation: hold for loose stool. 11. calcium carbonate 200 mg (500 mg) Tablet, Chewable [Age over 90 ]: One (1) Tablet, Chewable PO Q 12H (Every 12 Hours). 12. cholecalciferol (vitamin D3) 400 unit Tablet [Age over 90 ]: One (1) Tablet PO DAILY (Daily). 13. insulin lispro 100 unit/mL Solution [Age over 90 ]: AS DIR Subcutaneous four times a day: Per sliding scale. 14. insulin glargine 100 unit/mL Solution [Age over 90 ]: Thirty Five (35) units Subcutaneous at bedtime. 15. metolazone 2.5 mg Tablet [Age over 90 ]: Two (2) Tablet PO every eight (8) hours: 30mins prior to lasix dose. 16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 18. Furosemide 100 mg IV Q 8H hold for SBP<100 19. Outpatient Lab Work Patient requires daily sodium, potassium, and magnesium checks while on lasix and tube feeds so that free water flushes and lasix can be dosed appropriately and lytes can be repleted. 20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Pancreatitis ACute Systolic heart failure Deconditioning from prolonged hospitalization Dysphagia Diabetes 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: You were admitted to the hospital with pancreatitis. You had a lot of fluids to treat this which caused you to have trouble breathing. We have been helping with this with medications. You also did not eat for a long time so you are very weak. We have placed a feeding tube so you can have tube feedings while you gain your strength back. Completed by:[2168-5-18]	[ "285.9", "369.4", "427.31", "427.89", "518.81", "250.52", "428.0", "583.81", "274.9", "574.20", "250.62", "362.01", "496", "428.21", "357.2", "584.5", "250.42", "V43.64", "263.0", "276.0", "577.0" ]	icd9cm	[ [ [] ] ]	[ "99.15", "96.6" ]	icd9pcs	[ [ [] ] ]	19081, 19151	8849, 13996	320, 353	19302, 19302	4219, 4219		3126, 3135		16693, 19058		19172, 19281		16271, 16670			19480, 19849								3150, 4200																		2137, 2584				266, 282														381, 2118					4235, 8826			19317, 19456	16005, 16245				2606, 3027	3043, 3110
11,923	194,773	24682+57413	Discharge summary	report+addendum	Admission Date: [2192-9-6] Discharge Date:[2193-1-9] Date of Birth: [2143-6-17] Sex: M Service: CSU CHIEF COMPLAINT: A 49 year old man transferred from [Hospital6 33180] after a transesophageal echocardiogram showed aortic valve endocarditis with aortic insufficiency and a cath done at that time immediately following showed no flow limiting coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient was admitted to [Hospital6 3872] with a working diagnosis of pericarditis after the emergency room evaluation for fever and shaking chills associated with shortness of breath. The patient was then found to have positive blood cultures without recent dental work or surgery except for the removal of several warts from his right hand. The patient was treated at [Hospital3 1280] with vancomycin and oxacillin, however, his respiratory status worsened and he was ultimately intubated and then transferred to [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] for further care. PAST MEDICAL HISTORY: The patient's past medical history is significant for asthma, spontaneous pneumothorax. FAMILY HISTORY: Mother died of a stroke. His father had cardiomyopathy as well as lymphoma. SOCIAL HISTORY: Lives with his wife and 2 sons who are early teenagers. He denies tobacco or alcohol use. ALLERGIES: No known drug allergies. MEDICATIONS: On transfer include Protonix 40 mg daily, rifampin 300 mg b.i.d., oxacillin 2 grams q.4hours, Levaquin 250 mg daily, Tylenol 650 mg p.r.n., Restoril 7.5 mg p.r.n., Lasix 80 mg daily, Dilaudid 1 mg p.r.n. LABORATORY DATA: Lab data at the time of transfer: White count 28.7, hematocrit 36, platelets 395,000. PT 16, PTT 29, INR 1.8. Sodium 137, potassium 4.4, no chloride or CO2, BUN 83, creatinine 4.3, glucose 180. ABG 7.32, 39, 85, 21/-5 with vent settings of assist control 100%, tidal volume 600, respiratory rate 22 with no pressor support and 10 of PEEP. Chest x-ray done on admission showed bilateral pleural effusions without pneumothorax or infiltrates and endotracheal tube in good position. PHYSICAL EXAMINATION: Vital signs 99.4, heart rate 100, sinus tach, blood pressure 136/39, respiratory rate 24, oxygen saturation 100%. He had amiodarone at 1 mg/minute, nitroglycerin at 4 mcg/kg/minute and propofol at 40 mcg/kg/minute. Neurologically sedated and intubated. Respiratory: Coarse rhonchi throughout. Cardiovascular: Regular rate and rhythm with III to IV/VI systolic ejection murmur. The abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused. It was planned to place a Swan-Ganz catheter and then send the patient to CAT scan for an abdominal and a chest CT to look for septic sources and to rule out PE, however, upon arrival in the CSIU, the patient had a VT arrest. He was shocked several times and returned to a normal sinus rhythm following which he did go to CAT scan and had a repeat TEE at that time. Additionally, the electrophysiology, the interventional pulmonary and the renal service were all consulted. The patient was treated in the cardiac surgery intensive care unit for the next several days in order to stabilize him, and on the [12-14], he was brought to the operating room at which time he had a debridement of an aortic aneurysm as well as patch of that aneurysm and resuspension of his aortic valve. He tolerated the operation and was transferred back to the cardiothoracic intensive care unit. His postoperative course was extremely unstable and on the [12-19], he had a repeat transesophageal echocardiogram which showed severe aortic regurgitation with a vegetation of the aortic valve and 2+ mitral regurgitation without vegetations on the mitral valve. Ultimately the patient had a prolonged hospital course with several return trips to the operating room, each associated with short periods of paralysis, followed by slow vent weans. A summary of those events include the initial operation on the 25th for the aortic patch and resuspension of the valve, hematoma evacuation on the [11-20], return trip to the operating room on the [11-25] where he had a #27 St. [Male First Name (un) 923] pericardial aortic valve placed following which he had a postoperative pneumonia with pseudomonas. He did well on the initial postoperative course and was ultimately extubated on the [12-2], however, he suffered a cardiac and respiratory arrest on the [12-7] during which he was reintubated and brought back to the operating room for exploration. At that time, it was found that he had dehisced his aortic valve and he underwent aortic root replacement with a #23 homograft as well as a mediastinal washout. He also had exploratory laparotomy at that time that showed mesenteric ischemia and abdominal hematoma was also evacuated at that time. Culture material sent from the operating room ultimately grew [Female First Name (un) 564] from the pericardial tissue as well as from the chest wound and aortic tissue. The patient returned to the operating room again on the [12-17] for a planned closure of his abdomen, however, that was aborted when it was found that the chest wound had active infection and the thoracic service as well as the plastic surgery service were consulted at that time. The patient had a limited sternal debridement as well as a chest washout during that trip to the operating room. On the [12-19], the patient was again brought to the operating room where he had a cholecystectomy as well as a G- J tube placed and fascial layer of his abdomen was closed. He tolerated that operation well and was returned to the cardiothoracic intensive care unit where he remained hemodynamically stable for about a week and subsequently on the [11-29], he had an episode of bleeding which returned him to the operating room for a mediastinal exploration during which they found a dehiscence of suture line and an infected initial homograft. Therefore, he underwent replacement of the ascending aorta with a homograft and a patch of the pulmonary artery aneurysm that was also found at that time. Additionally, the patient had further sternal debridement as well as an omental flap brought up to the sternal space at that time. An attempt at skin closure was unsuccessful. The patient did well following this surgery and on the [12-2], he was found to have a DVT of his left upper extremity including the common femoral vein to the popliteal vein. He returned to the operating room at that time and had an IVC filter placed. On the [12-3], the patient again returned to the operating room where he underwent further washout of his thoracic cavity, additional sternal debridement and a redo of his omental flap. The patient again arrested on [11-4], following acute exsanguination from his chest which was open at the time, however, the omental flap was taken down, was placed on ECMO in the cardiac surgery intensive care unit, then brought to the operating room where he was put on bypass and he had a repair of his aortic homograft where it was found that he had dehisced 1 of his suture line. Additional pledgets were also placed in the pulmonary artery aneurysm suture lines. The patient tolerated this and returned to the cardiac surgery intensive care unit. The patient then had a period of about 2 weeks that were uneventful. On the [11-19], he was again brought to the operating room for an attempt at sternal closure with a pectoral flap advancement, however, the closure was aborted due to the size of the sternal wound and a VAX dressing was placed at that time. Additionally, during that trip to the operating room, the patient had an abdominal wound debridement and reclosure of the skin. On [11-20], the patient again returned to the operating room where he underwent a tracheostomy. The patient again did well in the postoperative period, however, on the [11-26], it was noted that the patient had diffuse open lesions and dermatology consult was obtained at which time the patient was diagnosed with a disseminated zoster which was treated with acyclovir. From an operative standpoint, the patient continued to make progress and do well. An endocrine consult was obtained on the [12-11] because the patient was having a hard time coming off low dose Neo-Synephrine drip. At that time, he was diagnosed as being hypothyroid and started on Synthroid. On [12-21], the patient returned to the operating room to have a tunnel line dialysis catheter placed and on the [12-28], the patient had a PICC line placed. The patient has continued to make good progress throughout the last several weeks to the point where we now feel is stable and ready to be transferred to rehabilitation. On a systems basis, the patient's status is as follows: Neurologically, the patient has had periods of metabolic encephalopathy during which he was unresponsive. However, at the current time, he is alert and oriented, very interactive and responsive, moves all extremities, follows commands, and answers questions appropriately with Passy-Muir valve in place. Respiratory status, the patient has had a tracheostomy which was performed on [11-20]. Currently he has a #8 [Doctor Last Name 4726]-Tex tracheostomy. He is tolerating long periods of trach collar during the day with minimal pressor support, in the nighttime 40%, 5 of PEEP and 5 of pressor support at night, trach collar 40% during the day, maintaining O2 saturations of 96% to 99%. His breath sounds are somewhat coarse especially in the right upper lobes. His most recent chest x-ray shows no infiltrates with a small right effusion. Cardiac status, status post multiple aortic surgeries with the last surgery being an attempt at sternal closure and that was done on [11-19], following which his sternal wound was left with an omental flap and a VAX dressing to allow for secondary closure. The patient has an aortic homograft which was finally implanted on [10-29]. Abdomen, the patient had an exploratory laparotomy which was initially done [10-7]. He also had several abdominal washouts and ultimately had his abdomen closed on [10-19] with additional debridement and skin closure on [11-19]. The patient also had a G-J tube placed and a cholecystectomy done on [10-19]. Currently, the patient is receiving tube feeds through his G-J tube and his abdomen is soft. He has active bowel sounds and his suture line is healing well. He has no sutures remaining in place. Renal status, the patient remains hemodialysis dependent on a Monday, Wednesday, Friday schedule. His most recent BUN and creatinine are 57 and 2.7 with a sodium of 143 and a potassium of 4.1. He has a tunnel catheter in his left internal jugular. It was placed on [12-31]. From an infectious disease standpoint, the patient's last white blood cell count is 6.6. His blood cultures from the [12-31] are pending. His urine culture from the [1-5] is negative. Blood cultures from the 17th are no growth to date. Sputum from the 17th shows pseudomonas swab from his chest. From the [12-28] is positive for pseudomonas sensitive to Colistin. Infectious disease recommendations with duration of antibiotic treatment will be done prior to discharge to rehabilitation. He is currently being treated with caspofungin 50 mg q.24hours, vancomycin 750 mg p.r.n. when the level was less than 15, tobramycin 90 mg daily on days of hemodialysis only. From an endocrine standpoint, the patient had thyroid functions repeated on the [1-7]. At that time, his TSH was 9.6 with a T4 of 7.7, T3 of 100, T uptake of 1.28, T4 index of 9.9 and free T4 of 1.6. Recommendation of endocrine at this time is to continue levothyroxine at 50 mcg IV daily or if it is to be changed to p.o., the patient would need to have his tube feeds held for several hours prior to and following his dose of levothyroxine. From extremities and skin perspective, the patient continues to have 2+ edema bilaterally. He has pneumo boots for DVT prophylaxis. He has a sacral decubitus which is being treated with Accuzyme and DuoDerm. He has a chest wound that continues to have a VAX dressing to it which is changed q.3days. There is good granulation tissue underneath the VAX dressing. The last change as of this dictation is on [1-8]. It is to be continued until chest closure is attained. The patient's physical exam at the time of dictation: Vitals: Temperature 99.9, heart rate 114, sinus tach, blood pressure 100/60, respiratory rate 34 on trach collar of 40%, saturation is 100%. General: Chronically ill appearing man in no acute distress. Neurologically, alert, responsive, follows commands. Pulmonary are somewhat coarse bilaterally. Cardiac: Open chest with VAX in place, regular rate and rhythm, somewhat tachycardic. Abdomen soft, nontender, nondistended with positive bowel sounds and G tube in place with no erythema or drainage from G tube site. Extremities are warm with 1-2+ edema bilaterally. Lab data: White count 6.6, hematocrit 25.5, platelets 218,000. Sodium 143, potassium 4.1, chloride 101, CO2 of 25, BUN 57, creatinine 2.7, glucose 92. Th[Last Name (STitle) 1050] is to be discharged to an extended care facility. He is to have follow-up with the infectious disease department here at [Hospital1 ] [Hospital1 ] in [2-23] weeks, follow-up with Dr. [Last Name (Prefixes) ] 4 weeks after his discharge from rehabilitation, follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 3-4 weeks after his discharge from rehabilitation, and follow-up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1159] 3-4 weeks following his discharge from rehabilitation. DISCHARGE DIAGNOSES: 1. Aortic valve endocarditis, status post homograft with an aortic valve replacement and repair of pulmonary artery aneurysm, status post sternal debridement with an omental flap and VAX dressing placement. 2. Status post exploratory laparotomy as well as cholecystectomy and a G-J tube placement. 3. Left lower lobe extremity deep venous thrombosis, status post inferior vena cava filter placement, 4. Status post tracheostomy. 4. Acute renal failure, status post placement of tunnel line hemodialysis catheter. 5. Hypothyroidism. 6. Thrombocytopenia due to treatment with Zosyn. 7. Status post episode of disseminated zoster. 8. Past medical history includes asthma. DISCHARGE MEDICATIONS: 1. Zinc sulfate 220 mg daily. 2. Flovent 2 puffs b.i.d. 3. Bisacodyl 10 mg p.r.n. 4. Combivent 2-4 puffs q.4hours p.r.n. 5. Accuzyme ointment 1 application daily to his sacral wound. 6. Darvocet N-100 one tablet q.6hours p.r.n. for pain. 7. Calcium acetate 667 mg 2 tablets t.i.d. with meals. 8. Caspofungin 50 mg q.24hours. 9. Pantoprazole 40 mg q.24hours. 10.Vancomycin 750 mg whenever the random level is less than 15. 1. Levothyroxine 50 mcg daily. 2. Tobramycin 90 mg daily. 3. Benadryl 50 mg at bedtime p.r.n. The patient's tube feeds are Nepro at 65 cc per hour. As stated, an addendum will be dictated prior to discharge to update infectious disease recommendations. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2193-1-8] 17:54:10 T: [2193-1-8] 20:58:00 Job#: [Job Number 62287] Name: [Known lastname ],[Known firstname ] Unit No: [Numeric Identifier 11200] Admission Date: [2192-9-6] Discharge Date: [2193-2-7] Date of Birth: [2143-6-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 674] Addendum: Since previous summary, pt. developed fever to 104. After multiple repeat cultures, CT scans, and removal of central lines, it was felt that the fevers were due to Colistin which was subsequently discontinued. He went to the OR on [2193-1-31] for placement of a new tunnelled dialysis catheter. He had a new PICC line placed. He again had hypotension requiring neosynephrine IV gtt, which has been discontinued. He has remained off pressors now for more than 3 days, and is ready for transfer to rehab. His dialysis need is being assessed on a daily basis as he has begun to produce more urine. He was dialyzed on [2192-2-6]. His vancomycin and tobramycin continue to be dossed by level. He is getting MeSalt dressings to his sacral ulcer daily. Major Surgical or Invasive Procedure: Several Aortic surgeries, sternal debribement/omental flap Ex Lap w/CCY-GJ tube placement IVC filter placement Tracheostomy HD catheter line placement Pertinent Results: Discharge Disposition: Extended Care Facility: [Hospital1 ] / [Location (un) 42] [Doctor Last Name ] [Last Name (Prefixes) ] MD [MD Number(1) 681] Completed by:[2193-2-7]	[ "584.5", "053.79", "112.5", "427.5", "038.11", "707.03", "996.71", "453.8", "518.84", "417.8", "422.92", "570", "441.1", "482.1", "348.31", "287.5", "575.11", "557.0", "286.9", "420.99", "996.61", "998.59", "995.92", "421.0", "785.51", "998.11", "997.1" ]	icd9cm	[ [ [] ] ]	[ "37.12", "34.79", "38.45", "35.21", "77.61", "03.31", "39.95", "35.11", "50.11", "51.22", "38.95", "54.11", "39.65", "43.19", "39.56", "39.31", "54.72", "96.6", "38.7", "39.61", "31.1", "34.3", "33.24" ]	icd9pcs	[ [ [] ] ]	16896, 17099		16699, 16852		16873, 16873		1195, 1272	13835, 14541	14564, 16661																										2159, 13814											151, 407														436, 1066													1089, 1178	1289, 2136
80,547	140,247	8003	Discharge summary	report	Admission Date: [2178-11-1] Discharge Date: [2178-12-2] Date of Birth: [2112-1-23] Sex: M Service: SURGERY Allergies: Mercaptopurine Attending:[First Name3 (LF) 1384] Chief Complaint: ESLD, ESRD on HD Major Surgical or Invasive Procedure: [2178-11-1]: Piggyback liver [Month/Day/Year ] with removal of the portal stent and duct-to-duct hepaticojejunostomy. [2178-11-1]: Cadaveric renal [Month/Day/Year ] left kidney to right iliac fossa. [2178-11-6]: Liver Biopsy 11/9/10L ERCP with pancreatinc and biliary stent placement [2178-11-11]: Kidney biopsy [2178-11-11]: Arteriogram with 6x18 mm Stent to Hepatic artery [2178-11-17]: ERCP: Pancreatic stent removal [2178-11-30]: Tunneled dialysis line placement [2178-12-1]: ERCP 2 biliary stents to Common bile duct (previous had migrated) [2178-12-1]: PICC line placement History of Present Illness: Mr. [Known lastname 28650] is a 66 year-old man with a history of nonalcoholic steatohepatitis complicated by cirrhosis with a prior MELD score of 18. He is status post TIPS procedure after decompensation [12-9] [4-10]. He is currently listed for [Month/Year (2) ] at [Hospital1 18]. This summer, the patient had a routine URI which resulted in ESRD secondary to post-streptococcus glomerulonephritis. He is on HD M/W/F. He was subsequently listed for a kidney [Hospital1 ]. Today, Mr. [Known lastname 28650] was offered a liver and kidney and was admitted in anticipation for transplantation. He has been healthy since his most recent admission to the hospital. He mentioned that he did have a tooth pulled for a cavity 2 days ago. He is not on any antibiotics. ROS: The patient denies: weight changes, fevers/chills, chest pain, SOB, cough, recent illnesses or hospitalizations, sick contacts, new skin lesions/rashes, dysuria, nausea/vomiting. Lactulose gives him diarrhea at baseline. Past Medical History: - NASH cirrhosis - diagnosed by biopsy in [2168], c/b ascites, s/p TIPS [2176-12-3] and redo [4-/2177] and s/p ablation of three grade I esophageal varices -[2178-11-1] Piggyback liver [Month/Day/Year ] with removal of the portal stent and duct-to-duct hepaticojejunostomy. - Ulcerative colitis diagnosed in [2176] - HTN - IDDM - S/p tonsillectomy - [2178]: ESRD secondary to post-streptococcal glomerulonephritis -[2178-11-1] Cadaveric renal [Month/Day/Year ] left kidney to right iliac fossa. Social History: Lives alone, wife died in [2168]. Smoked for 33 yrs X 1ppd and quit in [2160]. Does not drink alcohol, no drugs. He has two daughters who visit him frequently. Retired in [1-/2177], formerly a vice president in manufacturing. Family History: HTN, Pancreatic CA. Physical Exam: VS T 97.1 HR 62 BP 179/74 RR 26 SAT 97%RA Gen: A and O x 3, NAD. WDWN Card: RRR no m/r/g/c Pulm: CTA B. Decreased breathsounds in the bilateral bases Abd: Soft, non-tender, non-distended. No HSM. No masses Ext: venous stasis changes. Palpable PT/DP, popliteal, femoral pulses bilaterally. Palpable radial and brachial pulses bilaterally. Pertinent Results: At Admission:[2178-11-1] WBC-3.2* RBC-3.63* Hgb-11.9* Hct-36.0* MCV-99* MCH-32.7* MCHC-33.0 RDW-16.4* Plt Ct-50* PT-16.9* PTT-29.6 INR(PT)-1.5* Glucose-291* UreaN-28* Creat-4.0* Na-138 K-4.3 Cl-101 HCO3-31 AnGap-10 ALT-18 AST-35 AlkPhos-117 TotBili-2.0* Albumin-3.2* Calcium-8.5 Phos-4.9# Mg-3.0 Glucose-146* Lactate-1.5 Na-136 K-4.0 Cl-102 [2178-11-17] calTIBC-260 Ferritn-4327* TRF-200 [2178-11-20] PTH-59 [2178-11-24] PT-14.6* PTT-24.5 INR(PT)-1.3* [2178-11-24] Glucose-67* UreaN-46* Creat-4.8# Na-133 K-4.7 Cl-93 HCO3-24 AnGap-21* [2178-11-24] ALT-107* AST-97* AlkPhos-812* TotBili-23.3* [2178-11-23] Albumin-2.7* Calcium-8.6 Phos-2.8 Mg-2.3 At Discharge: [2178-12-2] WBC-4.3 RBC-2.89* Hgb-8.7* Hct-26.9* MCV-93 MCH-30.1 MCHC-32.4 RDW-21.0* Plt Ct-172 PT-14.3* PTT-22.7 INR(PT)-1.2* Glucose-147* UreaN-45* Creat-5.0* Na-134 K-3.7 Cl-96 HCO3-26 AnGap-16 ALT-70* AST-46* AlkPhos-528* Amylase-174* TotBili-6.9* Calcium-8.7 Phos-6.3* Mg-2.1 [2178-12-1] tacroFK-8.4 Brief Hospital Course: On [2178-11-1], he underwent piggyback liver [Date Range ] with removal of the portal stent and duct-to-duct hepaticojejunostomy and cadaveric renal [Date Range ] left kidney to right iliac fossa. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. A ureteral stent was placed as well as 2 drains around the liver and 1 drain around the kidney [Last Name (NamePattern1) ]. Postop, he was sent to the SICU intubated for management. LFTs increased and creatinine remained the same. Urine output was 190-240cc/day range. Liver duplex demonstrated patent vasculare flow. Renal duplex vasculature was patent and normal. He was weaned and extubated. Diet was slowly advanced. He was transferred out of the SICU on psopt day 4. LFTs continued to increase. Liver duplex on [11-5] demonstrated patent and normal venous/arterial flow. A liver biopsy was performed on [11-6] noting mild to focally moderate Zone 3 cholestasis with focal feathery degeneration of hepatocytes, consistent with preservation/reperfusion injury. On [11-9], repeat liver duplex showed patent hepatic vasculature. No biliary dilatation and no collections were identified. Splenomegaly was noted. An ERCP was performed on [11-10]. Findings were as follows: 1. No anastomotic stricture. 2. Diffuse beaded contour of intrahepatic ducts. Diagnostic considerations include changes related to arterial ischemia or primary sclerosing cholangitis. 3. Removal of sludge-like filling defect. On [11-11], IR performed the following: Celiac axis, SMA, and common hepatic artery arteriograms demonstrating common hepatic artery (70% plus) stenosis of the common hepatic artery, possibly at the point of anastomosis. Placement of 6 mm x 18 mm balloon-expandable stent within the common hepatic artery and deployment of 6 French Angio-Seal device to the left common femoral artery access point. He was on IV heparin for 24 hours then was started on ASA and plavix. Renal function did not improve. Dialysis was initiated via a right IJ line. A renal biopsy was performed on [11-11] showing considerable donor chronic vascular changes and some of the findings raise the possibility of (donor) diabetic nephropathy. Hemodialysis was continued. Given poor graft function, he was relisted for liver and kidney [Month/Year (2) ]. During the remainder of hospital course, he was dialyzed. Drains were removed. Diet was tolerated. [Last Name (un) ] was following throughout for blood sugar management. On [2178-11-17] he had another ERCP for Pancreatic stent removal. On [11-23] his WBC was noted to be going up, and blood cultures were sent. He was never febrile. The blood cultures came back postive for VRE, and although he was initially started on Vanco, he was changed to Daptomycin quickly once the culture data was returned. He will continue the daptomycin through [12-10]. Subsequent blood cultures were taken daily, and none have been positive since [11-26]. Final cultures should be followed up as an outpatient. Once the cultures had cleared, on [2178-11-30] a tunneled dialysis line placement was done for patient to receive outpatient hemodialysis. On [2178-12-1] because alk phos and bilirubin remained significantly elevated, he underwent another ERCP, the previous stent was noted to have migrated, so 2 biliary stents to the Common bile duct were placed. On the same day he also had PICC line placement for home antibiotic therapy to be completed [12-10]. Medications on Admission: Albuterol neb q6h prn, Amlodipine 10, Balsalazide 1.5g"', Avodart 0.5, Ergocalciferol qthurs, Clotrimazole 10"", Advair 250-50", Lactulose 20 g"", Rifaximin 400"', Ursodiol 300", Ascorbic 250", Calcium 500", Vitamin D 400, Multivitamin, Ferrous Sulfate 300", Propranolol 40", Sevelamer HCl 800"', Lisinopril 5, Nephrocaps 1 Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,FR). 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 6. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO four times a day. 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:2 11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 15. rifaximin 200 mg Tablet Sig: Three (3) Tablet PO twice a day. 16. Novolog 100 unit/mL Solution Sig: follow printed sliding scale Subcutaneous four times a day. 17. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 18. daptomycin 500 mg Recon Soln Sig: Eight Hundred (800) mg Intravenous Q48H (every 48 hours) for 4 doses: give after dialysis on [12-4] then [12-6] at home, and [12-10] at home. Disp:3 doses Refills:0 19. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): started [12-1]. 20. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 21. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: esrd nash cirrhosis DM s/p liver/kidney [Month/Year (2) ] extensive kidney donor disease Hepatic artery stenosis with ischemic liver disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the [Month/Year (2) 1326] Office [Telephone/Fax (1) 673] if you have any of the warning signs: fever, chills, nausea, vomiting, increased jaundice, increased abdominal pain/bloating, incision redness/drainage, confusion, shortness of breath or increased fluid retention You will need to have lab work every Monday and Thursday (starting [12-3]) at Quest Lab in [Location (un) 8973]. Do not take your Prograf on those mornings until your labwork is done. Resume hemodialysis at [Location (un) 8973] Kidney Center on [Location (un) 2974] [12-4] You will have a repeat ERCP on Tues [12-8] at the [Hospital Ward Name 516]. Do not eat anything that morning. No heavy lifting No driving until notified you may do so. Daptomycin, IV antibiotic will be given at dialysis on [Hospital Ward Name 2974] [12-4], you will have the medication at home on Sunday [12-6], on Tuesday while you are here for ERCP you will receive a dose, and then on Thursday [12-10] you will have your last dose of Daptomycin at home. Followup Instructions: You will receive a call re: time to come to [Hospital1 18] on [12-8] for repeat ERCP, which is at the [Hospital Ward Name 516], [Location (un) ] [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] CENTER (NHB) Phone:[Telephone/Fax (1) 673] Date/Time:[2178-12-10] 9:30 [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2178-12-10] 10:00 DR. [First Name (STitle) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 3752] Date/Time:[2178-12-17] 8:30 Completed by:[2178-12-2]	[ "041.04", "V45.11", "403.91", "285.9", "556.9", "571.5", "996.81", "585.6", "V09.80", "790.7", "996.82", "250.00" ]	icd9cm	[ [ [] ] ]	[ "39.79", "38.95", "00.93", "38.93", "50.59", "50.11", "51.87", "52.93", "51.10", "39.95", "55.69", "55.23", "97.56", "88.47" ]	icd9pcs	[ [ [] ] ]	10055, 10111	4222, 7758	292, 917	10300, 10300	3192, 3870	11539, 12195	2794, 2815		8133, 10032		10132, 10279		7784, 8110			10451, 11516								2830, 3173													3884, 4199									235, 254														945, 1965								10315, 10427					1987, 2522	2538, 2778
5,771	128,201	60	Discharge summary	report	Admission Date: [2173-7-24] Discharge Date: [2173-7-28] Date of Birth: [2095-6-20] Sex: M Service: MEDICINE Allergies: Cozaar Attending:[First Name3 (LF) 678] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: 78 year old male with a past medical history significant for DM, HTN, atrial fibrillation on coumadin, hx tachy-brady s/p pacemaker, ESRD on HD s/p recent ex-lap 2 for small bowel obstruction night prior to admission BRBPR with INR 2.7, HCT 28 at rehab. In the ED, T 98.3 HR 64 BP 96/44 RR 16 O2 sat: 100%. Two large bloody bowel movements 1 hour apart for which patient recieved 2 units packed rbc, 2 unit FFP, vit K 10 mg IV, Factor 9. Patient is negative NG lavage, then NG tube was removed. Patient seen by surgery who felt likely due to diverticular bleed. GI is aware and will evaluate once in the unit. Patient came in with triple lumen, and an 18 gauge was placed. EKG with ST depressions lateral leads with elevated troponin. Cardiology reviewed EKG and did not feel acute cardiac issue. Most recent vitals T 97.2 P 60 BP 150/42 R 14 O2 sat 100% on 2LNC. Upon arrival to the intensive care unit. Patient reports no further episodes of BRBPR. Patient endorses tender abdomen with any touch, but painless at rest. Patient is very hungry but reports he has been eating only small amounts at rehab. Patient reports cough productive of brown/red sputum since NG tube placement for SBO. Patient was lightheaded this AM, but that resolved with the transfusions. Review of systems: (+) Per HPI (-) Denies fever, chills, headache, sinus tenderness, rhinorrhea or congestion, shortness of breath, chest pain or tightness, palpitations. Denied nausea, vomiting, constipation. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias Past Medical History: - DM - HTN - Dyslipidemia - Bilateral cataracts - ESRD on dialysis MWF - Atrial flutter/atrial fibrillation s/p ablation. - s/p pacemaker placement with history of tachy-brady syndrome - Prostate cancer, diagnosed 12 years ago s/p orchietctomy and hormone therapy - Renal cell cancer, - Secondary hyperparathyroidism - TIA w/ ? seizure approx 5 yrs ago and this prompted coumadin initiation PSH: s/p pacemaker, s/p cataracts, s/p R. nephrectomy '[46], s/p b/l orchiectomy'[61], s/p LOA '[62], s/p ORIF R. bimalleolar ankle fracture '[63], s/p creation L. AV graft '[63], Repair of left arm AV graft pseudoaneurysm '[68], s/p Left forearm loop arteriovenous graft thrombectomy '[68], s/p revision AV graft '[70], s/p Thrombectomy and balloon angioplasty '[71] s/p exlap/LOA [6-24] Social History: Retired foundry worker who lives at home in [Location (un) 669] with his wife. Stopped smoking cigarettes over 20 years ago, smoked intermittently for years before that, but has difficulty quantifying use. Has not had alcohol in over 20 years, drinking only socially prior to that time. Denies a history of drug use. Family History: Family History: States that his siblings are healthy, but unsure on health of other family members Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD 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, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Exam on D/C: T 98.1 HR 86 BP 148/62 98% RA HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Pulm- CTA bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2173-7-24] 09:35AM WBC-7.3 RBC-2.89 HGB-8.4* HCT-27.6* MCV-95 MCH-29.1 MCHC-30.5* RDW-16.0* [2173-7-24] 09:35AM NEUTS-84.3* LYMPHS-9.0* MONOS-4.6 EOS-2.0 BASOS-0.1 [2173-7-24] 09:35AM PLT COUNT-209 [2173-7-24] 07:00AM GLUCOSE-92 UREA N-28* CREAT-4.6* SODIUM-137 POTASSIUM-6.0* CHLORIDE-99 TOTAL CO2-26 ANION GAP-18 [2173-7-24] 07:00AM ALT(SGPT)-11 AST(SGOT)-44* CK(CPK)-54 ALK PHOS-92 TOT BILI-0.5 [2173-7-24] 07:00AM LIPASE-405* Labs at discharge [2173-7-28]: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 6.4 3.29* 9.6* 30.3* 92 29.0 31.6 16.2* 168 Glucose UreaN Creat Na K Cl HCO3 AnGap 82 30* 5.5* 141 4.1 105 25 15 Calcium Phos Mg 8.7 5.2* 1.7 [2173-7-25] CT abdomen 1. No evidence of retroperitoneal hematoma. 2. Small bilateral pleural effusions, right greater than left, with adjacent basilar atelectasis. 3. 1.4 cm soft tissue density which appears to be contiguous with the transverse colon and may represent an inflamed diverticulum with a small amount of stranding adjacent to it. 4. Extensive atherosclerotic disease of the descending aorta and branch vessels. GI BLEEDING STUDY: INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[Age over 90 ]m, blood flow and dynamic images of the abdomen for 90 minutes were obtained. The patient was again imaged dynamically for 20 one minute images at 9 hours after the original injection. Left lateral views of the pelvis were also obtained. at one hour, 90 minutes and at 9 hours after injection. Blood flow images show tortuosity of the aorta, but no bleeding site. Dynamic images show no active bleeding site, however left lateral images show activity in the region of the rectum which appears to change its configuration on each lateral view, suggesting a rectal bleeding site Brief Hospital Course: 78 year old male with a past medical history significant for DM, HTN, atrial fibrillation on coumadin, hx tachy-brady s/p pacemaker, ESRD on HD status post recent exploratory laparotomy for small bowel obstruction admitted with lower GI bleed. . Lower GI Bleed: The patient had two large bowel movements consistent with hematochezia at presentation. Patient had known diverticular disease; nasogastric lavage was negative in the ED, and an upper GI bleed was thought to be less likely. Patient was receiving warfarin at rehab center prior to presentation; all anti-coagulation was held after admission. The patient initially was managed in the medical ICU, and received a total of 6 units of packed red blood cells. His hematocrit trended from 25.5 to 30.8, which was at his baseline. Gastroenterology evaluated the patient. Given his history of diverticulosis from a [2167] colonoscopy and recent exploratory surgery for a small bowel obstruction, urgent colonoscopy was deferred, as the patient was improving with conservative management. After the transfusions, the patient remained hemodynamically stable, and was transferred from the ICU to the floor on [2173-7-26]. Following transfer, the patient had two very small episodes of hematochezia, without hemodynamic compromise. Anti-coagulation continued to be held. The patient remained stable on the floor, without any recurrence of hematochezia. The patient will have a colonoscopy within the next two weeks by Dr. [First Name (STitle) 679], who is his gastroenterologist. . Diabetes Mellitus - The patient was managed with sliding scale humalog during his course with good glycemic control. . History of atrial fibrillation, status post ablation; history of tachy-brady syndrome status post pacemaker placement: Warfarin, aspirin and beta-blockade was held in the setting of the lower GI bleed. Amiodarone was continued. This regimen was continued upon discharge to [Hospital 671] rehab. The rehab center will contact the patient's PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216], in one week to decide when to restart anti-coagulation. . Hypertension- Metoprolol was restarted upon discharge to Radius. . Dyslipidemia: Simvastatin was continued during his hospitalization. . End stage renal disease on dialysis every Monday, Wednesday, Friday: The patient's hemodialysis schedule was continued during his hospitalization. Nephrocaps, renagel, and darbopoetin were also continued. The patient will remain on this schedule after discharge. . Secondary hyperparathyroidism: Cinacelcet and Zampler were continued. . Of note, the patient received a brief course of meropenem given history of drug-resistant urinary tract infections. This was stopped after a urine culture was negative. FEN- The patient was initially kept fasting, and liquids and a regular diet was gradually re-introduced without complication. . Prophylaxis: pneumoboots, ppi . Access: A left subclavian central line that had been placed during prior admission on [2173-7-16] was removed on [2173-7-28] prior to discharge. . Code: FULL . Communication: Patient, patient's wife, [Name (NI) ], and daughter [Name (NI) 680] phone for both: [Telephone/Fax (1) 681] . Disposition: to [Hospital 671] rehab Medications on Admission: Amiodarone [Cordarone] 100 mg daily B Complex-Vitamin C-Folic Acid [Renal Caps] 1mg daily Cinacalcet [Sensipar] 30 mg Tablet daily Hydralazine 25 mg Tablet TID Lanthanum [FOSRENOL] 1,000 mg Tablet, Chewable daily Metoprolol Tartrate 25 mg Tablet [Hospital1 ] Nifedipine 30 mg Tablet Sustained Release daily Ranitidine HCl [Zantac] 150 mg Tablet [Hospital1 ] Simvastatin 20 mg Tablet daily Sitagliptin [Januvia]25 mg Tablet daily Warfarin 2 mg Tablet 2 to 3 Tablet(s) by mouth daily as dir Aspirin 81 mg Tablet daily Discharge Medications: 1. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aranesp (Polysorbate) 40 mcg/mL Solution Sig: One (1) Injection once a week: every Friday. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. 9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. insulin sliding scale please see attached insulin sliding scale 11. Zemplar 2 mcg/mL Solution Sig: Two (2) mcg Intravenous qMWF with dialysis. Discharge Disposition: Expired Facility: [Hospital3 672] Hospital Discharge Diagnosis: Primary Diagnosis: Lower gastrointestinal bleed, likely secondary to diverticulosis Secondary Diagnoses: - diabetes mellitus - hypertension - Dyslipidemia - Bilateral cataracts - end stage renal disease on dialysis MWF - Atrial flutter/atrial fibrillation s/p ablation. - s/p pacemaker placement with history of tachy-brady syndrome - Prostate cancer, diagnosed 12 years ago s/p orchietctomy and hormone therapy - Renal cell cancer - Secondary hyperparathyroidism - transient ischemic attack with possible seizure approx 5 yrs ago and this prompted coumadin initiation PSH: s/p pacemaker s/p Right nephrectomy '[46] s/p bilateral orchiectomy'[61] s/p lysis of adhesions '[62] s/p open reduction internal fixation Right bimalleolar ankle fracture '[63] s/p creation Left arteriovenous graft '[63], Repair of left arm AV graft pseudoaneurysm '[68] s/p Left forearm loop arteriovenous graft thrombectomy '[68] s/p revision AV graft '[70] s/p Thrombectomy and balloon angioplasty '[71] s/p exlap/LOA [6-24] for small bowel obstruction Discharge Condition: stable, improved, baseline hematocrit, no evidence of active GI bleed Discharge Instructions: You were admitted after experiencing bloody bowel movements. In the Emergency Department, you started receiving blood transfusions. You were evaluated by both the surgeons and gastrointestinal physicians, and it was decided to continue to treat you with medications and transfusions, and not to do any procedures. You first received care in the ICU, where you slowly started to respond to treatment. You continued receiving your regular Monday, Wednesday, and Friday dialysis while in the hospital. You continued to improve, and you were transferred from the ICU to the general medical floor. It was decided to wait another 2-4 weeks to do a colonoscopy to look for the source of your bleeding, as you recently had surgery. You continued to do well on the floor, and did not need any more transfusions. You were discharged on [2173-7-28] to [Hospital 671] Rehab Center, and will follow up with your GI physician, [Last Name (NamePattern4) ]. [First Name (STitle) 679], see below for details. Thank you for allowing us to participate in your care. The following changes were made to your medications: - Your blood thinner medications were held in the hospital. Please don't take coumadin until Dr. [First Name (STitle) 216], your PCP, [Name10 (NameIs) ] to the physicians at [Hospital 671] rehab. - No medications were added to your regimen. Please see below for follow up appointments. Please call your PCP [Last Name (NamePattern4) ] 911 if you experience more bloody bowel movements, lightheadedness, abdominal pain, chest pain, shortness of breath, or any other concerning medical symptoms. Followup Instructions: *Please call the patient's PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216], on [2173-8-4], to discuss restarting coumadin. His anti-coagulation will be held until then. Please call [Telephone/Fax (1) 682] when patient arrives. This is Dr. [Name (NI) 683] office, his gastroenterologist. They will be able to set up a follow-up colonoscopy on [2173-8-11]. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684*]	[ "427.32", "427.31", "272.4", "V10.52", "V45.01", "403.91", "585.6", "285.1", "562.12" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	10813, 10862	5994, 9337	294, 301	11979, 12051	4090, 5971	13737, 14270	3105, 3190		9912, 10790		10883, 10883		9363, 9889			12075, 13714								3205, 4071	10990, 11958																	1616, 1887				227, 256														329, 1597						10902, 10969							1909, 2732	2748, 3073
28,492	194,943	33272	Discharge summary	report	Admission Date: [2166-3-21] Discharge Date: [2166-3-31] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 783] Chief Complaint: fall, facial fractures, hypertensive urgency Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 83-year-old man with PMH of HTN, BPH and Alzheimer's who presented following a witnessed fall from standing at [Hospital3 ] facility at 2:15 pm today. Initially presented to OSH complaining of R eye pain and decreased vision. Per chart the patient reported that his right leg gave out, however patient currently does not recall events. CT of facial bones demonstrated orbital floor and lateral orbital wall fractures, maxillary sinus fractures, and significantly proptotic right eye so he was transferred to [Hospital1 18] for further management. . In ED patient's vitals were T 97.1 BP 240/108 HR 80 O2 sat not documented. CT confirmed multiple fractures involving the inferior lateral wall of the orbit and the anterior, posterior, medial and lateral wall of the right maxillary sinus. He was evalauted by optho, plastics and trauma. Optho found no retrobulbar hematoma and was concerned for traumatic optic neuropathy and patient was given 60mg solumedrol. Plastics and trauma stated no surgical intervention at this time. BP was significantly elevated and patient was given labetalol 20mg IV x1, labetalol 10 IV x2, Hydral 20IV x2, 4mg morphine and 4m zofran IV. BP came down to 183/70. Patient was also given clinda 600mg IV and transferred to ICU for hypertensive urgency. . On arrival to the ICU the patient appeared comfortable and he denied pain. Could not recall earlier events. Denied CP, SOB, abdominal pain Past Medical History: HTN BPH Alzheimer's Social History: lives in [Location ]. h/o smoking in past, quit few years ago. Occasional EtOH use Family History: unknown Physical Exam: Vitals: T 100.1 99.1 146/64 76 22 94% RA Gen: Pleasant, elderly male, comfortable, NAD HEENT: R orbital/periorbital eccymosis/swelling, Proptosis NECK: Supple, No LAD, No JVD. No thyromegaly, + carotid bruit on R CV: RRR. nl S1, S2, II/VI SEM LUNGS: CTA b/l ABD: Soft, NT, ND. No HSM EXT: No LE edema NEURO: A+O x 2 (knows self and location Pertinent Results: [2166-3-20] 09:05PM BLOOD WBC-11.8* RBC-4.52* Hgb-13.8* Hct-39.1* MCV-87 MCH-30.6 MCHC-35.4* RDW-13.0 Plt Ct-198 [2166-3-31] 04:45AM BLOOD WBC-9.9 RBC-4.19* Hgb-13.0* Hct-37.2* MCV-89 MCH-31.0 MCHC-34.9 RDW-13.6 Plt Ct-270 [2166-3-20] 09:05PM BLOOD Glucose-180* UreaN-15 Creat-0.7 Na-143 K-3.5 Cl-106 HCO3-25 AnGap-16 [2166-3-31] 04:45AM BLOOD Glucose-106* UreaN-25* Creat-0.7 Na-143 K-3.7 Cl-109* HCO3-24 AnGap-14 [2166-3-21] 09:08PM BLOOD ALT-15 AST-21 CK(CPK)-187* AlkPhos-78 TotBili-0.5 [2166-3-20] 09:05PM BLOOD cTropnT-<0.01 [2166-3-21] 02:36PM BLOOD CK-MB-5 cTropnT-<0.01 [2166-3-21] 09:08PM BLOOD CK-MB-5 cTropnT-<0.01 [2166-3-21] 09:08PM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0 [2166-3-21] 09:08PM BLOOD VitB12-336 [2166-3-21] 09:08PM BLOOD TSH-1.1 [2166-3-20] 09:15PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 [2166-3-21] 02:36PM URINE RBC-512* WBC-8* Bacteri-FEW Yeast-NONE Epi-<1 [2166-3-25] 07:59PM URINE CastHy-3* [2166-3-28] 04:33PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.019 [2166-3-28] 04:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG [2166-3-25] 07:59PM URINE RBC-54* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 . [2166-3-28] 4:33 pm URINE Site: CLEAN CATCH Source: CVS. FINAL REPORT [2166-3-31] URINE CULTURE (Final [2166-3-31]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| PSEUDOMONAS AERUGINOSA \| \| AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S . CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [2166-3-21] 12:25 AM CT SINUS/MANDIBLE/MAXILLOFACIA Reason: S/P FALL [Hospital 93] MEDICAL CONDITION: 83 year old man s/p fall with R facial trauma, with R eye pain, proptosis, vision loss REASON FOR THIS EXAMINATION: please do coronal and sagittal reformats to evaluate for R orbital fractures CONTRAINDICATIONS for IV CONTRAST: None. There is also a fracture of the lateral wall of the right orbit. INDICATION: 82-year-old man with fall and right facial trauma and right eye pain, proptosis, and vision loss. No comparison is available. TECHNIQUE: Axial MDCT images of the paranasal sinuses were obtained with no IV contrast administration. Sagittal and coronal reformatted images were then obtained. Anterior, posterior, medial, lateral and superior wall of the right maxillary sinuses are fractured in multiple points. There is a moderate sized hematoma within the right maxillary sinus. The lateral inferior and medial wall of the orbit (lamina papyracea) are also fractured with a resultant orbital hematoma which is abutting the inferior rectus muscle. Intraconal air is also visualized. The right ostiomeatal complex is completely opacified. The left ostiomeatal complex is patent. Mild mucosal thickening of the left maxillary sinus and ethmoid sinuses are noted. Frontal and sphenoid sinuses also show some mucosal thickening. The fovea ethmoidalis is [Last Name (un) 36826] type 2 bilaterally. IMPRESSION: 1. Extensive fracture of the right maxillary sinus walls and the wall of the orbits as described. 2. Intraorbital hematoma and intraconal air are visualized. MR of the orbit is recommended for further characterization of intra- and extra-conal pathologies. NOTE ADDED AT ATTENDING REVIEW: There are several fractures, medially and laterally, of the right orbital floor, but the medial orbital wall appears intact. There is opacification of adjacent ethmoid air cells, in this setting suspicious for fracture, but no fracture is demonstrated on this study. . CT HEAD W/O CONTRAST [2166-3-21] 12:24 AM CT HEAD W/O CONTRAST Reason: S/P FALL [Hospital 93] MEDICAL CONDITION: 83 year old man s/p fall with R facial trauma and loss of vision in R eye REASON FOR THIS EXAMINATION: please rule out ICH CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 83-year-old man with fall and right facial trauma and loss of vision in the right eye. TECHNIQUE: Axial MDCT images of the head were obtained with no IV contrast administration. FINDINGS: No edema, masses, mass effect, hemorrhage or infarction is detected. The ventricles and sulci are mildly prominent consistent with involutional changes. Diffuse periventricular white matter hypodensities are consistent with involutional changes. The bone windows demonstrate multiple fractures involving the inferior orbital rim, inferior lateral wall and of the lateral wall of the orbit and the anterior, posterior, medial and lateral wall of the right maxillary sinus. Intraconal air and hematoma is visualized. The right maxillary sinus is filled with the hematoma. There is also mucosal thickening of the ethmoid sinuses. IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. Extensive fractures involving the right maxillary sinus and right orbit as are completely described in a CT of the sinus. CT HEAD W/O CONTRAST [2166-3-21] 12:24 AM CT HEAD W/O CONTRAST Reason: S/P FALL [Hospital 93] MEDICAL CONDITION: 83 year old man s/p fall with R facial trauma and loss of vision in R eye REASON FOR THIS EXAMINATION: please rule out ICH CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 83-year-old man with fall and right facial trauma and loss of vision in the right eye. TECHNIQUE: Axial MDCT images of the head were obtained with no IV contrast administration. FINDINGS: No edema, masses, mass effect, hemorrhage or infarction is detected. The ventricles and sulci are mildly prominent consistent with involutional changes. Diffuse periventricular white matter hypodensities are consistent with involutional changes. The bone windows demonstrate multiple fractures involving the inferior orbital rim, inferior lateral wall and of the lateral wall of the orbit and the anterior, posterior, medial and lateral wall of the right maxillary sinus. Intraconal air and hematoma is visualized. The right maxillary sinus is filled with the hematoma. There is also mucosal thickening of the ethmoid sinuses. IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. Extensive fractures involving the right maxillary sinus and right orbit as are completely described in a CT of the sinus. . CT C-SPINE W/O CONTRAST [2166-3-21] 12:26 AM CT C-SPINE W/O CONTRAST Reason: S/P FALL [Hospital 93] MEDICAL CONDITION: 83 year old man s/p fall with R facial trauma REASON FOR THIS EXAMINATION: please eval for traumatic injury, repeat per Surgeyr request CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 82-year-old man with fall and right facial trauma. Please evaluate for traumatic injury to the spine. No comparisons available. TECHNIQUE: Axial MDCT images of the cervical spine were obtained with no IV contrast administration. Sagittal and coronal reformatted images were the obtained. FINDINGS: Vertebral body heights are well preserved. No fracture is identified. No paravertebral soft tissue swelling is identified. No malalignment is noted. There is disc space narrowing with spondylotic changes with anterior osteophyte formation at the level of C5-C6 and C4-C5. Mild degree of canal narrowing is also noted at the same level due to uncovertebral joint hypertrophy. Outline of the thecal sac appear to be grossly intact. Please note that the CT does not provide intrathecal details comparable to MRI. The thyroid lobes are very heterogeneous. The visualized portions of the lung apices are normal. The visualized portion of the paranasal sinuses and mastoid air cells are clear. Diffuse soft tissue stranding and hematoma is noted in the right side of the submandibular space most likely related to the patient recent trauma. IMPRESSION: 1. No acute intracervical pathology including no fracture. 2. Diffuse degenerative changes of the cervical spine with a spondylosis at the level of C5-C6. NOTE ADDED AT ATTENDING REVIEW: There is significant spinal canal narrowing at C5-6 due to intervertebral osteophyte formation. This likely encroaches on the spinal cord, but the cord cannot be resolved on non contrast CT. There is extensive soft tissue swelling over the right face and upper neck, perhaps related to the right maxillary sinus posterior walll fracture. The right maxillary sinus is incompletely imaged, but appears opacified. The thyroid nodules may require further evaluation with ultrasound if this has not been done. . CAROTID SERIES COMPLETE PORT [2166-3-21] 2:49 PM CAROTID SERIES COMPLETE PORT Reason: SYNCOPE, RT BRUIT [Hospital 93] MEDICAL CONDITION: 83 year old man with syncope and R sided bruit REASON FOR THIS EXAMINATION: eval for stenosis STUDY: Carotid series complete. REASON: Syncope and right-sided bruit. FINDINGS: Duplex evaluation was performed of bilateral carotid arteries. There is heterogeneous plaque in the proximal ICA bilaterally. On the right, peak velocities are 58, 72, and 99 cm/sec in the ICA, CCA, and ECA respectively. This is consistent with less than 40% stenosis. On the left, peak velocities are 80, 92, and 106 cm/second in the ICA, CCA, and ECA respectively. This is consistent with less than 40% stenosis. There is antegrade vertebral flow bilaterally. IMPRESSION: Bilateral 40% carotid stenosis. . CHEST (PA & LAT) [2166-3-25] 7:18 PM CHEST (PA & LAT) Reason: infiltrate, consolidation [Hospital 93] MEDICAL CONDITION: 83 year old man with agitation. REASON FOR THIS EXAMINATION: infiltrate, consolidation PA AND LATERAL CHEST, [3-25] HISTORY: Agitation. IMPRESSION: AP and lateral chest compared to [3-21]: Lung volumes are low, but no focal pulmonary abnormality is seen. Heart size normal. No pleural effusion or pneumothorax. . MR HEAD W/O CONTRAST [2166-3-26] 12:52 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: stroke, parietal-occipital ischemia [Hospital 93] MEDICAL CONDITION: 83 year old man with dementia, unresponsive episode. REASON FOR THIS EXAMINATION: stroke, parietal-occipital ischemia CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 83-year-old male with Alzheimer's dementia after unresponsive episode with concern for acute infarction. COMPARISON: Non-contrast head CT, [2166-3-24] and [2166-3-21]. TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain without IV gadolinium. Diffusion-weighted images were obtained as well as MR angiogram of the brain and circle of [Location (un) 431] with time-of-flight sequences. MR OF THE BRAIN WITHOUT IV GADOLINIUM: There is no diffusion evidence of acute infarction. There is no shift of normally midline structures, mass effect, or hydrocephalus. Multiple tiny punctate foci of susceptibility artifact, which are superficially located within cerebral sulci and more numerous of the left frontal lobe, appear to correlate to tiny punctate calcifications on non-contrast head CT and probably relate to small vessel vascular calcification. There are no findings suspicious for acute intracranial hemorrhage. Right maxillary and orbital wall fractures are better evaluated on the recent CT of the facial bones. The right maxillary sinus remains opacified with hyperintense material compatible with blood. Hyperintense FLAIR signal abnormality is noted of the periventricular white matter. There are also several small scattered hyperintense FLAIR foci of the subcortical and deep white matter. These findings are consistent with sequelae of chronic microvascular infarction. TIME-OF-FLIGHT MR ANGIOGRAM OF THE BRAIN AND CIRCLE OF [Location (un) ]: The anterior and posterior circulations including circle of [Location (un) 431] are patent. A tiny 2-mm infundibulum is noted at the origin of the left posterior communicating artery. A symmetric tiny 2-mm outpouching of the supraclinoid right internal carotid artery is noted at the expected origin of the right posterior communicating artery, which is not definitely seen. This finding also likely represents a tiny infundibulum. There is no evidence of aneurysm, dissection, vascular malformation, or hemodynamically significant stenosis. IMPRESSION: 1. No evidence of acute infarction. 2. Right orbital and maxillary fractures are better evaluated on recent CT of the facial bones. 3. Normal MRA head. . CHEST (PORTABLE AP) [2166-3-30] 1:36 PM CHEST (PORTABLE AP) Reason: consolidation, infiltrate. [Hospital 93] MEDICAL CONDITION: 83 year old man with Alzheimer's, SOB. REASON FOR THIS EXAMINATION: consolidation, infiltrate. CHEST SINGLE VIEW ON [3-30]. HISTORY: Shortness of breath. REFERENCE EXAM: [3-25]. There is increased opacity at both bases and it is unclear if this is due to volume loss versus early infiltrate. Otherwise, the lungs are clear. Given history, a followup film would be helpful. Brief Hospital Course: 83-year-old man with PMH of HTN, BPH and Alzheimer's who presented following a witnessed fall with multiple facial fractures and hypertensive urgency. . # Facial fractures: has mult. fractures of R orbit and maxillary sinus on CT. Evaluated by optho, plastics and trauma. Treated with high dose prednisone to prevent swelling. He was also treated with clindamycin for 7 days. Right eye was treated with erythromycin ointment for lubrication. It was discontinued once he was able o fully close his eye. Given that he suffered vision loss in his right eye, no surgery was recommended. the patient wa splaced on sinus precautions, and told to avoid blowing his nose. He was treated with standing tylenol for pain. . # Hypertension: Patient treated with only atenolol as an outpatient. Presented with hypertensive urgency 240/80 in the ED. Pressures decreased with IV labetolol and hydralazine. Thought secondary to pain and stress. He was treated with increasing doses of captopril, metoprolol, HCTZ, and hydralazine. His hypertension was exacerbated during periods of agitation. he was treated with haldol and zyprexa for his agitation. His hypertension would resolve, however haldol and zyprexa also caused the patient to become somnolent, and bradycardic. The geriatric service recommended that haldol and zyprexa should be avoided. If treatment for agitation is absolutely necessary, they recommend using zyprexa 1.25mg [Hospital1 ]. The patient received one dose of zyprexa 1.25mg Po and became somnolent. . # s/p fall: unclear whether patient had true syncope vs. mechanical fall. CE neg. x2. EKG without ischemic changes. Neurologically intact. syncope workup did not reveal syncope as a cause for his fall. . #Altered Mental status: The patient developed periods of forgetfulness and periods of delirium, in which he would try to get out of bed, rip out IV's, and have delusions that his wife was still alive. Per the patient's family, the patient is forgetful and needs to be reoriented several times a day. However, they report that delusions regarding his wife are new. It is thought that oxycodone may have contributed to his delirium and should be avoided. he wa salso given zyprexa and haldol for agitation and the patient would become incredibly somnolent with these medications. Even zyprexa doses as low as 1.25mg caused the patient to become somnolent. Zyprexa, haldol, anticholinergics, benzodiazepines, and antihistamines should therefore be avoided. . #UTI: Urine culture from [3-28] was found to be growing pan sensitive e.coli and p. aerugenosa. These bacteria are sensitive to cipro. This urine culture grew these bacteria in the setting of a negative ua. The patient will be treated with ciprofloxacin PO for 7 days. A followup urinalysis and urine culture should be sent after copmpletion of antibiotics. . #Body Rash: Erythemetous rash encompassing the patient's entire back, and body folds was detected on [3-28]. he was evaluated by dermatology, and treated with triamcinolone cream, and sarna lotion. Dermatology believes the rash is related to prolonged bedrest, with sweat and occlusion of the skin. In addition to the lotions, they reccommend frequent body position changes. they also recommend placing absorbant materials such as cotton towels or abd pads underneath the patient to decrease moisture. the topical triamcinolone can be decreased once the patient becomes more ambulatory with fewer time spent lying on his back. . #:Low Urine Output: The patient continued with poor Po intake and had several days of poor urine output. His urine output increased with boluses of normal saline. . # BPH: flomax was continued . # Dementia: aricept was continued. Medications on Admission: Aricept 10mg daily Effexor 250mg [Hospital1 ] Flomax unknown dose Atenolol 25mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [Hospital1 ]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Donepezil 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO HS (at bedtime). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-1] Drops Ophthalmic QID (4 times a day). 5. Acetaminophen 325 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Docusate Sodium 50 mg/5 mL Liquid [Month/Day (2) ]: Two (2) PO BID (2 times a day). 7. Venlafaxine 37.5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 8. Senna 8.6 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Hydrochlorothiazide 12.5 mg Capsule [Last Name (STitle) ]: Two (2) Capsule PO DAILY (Daily). 11. Captopril 25 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO TID (3 times a day). 12. Triamcinolone Acetonide 0.1 % Cream [Last Name (STitle) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 13. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal QAM (once a day (in the morning)). 14. Camphor-Menthol 0.5-0.5 % Lotion [Hospital1 ]: One (1) Appl Topical TID (3 times a day) as needed. 15. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 1.5 Tablets PO TID (3 times a day). 16. Ciprofloxacin 500 mg Tablet [Hospital1 ]: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 17. Outpatient Lab Work Urinalysis, urine culture once patient completes 7 days of antibiotic therapy for UTI. Discharge Disposition: Extended Care Facility: [Location ] manor Discharge Diagnosis: Mechanical Fall facial fractures. Dementia Delirium Hypertensive urgency Discharge Condition: Good. Discharge Instructions: You were admitted to the hospital after sustaining a fall and fracturing bones surrounding your eye, including the maxillary sinus, lateral and inferior orbital walls. You also suffered traumatic optic neuropathy with loss of vision in your right eye. You were also found to have elevated blood pressures. . Please avoid any sedating medications, benzodiazepines, anticholinergics, antihistamines. . Please return to the hospital if you develop difficulty breathing, or chest pain. Followup Instructions: You will need to follow-up with ophthalmology in [1-1] weeks. Please call [Telephone/Fax (1) 253] to arrange for follow-up. . Please follow-up with your PCP [First Name4 (NamePattern1) 3065] [Last Name (NamePattern1) 37933] [Telephone/Fax (1) 26774] within 2 weeks. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "801.01", "293.0", "600.00", "692.9", "401.9", "950.9", "802.6", "921.2", "331.0", "802.8", "599.0", "E885.9", "041.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	21734, 21782	16032, 17766	306, 313	21898, 21906	2336, 4912	22438, 22857	1950, 1959		19885, 21711	15623, 15662	21803, 21877		19770, 19862			21930, 22415								1974, 2317																						222, 268	15691, 16009													342, 1786								17781, 19744					1808, 1830	1846, 1934
1,620	197,959	23157	Discharge summary	report	Admission Date: [2106-12-9] Discharge Date: [2106-12-24] Date of Birth: [2076-7-26] Sex: F Service: MEDICINE Allergies: Compazine / Cefepime Attending:[First Name3 (LF) 6169] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 30 y/o female with a h/o leukemia s/p BMT in [12-7] presenting with shortness of breath. She reports a 3 week history of cough, productive occasionally of white sputum, but that her symptoms of shortness of breath with excertion became acutely worse. She presented to the heme/onc clinic and was found to have desaturations to 70%. In the ED: CXR with interstitial markings on left, CTA performed showed a PE, ground glass process c/w with possible oppotunisitic infection. Febrile to 101.4, she received cefrtriaxone, azithro, heparin gtt. ECG was unremarkable. Past Medical History: AML - s/p allo BMT in [12-7], relapse [6-8], s/p MET (mitoxantrone, etoposide, and cytarabine-MEC) treatment with DLI. Has had tx c/b coag neg. staph bacteremia, mucositis, vaginal bleeding. Relapse [7-8] - had CT scan showing ground glass opacities, was on multiple antibiotics, including fungal and anti-viral agents - discharged with levoflox and fluconazole with improvement. HTN s/p gastric bypass [2104] h/o MRSA, VRE, C Diff s/p line sepsis [2106-3-3] gastric ulcer with UGIB s/p vessel clipping [2106-8-3] Social History: Originally from [Country 3587] but moved to the US when she was 2 yrs old, currently lives in [Doctor Last Name 792]with her husband and daughter, used to work as a [Name (NI) ] and phlebotomist until [9-6]. +Tobacco- ~10pk-yrs, quit 2 yrs ago. Denies EtOH and drugs. Family History: MGM - CLL, mom DM [Name (NI) ], HTN, dad HTN, sister asthma Physical Exam: Per Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] T:98.8 BP:133/60 O2:95% on 100% non-rebreather, 90%sleeping, Gen: Alert, oriented, NAD HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: decreased BS bilaterally. Good air-movement in superior fields ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [1-4]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: 141 I 105 I 12 ---------------< 116 4.1 I 26 I 0.7 . Ca: 8.9 Mg: 1.9 P: 3.2 ALT: 69 AP: 563 Tbili: 0.9 Alb: 3.5 AST: 79 LDH: 322 [Doctor First Name ]: Lip: 33 . 12.7 9.2 >-----< 118 39.1 N:68.5 L:27.1 M:3.5 E:0.5 Bas:0.4 Gran-Ct: 6320 . PT: 11.5 PTT: 23.3 INR: 1.0 D-Dimer: 917 . [2106-12-9]: CTA: 1. Filling defect in the right upper lobe apical segmental pulmonary arterial branch consistent with a pulmonary embolism. 2. Mosaic attenuation in the upper lobes bilaterally could represent air trapping, small airways disease, or alveolitis. Additionally, there are multiple areas of ground-glass opacity predominantly in a bronchovascular distribution in the upper lobes, left worse than right with additional areas that are more peripherally located. This finding is nonspecific, however, given the patient's history, early infectious process including opportunistic infection could be considered. Depending on the degree/nature of the patient's immunocompromised status, pneumocystis jerovici could also be considered. 3. Atelectasis in the lingula and left lower lobe. 4. Nonspecific cluster of nodular opacities in the right lower lobe. . [2106-12-9]: CXR: Resolution of left lower lobe pneumonia. New left-sided pleural effusion, small . [2106-12-11]: CXR: Cardiac silhouette and mediastinum is normal. There is again seen some hazy opacity at the left base which may represent early infiltrate versus atelectasis. There is also a new area of increased density within the left upper lung zone, also concerning for developing infiltrate. The right lung is clear. There is no signs of pulmonary edema. There is a left pleural effusion, which is small. . [2106-12-17]; CXR: 1. Persistent left upper lobe consolidation, most likely infectious. 2. Resolution of left retrocardiac atelectasis. . [2106-12-19]: CXR: Continued left upper lobe infiltrate . [2106-12-20]: CT Chest: 1. Left lower lobe pneumonia has resolved. 2. Generalized increase in multifocal peribronchial infiltration, particularly left upper lobe, could be due to either opportunistic infection, typically viral or pneumocystis, or recurrence of graft versus host disease, less likely hemorrhage, and not fungal or bacterial infection. 3. New pneumomediastinum, presumably related to coughing or bronchospasm in the absence of mediastinal fluid collection or esophageal abnormality. 4. Multifocal air trapping, presumably bronchiolitis obliterans. 5. Anterior extrapleural/chest wall mass or infection, stable since [12-9], new since [6-15]. This lesion should be accessible to transthoracic needle aspiration. . Micro: Blood cultures from [12-9] 12/8 [12-12] 12/11 [12-14] [12-15] negative urine cx [12-9] neg sputum cx neg, PCP negative direct flu antigen negative CMV negative [12-10], pending for [12-21] cryptococcal neg urine legionella negative resp viral antigens negative B Glucan negative histo negative Adenovirus negative galactomannin pending Brief Hospital Course: The patient is a 30 yo woman with h/o AML s/p allo BMT presenting with fever, hypoxia, a small PE and ground-glass opacities on CT scan. Hospital course by problem: . # Respiratory/ID: The patient was admitted from the emergency department to the ICU for evaluation and treatment of her severe hypoxia (70%). She did not require intubation as she had excellent oxygen saturations with non-invasive measures. The source of her hypoxia was not readily identified, but possible contributing etiologies considered were: PCP pneumonia, [Name Initial (PRE) ] known PE seen on CTA, atypical/fungal infection, or GVHD of the lung. She was given broad spectrum antibiotics including vanco, zosyn, azithro and bactrim DS 2 tabs TID. Labs were sent as above. Bronchoscopy was considered but there was concern she would be unable to tolerate it given her poor respiratory status. The infectious diseases team was consulted. She was transitioned to azithro and pip/tazo to complete a 14 day course for unknown opportunistic/atypical organism. Her respiratory status improved and she was transferred to the floor. She was weaned down from 6L O2 and was able to ambulate while on 3L. We discharged the patient with home O2 with goal of O2 sat greater than 92%. We also prescribed nebulizers (albuterol and ipratropium). She will return to the clinic on Sunday (two days after dispo) for O2 monitoring. . # Respiratory/PE: The patient had a small PE on her initial CT angiogram. She was treated with heparin and transitioned to lovenox 90mcg [Hospital1 ]. She was continued on this upon discharge. . # Respiratory/Inflammation: The patient had a followup CT scan after transfer to the floor. It was concerning for bronchiolitis obliterans given the airtrapping. We increased her steroids to 20mg [Hospital1 ] and she continued to improve clinically. We also increased her cellcept prior to discharge. . # AML: s/p BMT and DLI. We did not notice any blasts in her peripheral white blood cells. We continued her cellcept and prednisone for her history of GVH. We also continued the bactrim prophylaxis. We increased the cellcept prior to discharge. We also added acyclovir to her prophylaxis. We did not start vori or fluc given her transaminitis. . # Nodular mass on anterior chest wall: Both of the CT chest scans showed a nodular mass on the anterior chest wall. We discussed this with the radiologist and it was not clearly infectious in etiology. She did not have any tenderness over this region. We did not perform a biopsy of the lesion. It may need followup imaging as an outpatient. . # Nodular mass on right side of back: Patient had a 1cm nontender nodular mass on the right side of her back. It was just deep to an ecchymotic lesion. It was not fluctuant or fixed. We will monitor it during followup visits to see if it requires dermatology evaluation. . # Transaminitis: The patient has a history of GVH of the liver. Her liver enzymes gradually trended upward during her admission. We were concerned that it was secondary to antibiotics. She did not complain of any right upper quadrant or abdominal pain. After discontinuation of the antibiotics, her enzymes trended slightly downward. We wanted to repeat these tests two days after discharge when she returns to clinic. . # CODE: FULL CODE . # COMM: Sister, [Name (NI) 59576]: [Telephone/Fax (1) 59577](home) [Telephone/Fax (1) 59578](work) Medications on Admission: Prednisone 10mg po Qday CellCept 250mg po TID Nitrofurantonin Bactrim 1DS 3 times/week Pantoprazole 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. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:1 bottle Refills:0 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q3H (every 3 hours). Disp:120 nebulizer Refills:2 4. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours) for 6 months. Disp:60 syringes Refills:5 5. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). Disp:60 nebulizers Refills:2 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-4] Sprays Nasal QID (4 times a day) as needed for dryness. Disp:qs qs Refills:0 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:12 Tablet(s) Refills:2 9. home oxygen please treat with home oxygen at 3L with goal O2 saturation of 92%. [Month (only) 116] titrate as needed. 10. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 11. Outpatient Lab Work please return to [Hospital Ward Name ] 7 on Sunday, [12-26] for O2 check, LFTs, CBC, and chemistries. 12. nebulizer please provide pt with nebulizer and all necessary equipment for home nebulizer treatments. 13. O2 saturation check please check O2 saturation daily. Goal is O2 sat>92%. Adjust home O2 requirement accordingly. 14. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 6549] Discharge Diagnosis: Primary: - shortness of breath - bronchiolitis obliterans - pulmonary embolus - AML s/p allo BMT, MEC, and DLI Secondary: - HTN - s/p bariatric surgery - s/p tonsillectomy - hx of MRSA, VRE, C Diff Discharge Condition: fair Discharge Instructions: You were admitted with shortness of breath. We treated you with antibiotics and increased your steroid dosage. You continued to improve and you were stable for discharge. . Please take your medications as instructed. Please followup with Dr. [First Name (STitle) 1557]. Please contact Dr.[Name (NI) 6168] office if you develop worsening shortness of breath, chest pain, abdominal pain, fevers, or chills. Followup Instructions: Please followup with Dr.[Name (NI) 6168] office as scheduled. Please return on [2106-12-26] to [Hospital Ward Name 1826] 7 to have lab work and to assess for breathing function.	[ "205.01", "415.19", "996.85", "786.6", "486", "401.9", "V45.86", "516.8", "E878.0", "799.02" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11006, 11061	5625, 5763	302, 308	11303, 11310	2572, 2572	11775, 11969	1785, 1850		9219, 10983		11082, 11282		9095, 9196			11334, 11752								1865, 2553																						243, 264											5791, 9069			336, 906					2588, 5602								928, 1467	1483, 1769
28,868	145,654	21305	Discharge summary	report	Admission Date: [2141-9-8] Discharge Date: [2141-10-9] Date of Birth: [2094-6-12] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 5790] Chief Complaint: Osteomyelitis and neck abscess Major Surgical or Invasive Procedure: [2141-9-9]: Removal of hardware at C5-C6, redo cervical diskectomy at 5-6, anterior cervical diskectomy at C6-C7, evacuation of paraspinal abscess. Transcervical incision and drainage of prevertebral space abscess. [2141-9-11]: Flexible esophagoscopy and I&D of left neck and supraclavicular fossa. [2141-9-15]: Incision and drainage of left supraclavicular fossa abscess and placement of a 20-French Ponsky PEG tube. [2141-9-29]: CT guidance, an 18-gauge [Last Name (un) 11097] needle was inserted directly into the collection and approximately 6 cc of opaque light red fluid was aspirated and sent for Gram stain and culture. [2141-10-2]: PICC line placement. History of Present Illness: Ms. [Known lastname ] is a 47 year-old woman with h/o C5/6 laminectomy and anterior fusion in [5-/2138], now transferred from [Hospital3 ] for evaluation of abscess. States that she was doing fine neurologically until about one week ago, aside from rare episodes of non-urge, non-stress urinary incontinence over the past few months. Approximately one week ago, she was standing when her legs suddenly became weak bilaterally, and she fell. She does not report any head trauma or other subsequent injury. Since that time, she has noted multiple other symptoms including tactile fevers, shaking chills, throat pain, dysphagia, right sided rib pain, odynophagia, anterior neck pain and swelling. She presented a few days ago to [Hospital3 ]. She had a CXR taken which revealed bilateral lower lobe infiltrates and ?atypical pneumonitis. She was subsequently admitted to the medical service. Subsequent work up included a barium swallow study which, per report, was concerning for a ruptured esophageal diverticulum. CT neck was reportedly normal, but CT chest showed a ring enhancing area anterior to C5-C7 vertebral bodies. Enhancement was noted on MRI C spine as well. She was started on antibiotics while at [Hospital3 ], after she spiked a temperature. She was subsequently transferred to [Hospital1 18] for neurosurgery and ENT evaluation. Past Medical History: 1. C5/C6 laminectomy and anterior fusion 2. ?Esophageal rupture, as above 3. Asthma 4. Status post tonsillectomy Social History: Has two children. Ex-pharmacist. 25 pack year smoker. Rare alcohol use. No drug use. Family History: Non-contributory Physical Exam: On admit: Temp: 101.6 BP: 114/57 HR: 122 RR: 30 Ox: 95%/2L Gen: Ill appearing, tachypneic. HEENT: MM dry. Wearing collar. Left anterior neck soft tissues swollen, painful to palpation. No overt crepitus in supraclavicular regions. ?swelling in posterior pharynx though no exudate, pus. Voice hoarse. No stridor. Neck: Collar, as above. Lungs: Rhonchi in both lower lungs. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Belly button pierced, well-healed. Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam but mildly inattentive. Oriented to person, place, and date. Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. No apraxia, no neglect. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Strength full power [4-15] throughout. +Asterixis. No drift. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. No sensory level anteriorly. Reflexes: Present, normal and symmetric. Toes downgoing bilaterally. Coordination: Normal on finger-nose-finger, rapid alternating movements. Pertinent Results: [2141-9-9] WBC-18.5# Hgb-9.4 Hct-32.0 Plt Ct-395 [2141-9-17] WBC-9.8 Hgb-9.2 Hct-28.0 Plt Ct-782* [2141-9-20] WBC-11.1 Hgb-8.9* Hct-27.6 Plt Ct-750* [2141-9-24] WBC-15.1 Hgb-9.5* Hct-28.6 Plt Ct-710* [2141-9-26] WBC-26.2 Hgb-10.4# Hct-30.9 Plt Ct-475 [2141-9-28] WBC-9.1 Hgb-10.2* Hct-30.5Plt Ct-379 [2141-10-6] WBC-12.4 Hgb-11.8* Hct-36.3 Plt Ct-499* [2141-10-9] WBC-6.6 Hgb-10.7* Hct-32.0 Plt Ct-499* [2141-9-11] Neuts-94.7* Bands-0 Lymphs-4.0* Monos-1.1* Eos-0.2 [2141-9-24] Neuts-84.6* Lymphs-11.7* Monos-3.4 Eos-0.1 Baso-0.2 [2141-10-1] Neuts-85.3* Lymphs-9.6* Monos-2.2 Eos-2.7 Baso-0.3 Chem: [2141-9-9] Glucose-113* UreaN-12 Creat-0.7 Na-134 K-3.6 Cl-99 HCO3-28 [2141-9-27] Glucose-79 UreaN-5* Creat-0.5 Na-136 K-3.7 Cl-102 HCO3-28 [2141-10-9] CK(CPK)-25* [2141-10-6] ALT-17 AST-18 AlkPhos-127* TotBili-0.5 Micro: [9-9] swab: MSSA, strep viridans, yeast [9-9] tissue cx: strep viridans, strep milleri; privotella [9-9] sputum cx: sparse oropharyngeal flora, yeast [9-10] bld cx: neg x2 [9-14] pleural fluid: neg [9-15] abscess: strep milleri, lactobacillus [9-17] sputum: staph aureus, resistant to PCN [9-26] Pleural fluid: 3+PMNs, cx: enterococcus sp. [9-27] H.Pylori negative [9-29] abcess: 4+ PMNs, no orgs. no growth on cx. [9-30] blood and urine cx: no growth [10-2] CVL tip cx: no growth [10-6] pleural fluid: 3+PMNs [2141-9-9] CT CHEST W/CONTRAST 1. Diffuse tree-in-[Male First Name (un) 239] and dependent ground glass opacities likely representing aspiration. 2. Small bilateral pleural effusions, right greater than left. 3. Please see CT neck examination performed on the same day for comment on irregular fluid-filled lower cervical esophagus with paraesophageal foci of air. Esophageal rupture cannot be excluded. 4. 7-mm left upper lobe nodule. This may be infectious or inflammatory in etiology, but can be followed with dedicated chest CT in three months. [9-9] CT NECK W/CONTRAST (EG:PAROTIDS) IMPRESSION: 1. Multiple small abscesses, obliteration of the deep and superficial fascial planes, and stranding and emphysema centered at C5/6. What is presumed to be the esophagus in this region is irregular and fluid filled and esophageal perforation cannot be excluded and would best be evaluated via contrast esophagogram with fluoroscopy. Heterotopic bone posterior to the esophagus at this location may indicate mechanism of injury. Given obliteration of the deep and superficial fascial planes and extensive subcutaneous emphysema, a rapidly spreading infection also cannot be excluded and close clinical correlation is recommended. CT CHEST W/CONTRAST [2141-9-11] 1. Perforation of the posterior esophagus at the C4/C5 level with extravasation of oral contrast and connection to the neck incision. This has caused a massive infectious process with multiple small abscesses in the left supraclavicular region and pockets of air which have further increased in extent since [2141-9-9]. There is beginning extension of infectious process into the superoposterior mediastinum. 2. New development of aneurysm or pseudoaneurysm arising from the left vertebral artery. As this is in the region of the planned surgical drainage, special attention is required in order to avoid vascular injury. 3. Increase in size of bilateral pleural effusions. 4. Slight improvement in multifocal ground-glass opacities and tree-in-[Male First Name (un) 239] opacities. 7-mm left upper lobe nodule. This may again be infectious or inflammatory in etiology and can be followed with dedicated chest CT in three months. CT NECK W/CONTRAST (EG:PAROTID [9-24] IMPRESSION: 1. Mild interval increase in size of a 1.5-cm pseudoaneurysm of the left vertebral artery at the C6-7 level compared to [2141-9-14]. 2. Destructive changes of C6 and C7 vertebral bodies with posterior displacement of C6 and focal kyphosis. These findings may relate to motion after removal of hardware but osteomyelitis must be strongly considered. Consider MR of the cerival spine for better evaluation, especially for the presence of epidural involvement. 3. Residual 2.5 x 1.3 x 3.9 cm fluid collection with an enhancing rim within the left tissues of the supraclavicular region. This area overall appears significantly improved compared to 10//[3-18]. Other associated findings as described above. MR [Name13 (STitle) ] W& W/O CONTRAST [2141-9-27] 3:22 PM FINDINGS: At C5-6 and C6-7 increased signal is identified within the partially obliterated discs with increased signal within the adjacent vertebral bodies. There is enhancement seen in this region following gadolinium administration with a focal area of low signal seen within the C6-7 intervertebral disc area. In addition, there is widening of the prevertebral soft tissues identified with small pockets of air and low signal indicating abscess. There are also soft tissue changes seen within the left supraclavicular region in the region of trapezius muscle with a focal abscess. Additionally, there is enhancement seen in the region appropriate for proximal left vertebral artery which was seen as a pseudoaneurysm on the previous CTA examination of [2141-9-25]. Surrounding the dilated pseudoaneurysm of the left vertebral artery there is also an irregular area of fluid collection identified measuring approximately 3 cm indicating an abscess. IMPRESSION: Findings indicative of discitis and osteomyelitis at C5-6 and C6-7 with prevertebral abscess in the left supraclavicular region involving the trapezius muscle as well as in the left anterior aspect of the neck along the course of the left vertebral artery with an area of enhancement indicating vertebral artery pseudoaneurysm seen by the previous CTA examination. Epidural soft tissue enhancement indicating phlegmon is seen with mild indentation on the spinal cord without evidence of epidural abscess. MR [Name13 (STitle) ] W& W/O CONTRAST [2141-10-4] 6:16 PM FINDINGS: Comparison with the prior examination discloses high T2 signal within both the C5-6 and C6-7 disc spaces. There is also now a small area of high T2 signal within the prevertebral soft tissue spanning the C5-6 disc space. While these post-contrast scans are of poor quality due to extensive patient motion, there is likely a small amount of pathological contrast enhancement within the anterior epidural space posterior to the C6-7 interspace. Given the prior findings, the findings are quite consistent with extensive infectious disease within the intervertebral disc, epidural and prevertebral spaces. Left-sided posterior paraspinal abscesses, that were defined on prior imaging studies appears somewhat smaller at this time, particularly the more posteriorly situated abscess. There is no definite signal abnormality within the visualized spinal cord, although the deformed vertebral segments at the C5-C7 level resulting continued impression upon the ventral cord surface. CT C-SPINE W/O CONTRAST [2141-10-7] 3:55 AM FINDINGS: The appearance of the cervical spine appears unchanged with no evidence of acute fracture or dislocation. Extensive degenerative sclerotic changes at C5-C6, involving the C4 vertebral body, and degeneration of the inferior endplate of C6 and superior endplate of C7 are stable as is the posterior displacement of C5 and C6 with a cranial angulation of the posterior aspect. No prevertebral soft tissue swelling is identified. Visualized contents of the intrathecal sac appear unremarkable. Evaluation of lung apices displays evidence of centrilobular emphysema. Soft tissue mass within the lower left neck consistent with patient's known treated pseudoaneurysm is unchanged from one day prior. Brief Hospital Course: Patient was admitted to Neurosurgery service on [2141-9-9] for paravertebral spinal fluid collection and an epidural spinal abscess which was most prominent at C5-6 and C6-7. On the day of admission, she went to the operating room with neurosurgery/ENT and underwent: 1. Removal of hardware at C5-C6; 2. Redo cervical diskectomy at 5-6; 3. Anterior cervical diskectomy at C6-C7; 4. Evacuation of paraspinal abscess. She was extubated on POD#1 and started PO diet with increased drainage from the wound. On [9-15] she went back to OR with thoracic and had repeat incision and drainage of left supraclavicular fossa abscess and placement of a 20-French Ponsky PEG tube. She also received units of blood transfusion. ID: was consulted and she was Started on Vanc/Aztreonam/Flagyl. ID continued following on her antibiotic treatment and dosage adjustment. Fluconazole was added on [9-9] for yeast from her neck wound. They continued to follow her cultures. On [9-20] the stopped the Aztreonam and started Clindamycin awaiting sensitivities. On [9-22] Clindamycin was stopped. Levofloxacin was started empirically for GNRs. On [9-30] she spiked a temp to 101.2. The cental line was removed and she was pancultured. The pleural cultures grew VRE. The Vancomycin was changed to Linezolid. The culture from the neck abscess had no growth. She remained afebrile, a PICC line was placed on [10-2]. On [10-6] she was positive for C. Diff. Flagyl was continued. She continued to improve and was discharge to home on Daptomycin, Ciprofloxacin, Fluconazole and Flagyl through [11-10]. On [9-9] the swallow evaluation and chest CT revealed cervical esophageal perforation with neck and supraclavicular fossa abscesses. Thoracic was consulted and she underwent a flexible esophagoscopy and I&D of left neck and supraclavicular fossa with thoracic on [9-11]. She was put on strict NPO postoperatively and a Dobbhoff feeding tube was inserted on [9-12], which was self-removed by the patient shortly afterwards. She went back to OR with thoracic and had repeat incision and drainage of left supraclavicular fossa abscess and placement of a 20-French Ponsky PEG tube. She also received units of blood transfusion. On [9-14] psychiatry was consulted for evaluation of intermittent confusion, recommended starting Haldol and Ativan treatment for delirium. On [9-14] repeat chest CT showed marked interval increase in size of large bilateral pleural effusions with loculated components; and persistent multifocal ground-glass opacities within the lungs; incompletely imaged left supraclavicular region, where fluid collection and subcutaneous emphysema are again seen. She underwent chest tube placement at bedside on [9-14] with thoracic surgery and had 700cc drainage. On [9-20] the Chest-tube was removed. Repeat Chest CT on [10-5] revealed a loculated right pleural effusion which was drained for 70cc. Respiratory: intubated [9-15] for acute respiratory distress. She remained stable and was extubated on [9-19]. Her respiratory status continued to improve and she was weaned from oxygen with saturations in the 90's. On [9-26] she developed acute respirator distress and hematemesis. Atraumatic intubation at the bedside was performed. She was extubated on [9-25] without difficulty with saturations 98% on 2 Liters nasal canula. Her discharge oxygen saturation was 95% on room air. Cardiac: she remained in sinus rhythm throughout her hospital course. GI: On [9-26] GI was consulted for hematemesis: EGD was performed and bleeding was mostly likely from the site of previous esophageal defect/perforation. She was transfused with 2 Units Packed-Red-Blood Cells. She had no further bleeding and her hematocrit remained stable. Nutrition: was consulted and she was started on Replete with fiber Goal of 70cc/hr which she tolerated. She was discharged on Probalance 4 cans qid. GU: Voiding without difficulty Wound: Neck incision was well healed on discharge. Pain: PCA Dilaudid and Roxicet with good control. On [2141-10-4] she developed radiculopathy pain down both arms. The pain service was consulted and recommended a fentanyl patch and Neurontin. She had no relief and therefore she was started on methadone with Roxicet for breakthrough pain with good pain control. Neuro: On [2141-9-24] her WBC continued to rise. Neurosurgery was consulted. A Repeat CT of the Chest/Neck revealed a left vertebral Pseudoaneurysm 1.5 5cm by 1.2 cm. The left supraclavicular abscess had decreased. It also revealed osteomyelitis of the C5-C6 vertebral bodies. CTA of the neck on [9-26] did not reveal a esophageal fistula. It did re-confirmed thrombosis of the left vertebral artery from the origin of C1. Neurosurgery recommended an MRI which was done on [9-27]. It showed vertebral destruction/involvement with some compression of the cord. Of note a fluid collection was noted at the neck which 6cc was aspirated and sent for cultures on [9-29]. A repeat Cervical MRI showed no further compromise changes. The left posterior paraspinal abscess was somewhat smaller. No surgical decompression was warranted. A CTA of the neck on [10-5] show that the left vertebral artery remains occluded and no further imaging is required. Mobility: She continue to work with Physical Therapy. Disposition: Discharged to home in stable condition on home intravenous antibiotics. She will follow-up with Infectious Disease as an outpatient and Dr. [Last Name (STitle) ] for a barium swallow in one week. Medications on Admission: Oxycodone Fioricet Combivent Albuterol Xanax Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24 hr [Last Name (STitle) ]: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily): Give Via G-tube. Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 3. Metronidazole 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day): Crush & Give via G-Tube. Disp:98 Tablet(s) Refills:0 4. Fluconazole 200 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q24H (every 24 hours): Crush & give via G-Tube. Disp:32 Tablet(s) Refills:0 5. Acetaminophen 160 mg/5 mL Solution [Last Name (STitle) ]: Thirty (30) mL PO TID (3 times a day). Disp:2700 mL Refills:2 6. Oxycodone 5 mg/5 mL Solution [Last Name (STitle) ]: [4-20] mL PO Q3H (every 3 hours) as needed for pain. Disp:2400 mL Refills:0 7. Gabapentin 400 mg Capsule [Month/Year (2) ]: One (1) Capsule PO Q8H (every 8 hours): Crush & Give via G-tube. Disp:90 Capsule(s) Refills:0 8. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 10. Daptomycin 500 mg Recon Soln [Month/Year (2) ]: One (1) Recon Soln Intravenous Q24H (every 24 hours). Disp:32 Recon Soln(s) Refills:0 11. Levofloxacin 500 mg Tablet [Month/Year (2) ]: One (1) Tablet PO once a day: Crush & Give via G-tube. Disp:32 Tablet(s) Refills:0 12. Outpatient Lab Work Please obtain weekly CBC, Chem 7, LFTs, and CK level. Fax results to Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7443] at [Telephone/Fax (1) 1419] 13. Normal Saline Flush 0.9 % Syringe [Telephone/Fax (1) ]: One (1) 10 ML Injection every eight (8) hours: Flush PICC q8hrs . Disp:132 10 ML Refills:2 14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Telephone/Fax (1) ]: One (1) ML Intravenous DAILY (Daily) as needed. Disp:qs for 32 days ML(s) Refills:2 15. Methadone 10 mg Tablet [Telephone/Fax (1) ]: 1.5 Tablets PO TID (3 times a day): Crush and give via G-Tube. Disp:135 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Cervical esophageal perforation with neck and supraclavicular fossa abscess. Epidural space abscess with extension to the prevertebral space. Discharge Condition: stable Discharge Instructions: Call Dr.[Name (NI) 56337] office at [Telephone/Fax (1) 170] if you experience chest pain, shortness of breath, fever, chills, nausea, vomiting, diarrhea, or abdominal pain. Please call if you have difficulty tolerating tube feeds. If your feeding tube falls out, save the tube, call the office immediately [Telephone/Fax (1) 170]. The tube needs to be replaced in a timely manner. Do not put any medication down the tube unless they are in liquid form. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding. VNA instructions : Place a clean dressing over feeding tube site. Continue tube feeds and flushes as directed. Administer IV antibiotics as directed. Monitor neck wound sites. Tubefeeding: Probalance Full strength with 10g beneprotein/day - administer 420cc 4 times per day. Flush w/ 50 ml water q8h, before and after feedings. Activity: as tolerated. Walk at least 4 times per day for [9-25] minutes at a time w/ rest periods as needed. Medication: please followup with your primary care physician for pain medication management. Take antibiotics as prescribed until [11-10] or otherwise directed by infectious disease. Labs: Please obtain weekly CBC, Chem 7, LFTs, CK level. Please fax results to Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7443] at [Telephone/Fax (1) 1419]. Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2141-10-16] 11:00 [Last Name (un) 11482] [Doctor Last Name ] [Telephone/Fax (1) 170] on [10-17] at 10:30am on the [Hospital Ward Name 12837] [Hospital1 ] I, Pulmonary interventional unit. Barium Swallow [10-17] at 9:00am on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center [Location (un) 861]. NO TUBE FEEDS AFTER MIDNIGHT MONDAY. CXR: after barium swallow Completed by:[2141-10-10]	[ "530.6", "293.0", "V45.4", "442.81", "530.4", "783.21", "E849.7", "722.91", "511.9", "730.08", "578.0", "728.89", "433.20", "041.11", "682.1", "285.9", "518.81", "305.1", "873.20", "493.90", "041.09", "486", "996.78", "V09.0", "E885.9", "276.1", "008.45", "324.1" ]	icd9cm	[ [ [] ] ]	[ "87.62", "34.04", "42.23", "38.91", "99.21", "88.38", "38.93", "96.04", "99.04", "80.51", "96.59", "87.61", "43.11", "00.14", "34.91", "86.04", "45.13", "78.69", "96.71" ]	icd9pcs	[ [ [] ] ]	20222, 20280	12203, 17819	309, 999	20466, 20475	4379, 12180	21904, 22481	2659, 2677		17914, 20199		20301, 20445		17845, 17891			20499, 21881								2692, 3253																						238, 271														1027, 2399	3518, 4360							3269, 3502					2421, 2536	2552, 2643
26,161	188,491	13165	Discharge summary	report	Admission Date: [2107-1-11] Discharge Date: [2107-2-6] Date of Birth: [2060-1-14] Sex: F Service: SURGERY Allergies: Morphine Attending:[First Name3 (LF) 668] Chief Complaint: ESRD Major Surgical or Invasive Procedure: [1-25]:Exploration of kidney transplant, renal biopsy, wash-out hematoma and replacement of tunneled dialysis catheter. [1-11]:Kidney transplant, left iliac fossa, living unrelated donor. History of Present Illness: Ms. [Known lastname 39143] is a 46-year-old female with end-stage renal disease secondary to type 1 diabetes mellitus, who presents for a kidney transplantation Past Medical History: Her past medical history is significant only for diabetes, hypertension, hypercholesterolemia, and end-stage renal disease. She has had two prior C-sections, a laparoscopic cholecystectomy, and then PermCath that is placed in the right internal jugular vein. Physical Exam: On physical examination, Mr. [Known lastname 39143] is a very pleasant 46-year-old female in no apparent distress. Chest is clear. Abdomen is soft, nontender, and nondistended. No cervical or supraclavicular adenopathy. No carotid bruits. Her abdominal incision site is clean, and intact with overlying abdominal pads for drainage control. She has had no recent fevers or chills or drainage. Her femorals are 2+ and equal bilaterally. She has 2+ to 3+ peripheral edema. No evidence of lower extremity ulcers or ischemic changes Pertinent Results: [2107-1-11] 01:52PM GLUCOSE-140* UREA N-19 CREAT-3.3# SODIUM-141 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 [2107-1-11] 01:52PM PHOSPHATE-2.8# MAGNESIUM-1.2 [2107-1-11] 01:52PM WBC-5.2 RBC-4.13* HGB-11.6* HCT-36.1 MCV-87 MCH-28.0 MCHC-32.0 RDW-16.0* [2107-1-11] 01:52PM PLT COUNT-179 [2107-1-11] 12:53PM TYPE-ART PO2-118* PCO2-35 PH-7.44 TOTAL CO2-25 BASE XS-0 [2107-1-11] 12:53PM TYPE-ART PO2-118* PCO2-35 PH-7.44 TOTAL CO2-25 BASE XS-0 [2107-1-11] 12:53PM HGB-11.0* calcHCT-33 [2107-1-11] 12:53PM GLUCOSE-107* LACTATE-2.7* NA+-141 K+-3.8 CL--107 [2107-1-11] 12:53PM freeCa-1.16 [2107-1-11] 10:35AM TYPE-ART PO2-111* PCO2-37 PH-7.45 TOTAL CO2-27 BASE XS-1 INTUBATED-INTUBATED [2107-1-11] 10:35AM GLUCOSE-226* LACTATE-1.6 NA+-139 K+-4.1 CL--102 [2107-1-11] 10:35AM HGB-11.7* calcHCT-35 [2107-1-11] 10:35AM freeCa-1.05* [2107-2-6] 06:30AM BLOOD WBC-6.1 RBC-3.04* Hgb-8.9* Hct-25.5* MCV-84 MCH-29.4 MCHC-35.0 RDW-14.6 Plt Ct-370 [2107-2-5] 06:10AM BLOOD WBC-4.7 RBC-3.22* Hgb-9.2* Hct-26.9* MCV-84 MCH-28.6 MCHC-34.2 RDW-14.6 Plt Ct-321 [2107-2-4] 06:07AM BLOOD WBC-4.6 RBC-3.14* Hgb-9.2* Hct-26.5* MCV-84 MCH-29.2 MCHC-34.6 RDW-14.7 Plt Ct-255 [2107-2-3] 05:30AM BLOOD WBC-5.4 RBC-3.22* Hgb-9.5* Hct-26.4* MCV-82 MCH-29.3 MCHC-35.8* RDW-14.8 Plt Ct-189 [2107-2-2] 04:40PM BLOOD WBC-5.7 RBC-3.44* Hgb-10.5* Hct-28.7* MCV-84 MCH-30.4 MCHC-36.5* RDW-14.7 Plt Ct-189 [2107-2-2] 05:45AM BLOOD WBC-4.7# RBC-3.43* Hgb-10.1* Hct-28.2* MCV-82 MCH-29.5 MCHC-35.9* RDW-14.9 Plt Ct-155 [2107-2-1] 08:20PM BLOOD Hct-30.0* [2107-2-1] 02:59AM BLOOD WBC-2.1* RBC-3.07* Hgb-9.2* Hct-25.4* MCV-83 MCH-30.0 MCHC-36.2* RDW-15.2 Plt Ct-135* [2107-1-31] 04:05AM BLOOD WBC-1.1* RBC-3.45* Hgb-10.2* Hct-30.1* MCV-87 MCH-29.4 MCHC-33.7 RDW-14.8 Plt Ct-122* Brief Hospital Course: Ms. [Known lastname 39143] is a 46-year-old female with end-stage renal disease secondary to type 1 diabetes mellitus, who presents for a kidney transplantation [2107-1-11]. Procedure was performed by Dr. [First Name (STitle) ]. Please see operative note for details. Her postoperative course was complicated by hemolysis thought to be due to antibody immunity rejection. At the same time, she developed retroperitoneal hematoma. At the same time, she developed a malfunctioning dialysis catheter. On [2107-1-25] she returned to the operating room for kidney exploration and retroperitoneal wash-out and replacement of dialysis catheter which was advised and accepted. Postoperatively after washout she remained in the SICU for multiple plasmapheresis. She remaim stable and was tranasfered to the transplant surgery floor [Hospital Ward Name 121] 10 [2107-2-2]. On [2107-2-6] after evaluation by Transplant surgery, medicine and physical therapy staff patient was advise that she was safe to go home. Patient was educated on wound care and agreed with plan of discharge. Discharge Medications: 1. Monistat 3 200 mg Suppository Sig: One (1) Vaginal at bedtime for 3 days: use at bedtime. Vaginal supp-use at night x 3 days. Disp:qs 4% cream Refills:0 2. Tums Take 2 over the counter tums at night before bed 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 10. Flonase 50 mcg/Actuation Aerosol, Spray Sig: One (1) Nasal [Hospital1 ] (). 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:14 Tablet(s) Refills:0 12. Sirolimus 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily) for 1 weeks. Disp:7 Tablet(s) Refills:0 13. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) for 1 weeks. Disp:28 Tablet(s) Refills:0 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QDAY () for 1 weeks. Disp:14 Tablet(s) Refills:0 15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:14 Tablet(s) Refills:0 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for 1 weeks. Disp:14 Tablet(s) Refills:0 17. Medroxyprogesterone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:6 Tablet(s) Refills:0 20. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 21. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 22. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:14 Tablet, Delayed Release (E.C.)(s) Refills:0 24. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:14 Tablet(s) Refills:0 25. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain for 7 doses. Disp:7 Tablet(s) Refills:0 26. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:40 Tablet(s) Refills:0 27. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:6 10,000 unit/mL Refills:0 28. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for gas discomfort. Disp:30 Tablet, Chewable(s) Refills:0 29. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:14 Tablet(s) Refills:0 30. Sirolimus 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily) for 1 weeks. Disp:7 Tablet(s) Refills:0 31. NIFEdipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q 12H (Every 12 Hours) for 14 doses. Disp:14 Tablet Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital6 486] Discharge Diagnosis: end-stage renal disease secondary to type 1 diabetes mellitus Discharge Condition: stable Discharge Instructions: Please call transplant surgery at [Telephone/Fax (1) 673] if any fevers, chills, nausea, vomiting, abdominal pain, inability to eat food or drink liquids. If you have any increase drainage to incision, change in color on incision. Also if you have increase vaginal bleeding please call immediately. Please contact [Telephone/Fax (1) 673] to arrange appointment for lab works on [2107-2-8] and administration of Rituximab [2107-2-10] Followup Instructions: Please Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4653], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2107-2-8] 11:00 Provider: [Name10 (NameIs) 454],TWELVE DAY CARE [Hospital Ward Name ] 8 Date/Time:[2107-2-8] 12:00 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2107-2-8] 2:00 Completed by:[2107-2-6]	[ "585.6", "283.11", "583.81", "403.91", "V58.67", "284.8", "998.12", "996.1", "446.6", "996.81", "357.2", "584.9", "250.41", "428.0", "E878.0", "285.1", "250.61", "275.41" ]	icd9cm	[ [ [] ] ]	[ "99.05", "39.95", "99.28", "99.04", "55.69", "55.24", "99.07", "00.92", "54.0", "99.71", "38.95" ]	icd9pcs	[ [ [] ] ]	7918, 7968	3395, 4498	271, 469	8074, 8083	1514, 3372	8585, 9016			4521, 7895		7989, 8053					8107, 8562								962, 1495																						227, 233														497, 663													685, 947
25,312	145,651	43422	Discharge summary	report	Admission Date: [2195-11-26] Discharge Date: [2195-12-17] Date of Birth: [2145-12-30] Sex: M Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: Patient is a 49-year-old with past medical history significant for congenital bicuspid valve repaired with an organ donor [2186] who presented to the Emergency Department on [11-26] with a complaint of fevers of 103.0 F for one day, lower back pain of one month duration. The patient reports he had an annual physical with echo which was within normal limits and a flu shot late [Month (only) ]. Patient reports that he felt particularly "run" down status post shot with continued mild fatigue. The patient also had gums cleaned around that time with positive mild bleeding. The second week in [Month (only) 359], the patient developed dry cough. The patient was put on prophylaxis with Erythromycin during the dental cleaning. Treated with Azithromycin in [Month (only) 359] for his cough without improvement. He was placed on a one week course of Erythromycin. Bronchitis / cough resolved, but patient developed acute back pain between the shoulders. Patient described it as stabbing. The patient felt tired and weak increasingly which was attributed to excruciating back pain. This past Wednesday, the patient was walking with his daughter and knees buckled. The pain suddenly migrated to the lower back. Thursday in the AM, the patient reports fatigue and weakness. He could not rise from bed. He subsequently went to the Emergency Department. PHYSICAL EXAMINATION: Vital signs 100.4 F, 85, 102/46, 16 to 22, 99 to 100% on two liters nasal cannula. Generally the patient was diaphoretic in no acute respiratory distress. Head, eyes, ears, nose and throat: Normal. Heart: Pansystolic murmur at upper sternal border to carotids. It could be heard throughout the precordium. Lungs: Crackles at bases bilaterally, slight expiratory wheeze. Back: No vertebral tenderness. Extremities: No cyanosis, clubbing or edema. Neuro: [5-10] upper and lower extremity strength, 2+ reflexes throughout. PERTINENT LABORATORIES: Hematocrit 35.9, creatinine of 0.7. Urinalysis showed moderate protein. CK and troponin I were both normal. HOSPITAL COURSE: The patient was admitted to the Medicine Service on [2195-11-26] at which time blood cultures times three were sent and Vancomycin was started. In addition after Infectious Disease consult, Gentamycin was also started. Subsequent echocardiogram (TTE) showed moderate dilation of the left atrium, slight decrease in left ventricular function, severe aortic stenosis (question vegetation), severe aortic insufficiency with two vegetations on the mitral valve with moderate MR. The patient was also noted to have a hematocrit of 25.2 on his hospital day #3. MRI of the lumbar vertebral discs shows herniation between L3 and L4 with no evidence of epidural abscess. Blood cultures from [11-26] subsequently grew nutritionally variant strep. Intermittently the patient received packed red blood cells for hematocrit and subsequently hematocrit increased. On [12-3], the patient was found to be short of breath with tachypnea and having O2 requirement. Then at approximately 7 PM, the patient had a respiratory arrest and was intubated then admitted to the CCU. The patient was subsequently started milrinone drip to decrease afterload. The patient's cardiac index was 4.6 at that time with a wedge pressure of 18.2. The patient was placed on assist-control ventilation and sedated with Propofol. Mr. [Known lastname ] was subsequently started on Levofloxacin and Flagyl then continued on Vancomycin. The patient was believed to have ATN secondary to decreased urine output and rising BUN and creatinine which was 23 and 1.3 respectively. The patient subsequently resolved by increasing his urine output to an adequate level. Renal insufficiency was thought to be secondary to hypoperfusion, but resolved without permanent sequela. In the CCU the patient spiked a temperature of 101.8 F and patient was then subsequently pan cultured as above. Antibiotics were continued which included Vancomycin, Levofloxacin and Flagyl. Tube feeds were initiated in the CCU and on [2195-12-7] the patient was brought to the Operating Room for mitral valve repair and homograft roof replacement. The patient was on coronary bypass for 207 minutes and was cross clamped for 106 minutes. Postoperatively, the patient was started on Nitroglycerin to reduce preload and milrinone to help cardiac output and decrease afterload and Propofol for sedation. Postoperatively, the patient was placed on SIVM with tidal volume of 600, respiratory rate of 14 on 60% oxygen. Intraoperatively, the patient was transfused with two units of packed red blood cells and two units of FFP and two chest tubes were placed as well as two ventricular and two atrial wires. Postoperatively, he diuresed well on a Lasix drip and continued to have ongoing ectopy. On postoperative day #3, he was extubated without incident, but unfortunately, his creatinine and BUN were creeping up. On postoperative day #5, the patient had an episode of bradycardia to the 40s and Amiodarone was subsequently held. The creatinine improved from 2 to 1.7 and he continued to make good urine and respond well to Lasix challenges. On postoperative day #8, the patient was transferred to the Surgical Floor in good condition. He maintained his blood pressure and heart rate in the 70s with normal sinus rhythm without ectopy. Aggressive pulmonary toilet was continued in light of an aspiration pneumonia diagnosed during his postoperative day for which he continued to be treated with Levaquin. The patient received a PICC line for an extended period of IV antibiotics on postoperative day #10. Unfortunately, it was found that his white blood cell had increased from 14 the previous day to 16 and blood cultures, urine culture and chest x-ray were all done which did not show any changes and were all essentially negative. At that time, it was decided that the patient should also be treated with Gentamycin on a low dose secondary to his previous acute renal failure. The Gentamycin was started on a low dose and was titrated up to therapeutic levels to avoid nephrotoxicity. The patient was subsequently discharged in good condition to rehab for short term physical therapy and continued IV antibiotics. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To rehab. DISCHARGE DIAGNOSES: 1. Status post graft valve endocarditis. 2. Status post mitral valve repair, homograft root replacement complicated by respiratory failure, acute renal failure and aspiration pneumonia. FO[Last Name (STitle) 996]P: Patient is to follow up with primary care physician in one week and with Dr. [Last Name (Prefixes) ] in four weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 14176] MEDQUIST36 D: [2195-12-16] 21:56 T: [2195-12-17] 12:36 JOB#: [Job Number 93433]	[ "401.9", "428.0", "396.3", "997.3", "518.81", "507.0", "493.90", "584.5", "996.61" ]	icd9cm	[ [ [] ] ]	[ "35.12", "38.93", "39.61", "35.21", "96.72", "96.04", "42.23", "88.72" ]	icd9pcs	[ [ [] ] ]								6541, 7152						2270, 6458																					1580, 2252																									175, 1557															6483, 6520
3,633	157,060	15761	Discharge summary	report	Admission Date: [2106-10-6] Discharge Date: [2106-10-10] Date of Birth: [2085-11-3] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old woman who felt well until the morning of admission when she awoke with a "belly ache." She states that the pain was primarily hypogastric and was not radiating or associated with any precipitating factors. She stated that she checked a fingerstick glucose on the morning of admission, and it was 145; so "I didn't think anything of" the pain. The patient states that she did not have anything to eat; however, she did not take her morning Humalog sliding-scale insulin. At about 11 o'clock on the morning of admission, the patient states that she became nauseous and vomited "clear fluid." This fluid was nonbilious, nonbloody, and did not have a coffee-grounds appearance. She states that she vomited a total of four times on the day of admission; the last time was at 2:30 in the afternoon. At approximately 1 p.m., she began having diarrhea that was neither bright red nor jet black, but it was "dark." She last had diarrhea at approximately 3:15 on the afternoon of admission. Her abdominal pain persisted, however, and at 4:30 p.m. she called for an ambulance. Of note, the patient states that she was admitted to [Hospital3 1810] two weeks prior to this admission with hypoglycemia. On the day of this admission, the patient states that she took her regular nighttime insulin dose, but then did not eat "as soon as I should have, so I blacked out." The patient's fingerstick glucose was 45 at that time. At [Hospital3 1810], she had ketonuria and was treated for "dehydration" and released. She denies subsequent ketonuria. She states that she has otherwise felt well recently; and she denies recent upper respiratory symptoms, cough, fevers, chills, sweats, dysuria, frequency, hematuria, unusual vaginal discharge, chest pain, shortness of breath, headache, lightheadedness, dizziness, neck stiffness, photophobia, rash, sick contacts, recent travel (although the patient did return from [Country 6171] on [8-14]), raw fish or unusual foods, fresh-water swimming, or other complaints. Her last menstrual period was two weeks prior to admission. She states that she is completely compliant with her medications. During an interview in the Emergency Department, the patient stated that she had more right upper quadrant than hypogastric pain. She also complained of thirst. PAST MEDICAL HISTORY: Type 1 diabetes diagnosed at the age of nine. PAST SURGICAL HISTORY: Tonsillectomy. MEDICATIONS ON ADMISSION: 1. Insulin Glargine 30 units q.h.s. 2. Humalog insulin sliding-scale. ALLERGIES: CEFACLOR. SOCIAL HISTORY: The patient denies tobacco, alcohol, or recreational or intravenous drug abuse. She is a senior at [University/College 4700]. She denies current sexual activity. She has no history of unprotected sexual intercourse; although, she admits to protected intercourse twice in the past. FAMILY HISTORY: The patient's mother has a history of gallstones. PHYSICAL EXAMINATION ON PRESENTATION: On initial physical examination the patient's temperature was 97.5 degrees Fahrenheit, heart rate was 122, blood pressure was 155/77, respiratory rate was 24, and oxygen saturation was 100% on room air. In general, she was awake, spoke in full sentences, but was clearly short of breath, in mild distress secondary to her shortness of breath and abdominal pain. She had no sinus tenderness. Her pupils were equally round and reactive to light and accommodation. Extraocular movements were intact. The oropharynx was clear. Mucous membranes were dry; especially her tongue. Her neck was soft and supple. There was no lymphadenopathy or thyromegaly. Her heart rate was tachycardic, it was of a regular rhythm. There was normal first and second heart sounds, and there were no murmurs, rubs, or gallops. Her lungs were clear to auscultation bilaterally. Her abdomen was soft and diffusely tender; especially in the right upper quadrant much greater than the right lower quadrant which was also greater than the left upper or lower quadrants. She had a [Doctor Last Name ] sign, and she also had tenderness at McBurney point. She had no abdominal distention, and there were active bowel sounds. She had no costovertebral angle or paraspinal tenderness. No had no calf tenderness, no peripheral edema, and she had good peripheral pulses bilaterally. She was alert and oriented times three, and her neurologic examination was nonfocal. Her skin was warm, and she had mild facial erythema. PERTINENT LABORATORY DATA ON PRESENTATION: On initial laboratory evaluation the patient's white blood cell count was 30.5, hematocrit was 44.7, and platelets were 374. The differential of the white count included 80 polys, 4 bands, 7 lymphocytes, 9 monocytes, no eosinophils, and no basophils. Her PT was 15.1, PTT was 25.9, and INR was 1.6. Her serum chemistries revealed sodium was 144, potassium was 3.8, chloride was 113, bicarbonate was less than 5, blood urea nitrogen was 15, creatinine was 1, and blood glucose was 407. Her calcium was 7.4, magnesium was 1.5, and phosphate was 3.9. Her liver function tests were unremarkable. Her urinalysis demonstrated 30 protein, 500 glucose, greater than 80 ketones, 5 red blood cells, 1 white blood cell, a few bacteria, no yeast, 1 epithelial cell, and a pH of 5. An arterial blood gas done on room air in the Emergency Department demonstrated a pH of 6.88, PCO2 of 10, PO2 of 144, and a base deficit of 2. The urine pregnancy test was negative. RADIOLOGY/IMAGING: A right upper quadrant ultrasound done in the Department of Radiology was, in summary, a normal study; and there was no evidence of acute cholecystitis. She also had an abdominal CT scan without contrast that was also largely negative, with the exception of an incidental left ovarian cyst. Her chest x-ray demonstrated gaseous gastric distention consistent with a paralytic ileus; there was no evidence of free intraperitoneal air. HOSPITAL COURSE BY SYSTEM: 1. ENDOCRINE: The patient presented to the [Hospital1 346] Emergency Department with a serum glucose of 407, an anion gap of at least 26, dry mucous membranes, severe acidemia, glucosuria, and ketonuria; all of which were consistent with a presentation of diabetic ketoacidosis. Her severe acidemia likely caused her compensatory respirations tachypnea that quickly began to improve as her acidemia improved. She was administered a bolus of 10 units of regular insulin intravenously while in the Emergency Department, and she was then started on an insulin drip at 10 units of regular insulin per hour. She was also aggressively resuscitated with intravenous fluids; initially with 6 liters of normal saline while in the Emergency Department. These fluids were continued when the patient arrived in the Medical Intensive Care Unit. While in the Medical Intensive Care Unit, the patient's fingersticks were monitored every hour. Once her fingersticks began to trend downward and reached roughly a level of 250, the patient was started on D-5 half normal saline instead of regular normal saline as she had been receiving previously. The patient remained on an insulin drip, and her insulin drip was titrated to a goal of fingerstick [Location (un) 1131] of 140 to 180. She was ultimately tapered off of the insulin drip in the morning of [10-8]. She was also restarted on her baseline insulin regimen at this time. She was administered 30 units of insulin Glargine at 4 o'clock in the morning on [10-8]. Given that this medication was administered slightly later than the patient normally takes her evening insulin, her insulin regimen was adjusted as needed to maintain relative euglycemia throughout the remainder of the hospitalization. By the time of discharge, the patient was largely euglycemic on her baseline insulin regimen of Humalog insulin sliding-scale during the day and 30 units of insulin Glargine at bedtime. Of note, the patient's significant anion gap acidosis gradually resolved throughout the course of her hospitalization. Although, it was less than 5 on admission, it reached a plateau ranging between 24 and 27 by the time of her discharge from the hospital. 2. FLUIDS/ELECTROLYTES/NUTRITION: Given the patient's presentation with diabetic ketoacidosis, she subsequently manifested many of the electrolyte abnormalities consistent with this diagnosis. Of note, she developed severe hypokalemia, hypocalcemia, hypomagnesemia, and hypophosphatemia. All of these electrolytes were aggressively repleted throughout the course of her hospitalization. Her electrolytes had all stabilized within a normal range at the time of her discharge. 3. CARDIOVASCULAR: The patient's initial tachycardia and relative hypotension improved following her extensive fluid resuscitation. Overall, she was roughly 10 liters to 11 liters positive throughout this hospitalization. 4. GASTROINTESTINAL: Although there was an initial concern for an acute surgical abdomen, diabetic ketoacidosis can often present with abdominal pain that mimics a surgical abdomen. Although the possibilities of acute cholecystitis and acute appendicitis were ruled out with the appropriate imaging studies. The patient's abdominal pain spontaneously resolved by hospital day two. She had no subsequent nausea, vomiting, or diarrhea. 5. INFECTIOUS DISEASE: While the patient had a significant leukocytosis on presentation, this was also likely secondary to her presentation with diabetic ketoacidosis. Her leukocytosis spontaneously resolved with resolution of her diabetic ketoacidosis, and she had no longer had a leukocytosis at the time of discharge. 6. SUMMARY: Overall, at the time of discharge, the patient was tolerating a regular diabetic diet. She was back on her baseline insulin regimen, and all of her laboratory abnormalities present on admission had resolved. She was therefore deemed stable for discharge to home with close followup by her primary endocrinologist. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Type 1 diabetes mellitus. 3. Hypokalemia. 4. Hypophosphatemia. 5. Hypocalcemia. 6. Hypomagnesemia. MEDICATIONS ON DISCHARGE: 1. Insulin Glargine 30 units subcutaneous q.h.s. 2. Humalog insulin sliding-scale. DISCHARGE FOLLOWUP: The patient was instructed to phone her primary endocrinologist (Dr. [Last Name (STitle) 36244] at [Hospital3 18242] to arrange for a follow-up appointment with him during the week following discharge. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4561] Dictated By:[Name8 (MD) 2507] MEDQUIST36 D: [2106-10-10] 15:13 T: [2106-10-15] 10:47 JOB#: [Job Number 45385]	[ "427.89", "288.8", "560.1", "250.13", "787.91", "276.5", "V15.81", "787.01" ]	icd9cm	[ [ [] ] ]	[ "99.29", "96.07", "99.17", "38.93" ]	icd9pcs	[ [ [] ] ]							3061, 6112	10293, 10428				10454, 10540	2641, 2737							6140, 10167			2599, 2615														10182, 10272														10562, 11034									163, 2505													2528, 2575	2754, 3043
61,783	154,294	6722+55780	Discharge summary	report+addendum	Admission Date: [2196-12-4] Discharge Date: [2196-12-15] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 85 yo F with h/o CAD s/p CABG, chronic CHF and recent bowel surgery presents with hypotension now tx from [Hospital1 882] (orig from [Hospital ] rehab). Per [Hospital 100] rehab, BP has been low for several days, now not responsive to fluids. She was found overnight to systolics reportedly as low as 50s; ? still mentating. Thereafter, she was transferred to [Hospital 882] Hospital where she received 4L IVFs as well as IV zosyn. Patient was alert and oriented x3, code status was discussed with patient who stated DNR/DNI and that she doesnt want central line even if lifesaving. This was confirmed with her niece who is HCP, who states that her aunt discussed with her DNR and confirms. Thus, she was started on levophed through right PICC (placed prior to presentation, but unclear when) and was transferred to [Hospital1 18] ED for further management. . Of note, she has a hx of recent rectocolectomy for rectal perf with small bowel prolapse (2 feet of bowel resected) at [Hospital1 ] and has ostomy and choleostomy bag (placed for acalculus cholecystitis). Post op course was complicated by wound infection, pneumonia, c. diff and right hip cellulitis. She was treated periop with levofloxacin, flagyl and keflex. Discharge summary from [Hospital3 ] recommends course of keflex to end on [12-2], levofloxacin to end on [12-4] and flagyl to be continued through [12-9]. Her transfer record only lists flagyl as antibiotic so it is unclear whether she received full courses of these meds. . In the ED here, initial vitals were T: 95.4 BP: 116/88 HR: 100 RR: 26 O2 sat: 100% (unclear amount supplemental O2). Labs were notable for creatinine of 2.7 (CRI, but unclear baseline), bicarb of 10, and initial venous pH of 7.08 which improved slightly to 7.11 prior to transfer. Lactate was normal at 1.4. Initial glucose drawn from her PICC was 546 however this was thought d/t dextrose delivered through her PICC at [Hospital3 ] for hypoglycemia as repeats without intervention normalized. Arterial line placement was attempted in ? left wrist (with doppler) however pt extremely edemetous so attempt was unsuccessful. UA was not sent. CXR demonstrated hiatal hernia, cardiomegaly and inadequately characterized retrocardiac opacity. CT abdomen/pelvis was obtained which demonstrated transverse colon herniation into chest and small amount of free fluid within pelvis and perisplenic; viability of tissue in hernia could not be evaluated per radiology prelim read, however surgery evaluated imaging and suspect source is most likely intraabdominal, but patient adamantly refused surgical intervention. She received 1g IV vanco and 500mg flagyl as well as 25mcg fentanyl for back pain (it does not appear by documentation that she received any additional IVFs) and is now being admitted to the ICU for further management of hypotension. . Currently she reports generally feeling unwell, fatigued and complains of extremely dry mouth. She endorses productive cough. She denies significant SOB. She has no CP/palps. She endorses low back pain which she says is chronic. She denies abdominal pain and is unsure if her ostomy output has changed. She denies dysuria or urinary urgency. She denies rashes. She denies focal numbness, tingling, weakness (just marked generalized weakness). Past Medical History: -Rectal prolapse s/p rectocolectomy at [Hospital3 ] now with colostomy and choleostomy after complicated postop course -C. diff -Hypertension -Hyperlipidemia -CAD S/P 3-vessel CABG in [2187] (LIMA to LAD,SVG to OMI, SVG to PDA); Myocardial Infarction in [2194] -Chronic Heart Failure with preserved EF 55% with Inf HK (Echo [12-22]) -Paroxismal Atrial fibrillation (not on coumadin b/c of elevated K) -Hypothyroidism -Anemia -Chronic Kidney Disease (Baseline Cr 1.8-2.2) -Osteorathritis -Rotator cuff arthropathy Social History: Most recently living at [Hospital 100] Rehab. Prior to to that, she lived alone in [Location 4288] and performed all of her activities of daily living independently. Former smoker of 1ppd for 10 years, quit over 30years ago. No alcohol. Family History: Father died from pancreatic cancer and mother died from lung cancer. Physical Exam: VS Afebrile 140/86 P59 R20 99%RA GEN: pleasant elderly female, comfortable, nontoxic. Generalized anasarca, gradually improving. HEENT: eomi Neck: R IJ pulled ([12-15]), no evidence of infection RESP: CTA B. CV: RRR. no mrg. Abd: +BS. ostomy viable, brown stool. Biliary drain in place. Abd wound bandaged. EXT: generalized anasarca. NEURO: intact. Pertinent Results: On admission: [2196-12-4] 06:00AM BLOOD WBC-12.8* RBC-3.08* Hgb-9.5* Hct-30.3* MCV-99* MCH-30.8 MCHC-31.2 RDW-15.5 Plt Ct-347 [2196-12-4] 06:00AM BLOOD PT-37.8* PTT-46.0* INR(PT)-4.1* [2196-12-4] 10:40AM BLOOD Fibrino-662* D-Dimer-1741* [2196-12-4] 10:40AM BLOOD FDP-10-40* [2196-12-4] 06:00AM BLOOD Glucose-546* UreaN-42* Creat-2.4* Na-124* K-3.8 Cl-105 HCO3-9* AnGap-14 [2196-12-4] 06:00AM BLOOD ALT-7 AST-25 AlkPhos-61 TotBili-0.2 [2196-12-4] 06:00AM BLOOD Calcium-5.9* Phos-5.3* Mg-1.9 [2196-12-4] 10:40AM BLOOD TSH-23* [2196-12-4] 01:07PM BLOOD T4-3.3* T3-54* Free T4-0.48* [2196-12-5] 05:45AM BLOOD Vanco-22.3* . On transfer to floor: [2196-12-12] 04:42AM BLOOD WBC-10.6 RBC-3.33* Hgb-10.2* Hct-30.7* MCV-92 MCH-30.7 MCHC-33.2 RDW-15.9* Plt Ct-200 [2196-12-12] 04:42AM BLOOD Glucose-86 UreaN-37* Creat-1.2* Na-140 K-4.2 Cl-116* HCO3-16* AnGap-12 [2196-12-12] 04:42AM BLOOD Calcium-7.1* Phos-3.9 Mg-2.1 . [2196-12-4] CT abd/ pelvis without contrast: IMPRESSION: 1. A long segment of transverse colon herniates through a large diaphragmatic defect into the chest. There is no pneumatosis, although further evaluation of the bowel for ischemic changes is limited without the use of contrast. 2. Small amount of pelvic free fluid. Without oral contrast, it is difficult to differentiate free fluid from decompressed colon and small bowel. 3. Suture line with small pocket of gas and fluid adjacent that may be post- surgical (2:58). 4. The gallbladder is not well seen, which may be contracted around the drain. . [2196-12-11] CXR: The patient has a right-sided central line, unchanged in position. Portable AP film is of suboptimal quality. There is a degree of rotation also. The patient has prominence of the right hilum, likely vascular. Cardiomegaly, cardiac calcifications, and probable left retrocardiac atelectasis is unchanged. There is a degree of respiratory unsharpness on this radiograph also. No florid evidence of pulmonary failure. CONCLUSION Little change from prior radiograph. . . Discharge: [2196-12-14] 09:34AM BLOOD WBC-7.9 RBC-3.21* Hgb-10.0* Hct-30.5* MCV-95 MCH-31.3 MCHC-33.0 RDW-16.5* Plt Ct-182 [2196-12-15] 05:55AM BLOOD PT-21.5* PTT-30.1 INR(PT)-2.0* [2196-12-15] 05:55AM BLOOD Glucose-77 UreaN-30* Creat-1.1 Na-142 K-4.3 Cl-118* HCO3-17* AnGap-11 [2196-12-14] 09:34AM BLOOD Calcium-6.8* Phos-3.2 Mg-1.9 Brief Hospital Course: Mrs. [Known lastname 25588] is an 85 year old female with a PMH significant for CAD s/p CABG and recent hospitalization for rectal perforation and small bowel prolapse complicated by necrosis now s/p rectocolectomy and percutaneous chole with course complicated by pneumonia and C.diff transferred from OSH on [12-4] for septic shock secondary to fungemia and bacteremia. # Sepsis: Patient with blood cultures from [12-4] positive for coag negative Staph and [Female First Name (un) 564] parapsilosis. Also with positive C.diff from OSH in prior week and possible intraabdominal infectious process. - Continued PO vanco and IV flagyl for C. diff coverage - Continued caspofungin for fungemia. Continue for 14 days from first negative blood culture ([2196-12-5]). After transfer to floor, patient remained hemodynamically stable with gradually increasing blood pressure. No fevers, WBC normalized. . # Coagulopathy: Likely combination of nutritional deficiency in conjunction with antimicrobial therapy altering gut flora. Improves with intermittent po Vitamin K . # Acute on chronic renal failure: Improved to baseline by time of discharge. . # Anemia: stable and did not require any transfusions . # Rectocolectomy: Patient evaluated by surgery and wound care. Wound care recommendations provided for abdominal wound and ostomy. - Fentaynl patch - oxycodone prn dressing changes . # Biliary drain: scheduled to be removed in 3 weeks. . # PAF: Continues to appear to be in afib/flutter on telemetry. Pt was started on metoprolol 12.5 [Hospital1 ] for rate control and tolerating. . # History of CAD s/p CABG with MI in [2194]. Stable, although period of elevated biomarkers during hospitalization thought due to demand ischemia. - Aspirin continues to be held due to complicated recent surgical history. Please consider restarting Aspirin 81 mg in approx 1 week. . # CHRONIC CHF: In [11-22], LVEF>55% without evidence of diastolic dysfunction. Resumed on po lasix, tolerating well. Lasix dose increased prior to discharge to 40 mg po q am, 20 mg po qpm. Titrate prn according to volume status, blood pressure, and renal function. . # HYPERLIPIDEMIA: Hold statin for now. Restart in future . # HYPOTHYROIDISM: TSH elevated to 23. T3/T4 low. Levothyroxine dose was increased [12-5]. Recommend rechecking TSH/thyroid panel in approx 4 weeks and titrate synthroid as needed. . # Code: DNR/DNI . . Per Geriatrics consult: <br> <b>A. Potemtial for Delirium</b> --no evidence of delirium at this pint; 0/4 CAM criteria REC: cont. non-pharm measures, avoidance of anticholinergic/sedating Rx, daily CAM re-assesment; as per previous recs. <br> <b>C. Wound </b> --closure by secondary intention, no new Recs. (T-tube out in 3 weeks) <br> <b>D. Insomnia </b> --pt denies somnolenc w/ 25mg of trazadone --consider trazadone 25mg PO q 8PM; re-assess at 9PM if not somnolent give additional 25mg PRN. <br> Medications on Admission: 1. Amlodipine 5 mg a day. 2. Atenolol 12.5 mg a day. 3. Atorvastatin 20 mg a day. 4. Calcitriol 0.25 mcg PO daily. 5. Furosemide 20 mg a day. 6. Levothyroxine 150 mcg. 7. Lisinopril 10 mg. 8. Aspirin 81 mg. 9. [Doctor First Name ] 60mg PO bid. 10. Procrit [2188] units (? frequency) 11. Sodium bicarb 50meq IV bid (per [Hospital ] rehab transfer log) 12. Flagyl 500mg PO tid 13. SC heparin tid 14. Tylenol prn Discharge Medications: 1. Caspofungin 70 mg Recon Soln Sig: 50 mg Recon Solns Intravenous Q24H (every 24 hours) for through [2196-12-20] days. 2. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for through [2196-12-20] days. 3. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for through [2196-12-20] days. 4. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for dressing changes. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: # Fungemia; [Female First Name (un) ] parapsilosis # Sepsis # Coagulopathy # Acute on chronic renal failure # Anemia of chronic disease # History of rectocolectomy; abdominal wound healing by second intention # History of paroxysmal afib # Generalized anasarca # Hypothyroidism; TSH 23, synthroid increased # Hyperlipidemia Discharge Condition: Stable Discharge Instructions: Continue antibiotics as prescribed. Please discontinue foley as soon as possible. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2197-3-10] 3:40 . Per Surgery service: discontinue biliary drain in 3 weeks. . Wound care as per instructions provided in "Page 1". . Please monitor fluid balance, renal function, and blood pressure. Titrate lasix as needed. Name: [Known lastname 4392],[Known firstname 1911] S. Unit No: [Numeric Identifier 4393] Admission Date: [2196-12-4] Discharge Date: [2196-12-15] Date of Birth: [2111-10-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 128] Addendum: Pt discharged to [Hospital ] Rehab MACU. . Note clarification of Lasix dosing: 40 mg po qam; 20 mg po qpm (changed from 20mg po BID) Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - MACU [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 131] MD [Last Name (un) 132] Completed by:[2196-12-15]	[ "285.21", "584.9", "412", "276.2", "585.9", "276.1", "008.45", "995.92", "038.19", "427.31", "785.52", "403.90", "428.0", "112.5", "428.32", "V45.81", "272.4", "244.9", "V44.3" ]	icd9cm	[ [ [] ] ]	[ "99.04", "38.93" ]	icd9pcs	[ [ [] ] ]	13466, 13690	7371, 10319	275, 281	12402, 12411	4933, 4933	12541, 13443	4470, 4540		10791, 11941		12051, 12381		10345, 10768			12435, 12518								4555, 4914																						224, 237														309, 3639							4948, 7348						3661, 4192	4208, 4454
31,485	148,396	33067+57830	Discharge summary	report+addendum	Admission Date: [2170-11-20] Discharge Date: [2170-11-29] Date of Birth: [2149-6-30] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2724] Chief Complaint: LE paralysis Major Surgical or Invasive Procedure: Posterior Thoracic Fusion T [12-6] with left iliac crest bone graft History of Present Illness: HPI: 21 yo male with no medical problems sustained fall from dirt bike and landing on his back. He had LOC and amnesia for event. From onset, he had no movement of his legs bilaterally with intact sensation to LT. He presented to OSH where pelvic and chest xrays were reportedly negative. With likely cord trauma, pt was transported to [Hospital1 18] ED for further evaluation. ROS: Gen: No fevers/chills/sweats, CP, SOB, palpitations, N/V, URI, cough, abd pain, dysuria, melena, BRBPR, rash, travel Neurological: No deficits noted in: memory, personality, vision, hearing, language/speech, swallowing, coordination, writing, walking, bowel/bladder function. No history of stroke, HA, seizures. Past Medical History: none Social History: lives with family Family History: none Physical Exam: VS: T 97.2 HR 100 BP 144/63 RR 12-14 Sat 98 % on RA PE: General NAD HEENT AT/NC, MMM no lesions Neck Supple, no bruits Chest CTA B CVS RRR, no m/r/g ABD soft, NTND, + BS EXT no C/C/E, no rashes or petechiae NEUROLOGICAL MS: General: alert, appropriately interactive, normal affect Orientation: oriented to person, place, date, situation Speech/[Doctor Last Name ]: fluent w/o paraphasic errors; simple and complex command-following w/o L/R confusion. Repetition, naming intact CN: II,[Known lastname 1105]: VFFTC, pupils 4-2 mm bilaterally to light [Known lastname 1105],IV,V: EOMI, no ptosis. Normal saccades/pursuits V: sensation intact to LT/temp VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: voice normal, palate elevates symmetrically [Doctor First Name 81]: SCM/trapezeii [4-1] bilaterally XII: tongue protrudes midline without atrophy or fasciculation Motor: Normal bulk and tone; no tremor, rigidity, or bradykinesia. No pronator drift. good rectal tone per Trauma staff. (repeat rectal tone several hours later - without rectal tone) Delt [Hospital1 ] Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 IP Quad Hamst DF [Last Name (un) 938] PF L2 L3 L4-S1 L4 L5 S1/S2 Reflex: [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 1 1 1 0 0 mute R 1 1 1 0 0 mute Sensation: LT, vibration, JPS intact throughout. Temp level at T9; PP level at T8. Coordination: No dysmetria with Finger-nose-finger. Gait: not tested Pertinent Results: [2170-11-20] 05:15PM GLUCOSE-119* LACTATE-1.6 NA+-144 K+-3.4* CL--101 TCO2-31* [2170-11-20] 05:00PM UREA N-21* CREAT-1.2 [2170-11-20] 05:00PM AMYLASE-46 [2170-11-20] 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2170-11-20] 05:00PM WBC-19.6* RBC-4.90 HGB-14.8 HCT-43.1 MCV-88 MCH-30.2 MCHC-34.3 RDW-16.4* [2170-11-20] 05:00PM PT-13.5* PTT-21.2* INR(PT)-1.2* Shoulder XR: 1. Posterior dislocation of the left humeral head. No fracture identified. Tib/Fib: negative for fracture MR [Last Name (Titles) ]: 1.Acute displaced and comminuted fractures of T5 and T6, with anterior wedging of T6 and retropulsed fragments causing moderate-severe cord compression, 2. Focal high signal intensity within the cord at T5-6, likely representing contusion or edema. Prevertebral hematoma at the fracture site. Mild degenerative changes. CT torso: 1. Acute fractures of T5 and T6 with components of lateral translation and anterior compression resulting in an unstable injury. Additionally, there are small displaced osseous fragments projecting into the central canal at this level with associated narrowing of the central canal. Given all of these findings, an emergent MRI is recommended to further assess the spinal cord and to exclude the possibility of an epidural hematoma. 2. Left 6th posterior rib fracture. Nondisplaced posterior fracture of left second rib. 3. Posterior dislocation of the left humeral head with associated impaction fracture of the anteromedial humeral head (reverse [Doctor Last Name ] [Doctor Last Name 3450] fracture). 4. No evidence of solid organ injury. Brief Hospital Course: Pt was admitted to TICU for close observation. He was kept at bedrest. Pt brought to OR [2170-11-21] - T1-10 fusion and left iliac crest bone graft. He tolerated this procedure well but due to long time prone in OR was kept intubated and transferred to TICU. He was extubated without difficulty the first post op day. His diet and activity were advanced. He continued to have sensation in legs bilaterally and began to slowly regain some movement in lower extremities throughout hospitalization. His would was healing well with staples. Wound care did evaluate pt for blisters on buttock. His pain medication was transitioned to PO. He was seen by PT/OT and social work and is a good rehab candidate. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. 11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: T5/6 fracture and subsequent spinal contusion/paraplegia Traumatic spine injury with T5-6 subluxation Discharge Condition: stable Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ daily showers ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks posy op. ?????? 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 for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: HAVE YOUR STAPLES REMOVED [2170-12-3] PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL / WILL NOT NEED XRAYS PRIOR TO YOUR APPOINMENT Completed by:[2170-11-29] Name: [Known lastname 12504],[Known firstname ] [Known lastname 875] Unit No: [Numeric Identifier 12505] Admission Date: [2170-11-20] Discharge Date: [2170-11-29] Date of Birth: [2149-6-30] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2427] Addendum: Pt was seen and evaluated by Skin Care Nurse and found to have Pressure Ulcer (gluteal) and a Traumatic Ulcer (chin). Treatment recommendations were implemented. Discharge Disposition: Extended Care Facility: [Hospital3 1174] [Hospital ] Hospital - [Location (un) ] Discharge Diagnosis: Traumatic spine injury with T5-6 subluxation Pressure Ulcer (gluteal) Traumatic Ulcer (chin). [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2428] MD [MD Number(2) 2429] Completed by:[2170-12-1]	[ "806.20", "831.00", "807.02", "E823.2", "338.18", "707.05", "910.0" ]	icd9cm	[ [ [] ] ]	[ "81.05", "79.71", "38.7", "81.64", "79.39", "00.33" ]	icd9pcs	[ [ [] ] ]	8662, 8757	4582, 5297	334, 408	6710, 6741	2894, 4559	7810, 8639	1224, 1230		5352, 6444		8778, 9031		5323, 5329			6765, 7787								1245, 2875																						282, 296														436, 1145													1167, 1173	1189, 1208
30,111	150,757	30903	Discharge summary	report	Admission Date: [2137-4-21] Discharge Date: [2137-4-29] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: Abdominal Pain Fever Jaundice Change in mental status Major Surgical or Invasive Procedure: ERCP and stent placement History of Present Illness: This is a [Age over 90 ] year old male with A-fib, DMS, Parkinson's, now with fever, jaundice, mental status change. He was sent from [Hospital 100] rehab with 2-3 days fo these symptoms. His drain was removed on [2136-9-3] after cystic duct shown to be patent on cholangiography. Past Medical History: Parkinson's, CRI, DVT s/p filter, afib, hip fracture, IBS, DM2, lobectomy for PNA, PEG Social History: Resides at [Hospital 100] Rehab Family History: nc Physical Exam: 101.2, 116, 97/57, 22, 92% RA NAD, A+O x 3 NCAT, no LAD or masses Irreg, systolic click distendeed, hypo BS, soft, mildly diffuse tenderness. No [Doctor Last Name ], dullness to percussion Guaiac negative, no masses 1+ peripheral edema Pertinent Results: [2137-4-21] 11:30AM BLOOD WBC-15.6# RBC-4.07 Hgb-12.3* Hct-36.9* MCV-91 MCH-30.1 MCHC-33.2 RDW-15.2 Plt Ct-147* [2137-4-23] 03:30AM BLOOD WBC-12.0* RBC-3.32* Hgb-9.8* Hct-29.9* MCV-90 MCH-29.5 MCHC-32.8 RDW-14.9 Plt Ct-152 [2137-4-25] 04:30AM BLOOD WBC-9.6 RBC-3.22* Hgb-9.4* Hct-29.1* MCV-90 MCH-29.3 MCHC-32.4 RDW-15.0 Plt Ct-220 [2137-4-25] 04:30AM BLOOD Glucose-155* UreaN-47* Creat-2.0* Na-147* K-3.6 Cl-111* HCO3-25 AnGap-15 [2137-4-25] 04:30AM BLOOD ALT-17 AST-68* AlkPhos-339* Amylase-26 TotBili-8.9* [2137-4-25] 04:30AM BLOOD Lipase-33 [2137-4-24] 04:30AM BLOOD Albumin-2.8* Calcium-7.8* Phos-6.5# Mg-2.1 [2137-4-25] 04:30AM BLOOD Calcium-7.3 Phos-4.4# Mg-1.9 [2137-4-22] 03:05AM BLOOD calTIBC-231* Ferritn-528* TRF-178* . US ABD LIMIT, SINGLE ORGAN [2137-4-21] 1:44 PM IMPRESSION: 1. Cholelithiasis, with findings most compatible with chronic cholecystitis. 2. Small foci of [Last Name (LF) ], [First Name3 (LF) ] be related to recent cholecystostomy tube. Findings were posted to the ED dashboard at the time of interpretation. . Cardiology Report ECG Study Date of [2137-4-21] 12:05:52 PM The rhythm is initially a narrow complex tachycardia that gives way to sinus tachycardia at the end of the strip. Left axis deviation. Left anterior fascicular block. There are tiny R waves in the inferior leads consistent with possible prior inferior myocardial infarction. No previous tracing available for comparison. Read by: [Last Name (LF) 2194],[First Name3 (LF) ] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 117 114 114 302/401 4 -71 79 . PORTABLE ABDOMEN [2137-4-23] 7:08 AM IMPRESSION: No evidence of acute cardiopulmonary process. . Brief Hospital Course: This is a [Age over 90 ]M with hx of cholecystitis, cholecystostomy tube removed [8-27], now in from [Hospital ] Rehab w/MS changes, fevers, jaundice. He was admitted to the ICU and received fluid resuscitation. An ERCP consult was obtained and he went for urgent ERCP at the bedside with stent placement. Pus was noted after cannulation and stent. He required Levophed and propofol for a short time with intubated and was extubated on [2137-4-22]. He was started on Unasyn. Micro showed: [4-21] BCx - GNR [4-21] Bile - PMN, 4+ GNR, 2+ GPC, PSEUDOMONAS AERUGINOSA. He will require 2 weeks of Zosyn and Vanc. He was then transferred out to the floor and did well. Pain: He was on Tylenol standing TID. Abd/GI: He was NPO and was started on G-tube tube feedings. He was tolerating these. His abdomen was still distended. He was having bowel movements and was receiving enema's as he had a large amount of stool in the colon. At time of discharge, his abdomen had softened and he was less distended. His discharge tube feeding order is as follows: Tubefeeding: Probalance Full strength; Starting rate: 50 ml/hr; Advance rate by 10 ml q6h Goal rate: 75 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Flush w/ 100 ml water q6h Hyperbilirubin: His Tbili remained elevated even after stent placement to 10.9. The Tbili was slowly trendig down and was 5.8 prior to discharge. He had biliary stasis. His bilirubin should continued to be monitored and if remains elevated, will likely need repeat ERCP. Acute on Chronic Renal Failure: His Cr on admission was 3.0. After fluid resuscitation his CR improved to 2.0. Upon discharge his Cr is 1.6 ID: The patient will require 14 days of vanc/zosyn through PICC placed [4-26] Upon discharge, the patient was afebrile with all vitals stable, tolerating tube feeds, and in stable condition. Medications on Admission: tylenol, calcitonin, sinemet, vit D, colace, lovenox, famotidine, finasteride, fluticasone, folate, lasix, gabapentin, levoxyl, PPI, flomax Discharge Medications: 1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): via g tube. 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] PRN as needed for constipation. 4. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) ML PO TID (3 times a day). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): via gtube. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): Fingerstick Q6HInsulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [11-21] amp D50 61-120 mg/dL 0 Units 121-160 mg/dL 2 Units 161-200 mg/dL 4 Units 201-240 mg/dL 6 Units 241-280 mg/dL 8 Units > 280 mg/dL Notify M.D. TO Insulin SC (per Insulin Flowsheet) Sliding Scale Fingerstick Q6HInsulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [11-21] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 2 Units 141-160 mg/dL 4 Units 161-180 mg/dL 6 Units 181-200 mg/dL 8 Units 201-220 mg/dL 10 Units 221-240 mg/dL 12 Units 241-260 mg/dL 14 Units 261-280 mg/dL 16 Units > 280 mg/dL Notify M.D. . 9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): via gtube. 10. Levothyroxine Sodium 32.5 mcg IV DAILY 11. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 12. Pantoprazole 40 mg IV Q24H 13. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 14. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 14 days. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Gram Intravenous Q48H (every 48 hours) for 14 days. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Cholangitis Discharge Condition: Good Discharge Instructions: You were admitted with cholangitis. You had an ERCP and stent placed successfully with purulent drainage. 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. * Your skin, or the whites of your eyes become yellow. * 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. * You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[9-4] lbs) for 6 weeks. * You may shower and wash. No tub baths or swimming. Keep your incision clean and dry. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 2833] Date/Time:[2137-5-31] 10:30 Please follow-up with Dr. [Last Name (STitle) ] for repeat ERCP with stent removal in 2 months. Call ([Telephone/Fax (1) 10532] with questions or concerns. His office will contact you for an appointment.	[ "459.81", "576.2", "733.00", "V44.1", "V12.51", "585.9", "285.9", "332.0", "244.9", "427.31", "576.1", "041.7", "564.1", "338.29", "724.00", "584.9", "250.00" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.6", "51.87" ]	icd9pcs	[ [ [] ] ]	7112, 7177	2869, 4752	314, 341	7232, 7238	1123, 2846	8625, 8993	843, 847		4942, 7089		7198, 7211		4778, 4919			7262, 8602								862, 1104																						221, 276														369, 663													686, 774	790, 827
30,442	152,591	26332	Discharge summary	report	Admission Date: [2134-11-28] Discharge Date: [2134-12-3] Date of Birth: [2092-2-24] Sex: M Service: MEDICINE Allergies: Quinolones / Aspirin / Nsaids / Penicillins Attending:[First Name3 (LF) 348] Chief Complaint: CC:[CC Contact Info 65165] Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 42yoM bipolar transferred from psych facility for change MS, blurry/darting vision, Tmax 101.2 on admission. Pt with delusions and AH. Patient was initially admitted to [Hospital 65166] hospital on [11-25] w/ new-onset AH, fear of bacteria in his body, rash on trunk/extremities after falling in fish tank. Transferred to [Hospital 1680] [Hospital ] hospital on [11-26] for presumed exacerbation of bipolar disorder, transferred to [Hospital1 18] ED for change in mental status: confusion, waxing/[Doctor Last Name 688] LOC, pseudo-seizure activity, blurry vision, leaning toward left, and frequently unwilling to talk. In ED, evaluated by psych - delirium of unclear etiology, suspicion for serotonin syndrome (was on nortriptyline, effexor, paxil), recommended DC-ing all meds. Tmax 101.2, tachycardic to 112. EKG showed ?strain vs. ischemia, borderline LVH, Trop T negative x1, tox screen (+ benzos/opiates), BAL at initial hospital 1.2, CT head negative for ICH/edema, CXR negative, LP (-). Given haldol 5mg x3, ativan 2mg IVx4, Morphine 4 mg IV x5, 6 mg x1, 40meq K, ceftriaxone 2 gm IV x1, vanco 1 gm IV x1. Admitted to MICU for increased nursing requirements, with neuro and tox consults. On ROS upon admission, currently complains of pain in R shoulder, reproducible midline chest pain, and worms coming out of his throat suffocating him. Per patient's mother: patient has been tremulous x2 months, he has a cleaning lady and nurse who help him bathe/dress at home, baseline MS ranges from quiet to anxious and coherent to confused. Patient reports that he only took Baclofen 2 doses x 2days and stopped b/c he didn't like it. He does take Morphine 120 [Hospital1 ] at home. Past Medical History: PMH: -bipolar disorder -ankylosing spondylosis -chronic R shoulder pain, hx of clavicle fracture in [2129], s/p ? iliac crest bone graft, failed fixation, and s/p partial claviculectomy. s/p humerus fracture [1-30] and rotator cuff tear. -COPD (per [Hospital1 1680]) -DJD -peripheral neuropathy -? rheumatoid arthritis Social History: SH: He smokes approximately a pack a day and has done so for 10 years. Per [Hospital1 1680] records, pt has h/o EtOH dependence, sober x 8 years. Smokes occasional marijuana, last use allegedly 10 years ago. Per [Hospital1 1680] HRI records, pt lives by himself in [Location (un) 1157] area. On SSDI. Used to stock shelves at shipping & receiving warehouse. Pt is his own legal guardian. Family History: FH: NC Physical Exam: PE: T: 98.2 BP: 135/63 HR: 99 RR: 22 O2 95% RA Gen: Not oriented to place ([Location (un) 11084]), but then says he's in [Location (un) ], lying in bed, tremulous, cooperative. c/o worms suffocating him. HEENT: no conjunctival pallor, no scleral icterus appreciated, MMM, no posterior pharyngeal erythema appreciated. NECK: no submandibular or anterior cervical LAD. CV: RR, Nl S1, S2, no murmurs, rubs, gallops. Reproducible midline chest pain. LUNGS: CTAB, no wheezes/rhonchi/rales ABD: + BS, soft, non-tender, non-distended abd. No organomegaly appreciated. Stretch marks EXT: No lower extremity edema. 2+ DP pulses b/l. Multiple excoriations/scabs on lower extremities bilaterally. Ecchymosis around knees and elbows bilaterally. Diffuse erythematous macular rash on lower extremities. NEURO: PERRL 4 mm->2mm. EOMI. Palate elevates symmetrically. Tongue with slight deviation left. Few beats of nystagmus on lateral gaze. Diffuse oral, upper and lower extremity myoclonus. No foot clonus. Preserved sensation throughout. Normal passive ROM bilaterally, possible increased lower extremity tone compared to right. Patient unable to relax, so difficult to assess reflexes. Negative Babinski sign bilaterally. PSYCH: Visual hallucinations during interview (thought someone was hitting me with a fire extinguisher) Pertinent Results: LABS: na 144, K 3.1, cl 107, hco3 23, bun 26, cr 0.9, gluc 124, ck 1436, trop <0.0.1 x2, wbc 4, hct 33.3, plat 153. LP --> pro 57, gluc 61, 2 wbc, 10 poly. Urine benzos+, urine opiates+. UA wbc [3-29], rare bacteria. INR 1.2. . MICRO: [11-27]: Blood Cx NGTD [11-28]: CSF: gram stain: no microorganisms, Cx Pending . STUDIES: CXR (-) CT head (-) Brief Hospital Course: A/P: 42 yo M w/ Hx of bipolar disorder on Paxil, Effexor, nortriptyline; R shoulder pain on Morphine who presents with AH, agitation, and Tmax 101.2. . # Psych: Patient has possible serotonin syndrome (on Paxil 60mg daily, Effexor 300mg, and nortriptyline 40 [Hospital1 ]), presents with delerium, hallucinations, myoclonus/tremor, tachycardia, and fever. NMS is a possibility with fever and MS change (on olanzapine), but usually less acute in onset. Infectious causes have been effectively ruled out: CXR nl, UA with rare bacteria, blood cx NGTD, LP normal. The other likely diagnosis was baclofen withdrawal (rigidity, hallucinations, hyperthermia). Other diagnoses entertained also included anticholinergic delirium, opioid withdrawal (very high doses of morphine as outpatient and was recently switched <1 day to methadone), EtOH withdrawal as BAL 1.2 at OSH, [Location (un) 3484] syndrome as hypokalemic but random cortisol 20.6 so less likely, elevated Na, and agitation. Patient initially on Ativan and Cyproheptadine, which have been which were stopped. An ABG was checked and it was normal. TSH low normal at 0.83. The leading diagnosis was serotonin syndrome. In consultation with the psychiatry service all his psychiatric medications were held including effexor, nortriptyline, paxil, Zyprexa, Klonopin, Norflex, amantadine, Zonegram, Lamictal, Zolpedim, Methocarbamol. He was restarted on his Baclofen 5mg TID and maintained on a Valium CIWA scale for possible withdrawal and intermittent mild agitation. He required only 5mg Valium every 6 hours at maximum. At the time of discharge, his vitals were stable, without tachycardia or fever, the patient was calm and denying hallucinations. It was felt that he was stable enough to return home with close psychiatric follow up by his VNA and his outpatient psychiatrist. Prior to discharge we was restarted on olanzapine 20mg PO QHS with further medication changes to be determined by his outpatient psychiatrist. . # Peripheral Neuropathy: Patient began noting increasing old peripheral neuropathy in hands and feet after discontinuation of Nortryptyline. This medication was restarted in consultation with Psychiatry for the patients comfort with good effect. . # R shoulder pain: Patient on MS Contin 120 mg [Hospital1 ] as outpatient, switched to Methadone at [Hospital 1680] Hospital. The methadone was stopped and the patient was changed to PRN Morphine IR q4 with good effect and no signs of withdrawal. He should follow up with the Pain Center after discharge. . # Elevated CK: His CK was up to 1436 upon admission, with concern for rhabdomyolysis and neuroleptic malignant syndrome. However it continued to trend down with some gentle hydration, 1436->1175->817->362->188 upon discharge. . # EKG changes: Initially EKG showed ST depression in V2-V5, no prior EKG to compare. He was ruled out for acute coronary syndrome by negative cardiac biomarkers times 3 and and repeat EKG showed improvement/resolution of these changes. . # Hypercholesterolemia - Holding Lipitor while CK elevated . # fEN/PPx - no indication for PPI, not on PPI at home. No aspiration concern currently, Regular diet: feeds with supervision. - heparin SQ . # CODE - full. . # [Name (NI) ] - Mother [Name (NI) 65167] [Telephone/Fax (1) 65168] . Medications on Admission: MEDICATIONS PRIOR TO ADMISSION TO [Hospital ] HOSPITAL: (confirmed by CVS) -Patient has had multiple recent medication changes (zyprexa, effexor (recently uptitrated 300 from 150), nortriptyline) Zyprexa 30mg po HS Baclofen 10mg po TID Klonopin 0.5mg po TID Lipitor 20mg po HS Norflex 100mg po BID Amantadine 200/200/100 Zonegram 100mg po HS Fluconazole 50mcg nasal spray Morphine sulfate 120mg po Q12 Lamictal 200mg po daily (no recent changes) Effexor XR 150mg --->300mg Zolpidem 10mg po HS prn Paroxetine 60mg po qAM Hydrocodone/APAP 10/500 prn Folic acid 1mg po daily Methocarbamol 750mg prn Nortriptyline 40mg po BID . MEDICATIONS AT TIME OF TRANSFER TO [Hospital1 18] mevacor 20mg po HS notriptyline discontinued amantadine 75mg po HS baclofen 5mg po TID effexor Xr 225mg po daily MVI klonopin 0.5mg po TID lamictal 200mg po daily paxil 60mg po daily zonegram 100mg po HS ambien prn vicodin discontinued methadone 5mg po TID . ALLERGIES: Penicillin, Levaquin, NSAIDs Discharge Medications: 1. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:60 Tablet(s) Refills:1 2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for agitation. Disp:30 Tablet(s) Refills:0 3. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:30 Capsule(s) Refills:2 4. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Olanzapine 20 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Americare at Home Inc Discharge Diagnosis: Serotonin syndrome vs. Baclofen withdrawal Discharge Condition: Afebrile. All VSS. Calm and denies hallucinations. Discharge Instructions: You were admitted with confusion, hallucinations, tremors, fevers, and myoclonus. These symptoms were suggestive of either serotonin syndrome or Baclofen withdrawal. It was felt that many of your medications were contributing to your symptoms. We stopped all of your medications except the Baclofen, some Morphine for pain control, Valium for Anxiety, and nortryptyline for neuropathy. The psychiatrists with work with you to slowly add back medications to control your bipolar disorder in a safe manner. Your muscle enzymes were also slightly elevated but they have come back to normal. Your EKG was also slightly abnormal initially but also got better. Followup Instructions: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3647], North Central, Weds. [12-8] at 11:30am, [Telephone/Fax (1) 65169]. Please call to follow up with the Center for Pain and Medical Rehab (Dr. [First Name8 (NamePattern2) 17703] [Last Name (NamePattern1) 724]) : [Telephone/Fax (1) 65170] for further control of your pain.	[ "276.8", "496", "296.80", "338.4", "333.99", "738.4", "355.8", "E939.0", "719.41" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]	9577, 9629	4662, 7985	334, 340	9716, 9769	4276, 4638	10472, 10841	2895, 2903		9017, 9554		9650, 9695		8011, 8994			9793, 10449								2918, 4257																						265, 296														368, 865								880, 2105					2127, 2459	2475, 2879
31,519	130,943	45747	Discharge summary	report	Admission Date: [2140-3-7] Discharge Date: [2140-3-17] Date of Birth: [2067-10-28] Sex: F Service: MEDICINE Allergies: Halcion / Ambien Attending:[First Name3 (LF) 898] Chief Complaint: MS changes, malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. [Known lastname 97475] is a 72 yo F with ESRD on HD (MWF) [2-20] hypertensive nephrosclerosis, as well as malignant HTN and hyperparathyroidism, who presented with confusion and severe HTN (240's/140's) on [2140-3-7] and was admitted for hypertensive emergency and altered MS. She also has had diarrhea and abdominal pain with emesis x 1. She was due to receive HD on [2140-3-7] but missed her appt. She was brought in by her son for a change in mental status from baseline. Of note, her PD catheter was w/o a cap -- she was trialed on PD, but stopped because it was too difficult. She is currently on HD. . In the ED, initial V/S: T 96.4 HR 113 BP 187/116 RR 28 O2sat 96%RA. She was given Diovan 320, Hydral 10, Vanco, Ceftriaxone, and Kayexalate. Her BP was up to 240's/140's and she was started on a nitro gtt. Pt was seen by renal in the ED. She underwent a head CT, which showed no acute pathology. She was empirically covered with vancomycin and ceftriaxone for possible infection from PD cath; however, peritoneal fluid only had 35 WBC's. A CT abdomen and pelvis was unremarkable except for some cystic lesions in the tail of the pancreas for which the MICU team is recommending MRI f/u non-urgently. She required a nitro gtt for BP control in the MICU. The team felt her elevated pressures were [2-20] medication non-compliance, bad underlying disease, and underdialysis. They have made adjustments to her home PO regimen. MS changes are likely due to underlying cognitive decline vs. hypertensive encephalopathy vs. ? infectious etiology. She had one episode of Afib with RVR, which responded to Diltiazem gtt, and is on a heparin gtt. She will have her PD catheter removed and an AV fistula placed as an outpatient. . ROS: The patient denies confusion, headache, changes in vision, chest pain, SOB out of proportion to her usual SOB, abdominal pain, nausea, diarrhea, weakness or edema. Past Medical History: 1. CKD stage V. 2. Hypertensive nephrosclerosis. 3. History of malignant hypertension. 4. Osteoporosis seen in bone density [2137]. 5. No evidence of vascular calcification on recent MR imaging. 6. Anemia of chronic disease. 7. Hyperparathyroidism. Social History: Pt is a former smoker, but denies current use of tobacco alcohol, or illicit drug use. Pt has 2 children, is widowed, and formerly wored as an X-ray tech. Family History: NC Physical Exam: Physical Exam VS: Temp 96.8 BP 152/110 HR 88 RR 16 O2sat 99% 2L FS 104 GEN: Pleasant female lying in bed, NAD SKIN: No rashes/lesions/discolorations HEENT: NCAT, no scleral icterus, no conjunctival pallor, MMM, OP clear CV: Regular rhythm, normal rate, no M/R/G PULM: CTAB anteriorly ABD: NABS, no bruits, soft, NT/ND, no masses or organomegaly BACK: No spinal or costovertebral angle tenderness EXT: No c/c/e, warm, 2+ DP pulses bilaterally NEURO: A&O x 3, able to give coherent history Pertinent Results: [2140-3-7] 05:05PM BLOOD WBC-7.3 RBC-5.09# Hgb-14.1# Hct-46.1# MCV-91 MCH-27.6 MCHC-30.5* RDW-17.0* Plt Ct-234 [2140-3-7] 05:05PM BLOOD Neuts-84.6* Lymphs-10.1* Monos-4.5 Eos-0.4 Baso-0.4 [2140-3-7] 05:05PM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2* [2140-3-7] 05:05PM BLOOD Glucose-121* UreaN-47* Creat-7.5# Na-139 K-7.5 Cl-96 HCO3-19* AnGap-32* [2140-3-7] 05:05PM BLOOD ALT-15 AST-37 CK(CPK)-102 AlkPhos-177* TotBili-0.4 [2140-3-7] 05:05PM BLOOD Lipase-38 [2140-3-7] 05:05PM BLOOD CK-MB-9 [2140-3-7] 05:05PM BLOOD cTropnT-0.19* [2140-3-7] 05:05PM BLOOD Albumin-4.5 Calcium-10.2 Phos-7.1# Mg-2.4 [2140-3-7] 10:27PM BLOOD Hapto-46 [2140-3-7] 05:05PM BLOOD Digoxin-0.2 [2140-3-7] 05:15PM BLOOD Type-[Last Name (un) ] Temp-36.9 Rates-/36 O2 Flow-2 pO2-115* pCO2-31* pH-7.43 calTCO2-21 Base XS--2 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL [Last Name (un) 154] [2140-3-7] 05:15PM BLOOD Glucose-117* Lactate-3.0* K-6.3* . CXR: [2140-3-7] Right-sided dialysis catheter again seen with tip in the right atrium. Cardiac and mediastinal contours appear stable. Slight increase in interstitial markings seen, consistent with mild pulmonary edema. Moderate bilateral pleural effusions are identified. No definite focal consolidations identified. Likely atelectasis seen at the bases. Levoscoliosis of the thoracolumbar spine is identified. Calcifications are seen overlying the atherosclerotic calcifications noted within the aorta. IMPRESSION: Mild pulmonary edema with moderate bilateral pleural effusions. . Head ct: [3-7] NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage. Confluent periventricular hypoattenuation is consistent with chronic microvascular ischemic disease. No loss of [Doctor Last Name 352]-white matter differentiation to suggest an acute intravascular territorial infarct. The ventricles are normal in size and configuration. There is diffuse increased density and mild thickening of the calvarium, perhaps related to the patient's chronic renal disease. In addition, there is a focal area of nonspecific lysis within the left parietal calvarium (3:16). The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: 1. No acute intracranial hemorrhage or edema. 2. Chronic microvascular ischemic disease. . CT abd/pelvis: [3-7] IMPRESSION: 1. No acute intra-abdominal pathology identified. Scattered foci of free air throughout the abdomen, presumably related to the patient's peritoneal dialysis catheter. 2. Moderate-sized bilateral pleural effusions with associated atelectasis. Cardiomegaly. 3. Enlarging and new cystic lesions in the distal body and tail of the pancreas, for which further evaluation by MRI is recommended. Innumerable renal cysts, which can also be evaluated at the time of the MRI. . ECHO: IMPRESSION: Severe global LV hypokinesis. Moderate to severe mitral regurgitation, moderate aortic regurgitation, moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension and probable pulmonary artery diastolic hypertension. Severe left atrial enlargement. No prior echo for comparison. . PMIBI: INTERPRETATION: Left ventricular cavity size is at the upper limits of normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal severely globally hypokinetic. The calculated left ventricular ejection fraction is 26%. Compared with the normal study of [2138-11-17], there has been marked decrease of the EF and worsening of the global wall motion. IMPRESSION: 1. Normal myocardial perfusion. 2. Severe LV systolic dysfunction (EF 26%) and global severe hypokinesis. Brief Hospital Course: 72 yo F with PMH s/f ESRD and malignant HTN who was admitted with hypertensive crisis with altered mental status. . # HTN: Pt presented with BP's to 240/140. She is usually hypertensive at baseline, however, this is elevated for her. This is likely a combination of her baseline severe HTN combined with her recent medication non-adherence (it appears that upon her last hospital discharge pt was unable to manage her medications at home on her own) and likely under-dialysis with chronic fluid overload, esp. as pt had not missed dialysis and tolerated high volume removal without becoming hypotensive. Cardiology and renal were both consulted who worked to create a better BP regimen. The patient was eventually controlled with BPs in 130s, 140s on lisinopril 40 [Hospital1 ], felodipine [Hospital1 ] and carvedilol. Renal has been working with the pt to dialyze off more fluid. She will continue dialysis as an outpatient on her MWF schedule. She is to follow up with transplant surgery as an outpatient per their recommendation for future removal of her peritoneal dialysis catheter as well as evaluaton for placement of an AV fistula. Pt refused MRIs of head and abd to evaluate for pheochromocytoma and other etiologies of mental status change. She did have a CT abd pelvis which showed new cystic lesions in the pancreas with a recommendation for further evaluation with MRI which the patient has refused due to concerns re claustrophobia. Will follow up with her primary care physician for scheduling of open MRI. . # MS change: Per her family, these mental status changes are new. Possibly hypertensive encephalopathy. Resolved with improvement in her BP. Pt had no acute findings on head CT, refused MRI. . # AF with RVR: Patient had one episode in the MICU, and another on the floor on [3-10]. She responded to a total of 30mg IV diltiazem and 2.5mg IV metoprolol, after which she converted to normal sinus rhythm. Pt has left atrial dilation on echo. This episode of AF with RVR is likely due to a combination of fluid shifts in the setting of large volume HD and atrial stretch. Rhythm was controlled with carvedilol prior to d/c. Pt was bridged on heparin to coumadin. To continue coumadin on d/c. PCP [Last Name (NamePattern4) ]. [First Name (STitle) 1313] will follow levels and monitor dosing. . # Dilated cardiomyopathy: Pt had an echo on [3-9] showing dilated LV with EF of 20%. This was new from before. Pt had an uninterpretable ECG with no anginal sx on PMIBI, new global severe sytolic hypokinesis. This cardiomyopathy is new since [10-24]. TSH, ferritin and SPEP were nl. In theory this is tachycardia induced cardiomyopathy due to her AF, unclear how long she had been in this rhythm. Pt will follow up as outpatient with Dr. [First Name (STitle) 437], she will need a repeat ECHO before consideration of possible cardiac catheterization in the future. . On day of discharge pt's BPs were well controlled 130-140. Other VSS. Pt to follow up with PCP and Dr. [First Name (STitle) 437] as well as renal and at dialysis MWF, she does to [Location (un) ] in [Location (un) ]. Pt will be discharged home with her son with [Name (NI) 269] services. She was cleared by PT. Medications on Admission: Medications: per last d/c summary as pt. does not know her medications Cinacalcet 30 mg PO DAILY Valsartan 320 mg PO DAILY Lisinopril 40 mg PO BID Metoprolol Tartrate 25 mg PO BID Simvastatin 20mg qdaily colace qdaily (likely not taking these) Discharge Medications: 1. 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:1 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:1 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:1 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:60 Tablet(s) Refills:1 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Capsule(s) Refills:1 9. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: No more than 3 grams a day. 10. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 11. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO at bedtime: You will need your blood checked regularly to monitor your coumadin levels, your PCP will contact you regarding adjustments to your dose. . Disp:150 Tablet(s) Refills:2 12. Felodipine 5 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO twice a day. Disp:180 Tablet Sustained Release 24 hr(s) Refills:1 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: 1. Malignant HTN 2. Altered mental status 3. AF with RVR Secondary: 1. CKD stage V. 2. Hypertensive nephrosclerosis. 3. History of malignant hypertension. 4. Osteoporosis seen in bone density [2137]. 5. No evidence of vascular calcification on recent MR imaging. 6. Anemia of chronic disease. 7. Hyperparathyroidism. Discharge Condition: Stable Discharge Instructions: You were admitted with very high blood pressure. We controlled your blood pressure with medications and increasing your hemodialysis. You also had some confusion. We performed an MRI of your head which showed no evidence of an acute stroke. . Please take all of your medications as directed. You were started on several new medications, one of which was a blood thinner, coumadin or warfarin. You will need to have your blood levels monitored while on this medication. Please have your INR drawn during your next dialysis and have the results faxed to Dr.[Name (NI) 6460] office at [Telephone/Fax (1) 97476]. Please discuss the finding of a pancreatic cyst on your abdomen CT with Dr. [First Name (STitle) 1313] and the need for a follow up MRI to further evaluate this. . Please follow up as indicated below. . Please return to the emergency room if you experience worsening or persistent changes in your mental status (i.e., increasing confusion, etc.) or shortness of breath, chest pain, palpitations, lightheadedness/dizziness, or any other concerning symptoms. . Followup Instructions: Please follow up with your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 1312] [Last Name (NamePattern1) 1313], by calling [Telephone/Fax (1) 7318]. [2140-3-22] 3:30 fax [Telephone/Fax (1) 97476] You have a follow up appointment with Dr. [First Name (STitle) 437] in the [Hospital 1902] clinic on [2140-3-28] at 11am, please call his office if you need to reschedule or with any questions, [Telephone/Fax (1) 3512]. You should follow up with [First Name8 (NamePattern2) 5969] [Last Name (NamePattern1) 15170] ([Telephone/Fax (1) 20193] to schedule outpatient PD catheter removal and AV fistula and graft placement. You also have the following appointments scheduled in our system: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 11082], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2140-8-2] 10:30	[ "593.2", "577.2", "285.21", "437.2", "V15.81", "V45.1", "733.00", "428.20", "427.31", "425.4", "V15.82", "588.81", "403.01", "585.6", "428.0" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	12121, 12179	7052, 10313	311, 317	12563, 12572	3294, 4868	13707, 14601	2761, 2765		10607, 12098		12200, 12542		10339, 10584			12596, 13684								2780, 3275																						237, 273														345, 2289				4910, 7029									2311, 2572	2588, 2745
26,872	171,976	2536	Discharge summary	report	Admission Date: [2185-12-1] Discharge Date: [2185-12-5] Date of Birth: [2131-11-6] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Lipitor / Glucophage Attending:[First Name3 (LF) 3531] Chief Complaint: GI bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 54 year old female with hx GIB from Upper GI AVM's (stomach, duodenum, jejunum), on coumadin for extensive DVT s/p IVC filter, DM, asthma, and OSA who presents with 2 days of dark stools and lightheadedness. The patient reports that she has had dark, non-bloody stools for two days associated with lower quadrant cramping. She also reports lightheadeness on standing for the past week, no syncope. She denies any vomiting, nausea or hematemasis. She went to her PCP today who recommended that she go the ED. At her PCP's office, she was found to have a BP 110/60 sitting, tenderness in abd in lower midline, hemoccult + stools. At her PCP's office, labs were done which showed a Hb 7.3 and INR 2.5. Of note, she had a ferillicit infusion on [11-14] for chronic anemia likely [2-21] slow GIB. In the ED: triage VS 97.2 66 130/66 15 97%. She was found to have lower abd discomfort, guiac positive brown stool w/o any overt melena. Her HCT was found to be down 27 from 31 at the end of [Month (only) 359], but up from 25 during presumed GIB in [2185-8-20]. NG lavage was negative. She received FFP 2 units, vit K 10mg IV, protonix 80mg IV and IVF. She had a type and screen sent. CT abd was performed for abdominal pain which showed no acute process. Most recent vitals: 69 144/65 14 100%2L NC. Currently she feels well, with some nausea but no vomiting recently. Denies fever but has had some chills. Feels fatigued and weak. Mild abdominal pain. Denied cough, shortness of breath or chest pain Past Medical History: -GI Hx as of [7-/2185]: nine upper endoscopies, two small bowel enteroscopies, five colonoscopies and one sigmoidoscopy over the last six years. Multiple AVMs have been found and treated in her duodenum and jejunum. Her most recent scopes were last [Month (only) 547], when 2 angioectasias in the stomach, one in the jejunum, one in the descending colon were found. -Poorly controlled DMII -hypertension -asthma -anemia - profound iron deficiency [2-21] gastric and duodenal AV malformations as above, transfusion dependent, Hct baseline around 22-29 -depression -migraines -obesity -chronic abdominal pain -delayed gastric emptying -diverticulosis -extensive DVT [2-27] s/p thrombectomy, IVC filter placement, common and external iliac vein stenting on coumadin/plavix -OSA, on home BiPAP vs CPAP -? Meningioma (lesion identified by CT on [6-27] in left perimesencephalic region, being followed) -S/p appendectomy -S/p bilateral oophorectomy and hysterectomy -gout Social History: Negative for EtOH, very remote marijuana use (30 yrs ago). Positive tobacco use. Currently smokes 3 cigarettes/ day, 20 pack-year history. Formerly worked as a special needs counselor. Currently lives alone in an apartment in the [Location (un) 12859] in the [Location (un) 4398]. Has a son and grandchildren she sees frequently. Family History: Colon Ca in Mother and Grandmother both in 70s, HTN in Mother, Diabetes in grandfather. [Name (NI) ] family hx of thrombophilia. Son has recurrent epistaxis. Physical Exam: Vitals: T: 98.7 P: 70 BP: 142/90 R: 11 SaO2: 100% 2L NC General: obese AAF in NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, no lesions noted in OP but dry MM. Neck: supple, obese, difficult to assess JVP Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: obese, surgiclaly scarred, diffusely TTP, no peritoneal signs. Extremities: WWP. No C/C/E bilaterally, 2+ DP pulses b/l. Skin: no rashes or lesions noted Pertinent Results: Radiologic Data: Capsule Endoscopy: [8-/2185] 1. Coffee grounds in the stomach 2. delay in gastric emptying 3.Angioectasia in the proximal jejunum 4. Angioectasia in the ileum . EGD's: 11 EGD's since [2179], some with agioectasias,last EGD [2185-9-1] Erythema in the antrum compatible with mild gastritis A small bowel enteroscope was passed to what appeared to be the mid jejunum. No AVMs or other abnormalities were seen. Otherwise normal EGD to middle jejunum . Colonoscopies: 5 coloscopies since [2179], last [4-/2185] Polyp in the proximal ascending colon (polypectomy) Internal hemorrhoids Angioectasia in the descending colon Otherwise normal colonoscopy to cecum . Small bowel enteroscopy: [4-/2185] Angioectasia in the upper third of the stomach Angioectasia in the proximal to mid jejunum Otherwise normal EGD to third part of the duodenum . CT abd/pelvis: prelim no acute intra-abdominal process to explain pain . [12-6] MRA BRAIN: IMPRESSION: Marked degradation of image quality by patient motion. There is no definite evidence of a high flow [Month/Year (2) 1106] malformation, although given both patient motion and the extent of the imaging excursion, a CTA of the head would be far more sensitive for evaluation and would be less prone to motion artifact. [2185-12-1] 08:18PM WBC-5.3 RBC-3.39* HGB-6.8* HCT-23.1* MCV-68* MCH-20.1* MCHC-29.6* RDW-20.7* [2185-12-1] 08:18PM PLT COUNT-403 [2185-12-1] 08:18PM PT-17.5* PTT-24.6 INR(PT)-1.6* [2185-12-1] 12:30PM PT-25.9* PTT-26.2 INR(PT)-2.5* [2185-12-1] 12:15PM GLUCOSE-108* UREA N-12 CREAT-1.0 SODIUM-142 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15 [2185-12-1] 12:15PM WBC-5.5 RBC-3.90* HGB-7.8* HCT-27.4* MCV-70* MCH-20.1* MCHC-28.6* RDW-19.1* [2185-12-5] 06:35AM BLOOD WBC-5.9 RBC-4.13* Hgb-8.8* Hct-29.6* MCV-72* MCH-21.4* MCHC-29.9* RDW-21.2* Plt Ct-388 [2185-12-4] 08:50AM BLOOD WBC-9.2# RBC-4.58 Hgb-9.8* Hct-33.9* MCV-74* MCH-21.3* MCHC-28.8* RDW-20.5* Plt Ct-455* [2185-12-3] 04:20AM BLOOD WBC-5.1 RBC-4.17* Hgb-8.8* Hct-30.6* MCV-74* MCH-21.2* MCHC-28.8* RDW-20.2* Plt Ct-397 [2185-12-2] 07:44PM BLOOD Hct-28.5* [2185-12-2] 03:47AM BLOOD WBC-5.3 RBC-4.03* Hgb-8.5* Hct-29.5# MCV-73 MCH-21.1* MCHC-28.8* RDW-20.2* Plt Ct-387 [2185-12-1] 08:18PM BLOOD WBC-5.3 RBC-3.39* Hgb-6.8* Hct-23.1* MCV-68* MCH-20.1* MCHC-29.6* RDW-20.7* Plt Ct-403 [2185-12-1] 10:40AM BLOOD WBC-5.9 RBC-3.89* Hgb-7.9* Hct-27.8* MCV-72* MCH-20.2* MCHC-28.2* RDW-20.2* Plt Ct-503* [2185-12-5] 06:35AM BLOOD PT-12.6 PTT-22.8 INR(PT)-1.1 [2185-12-2] 03:47AM BLOOD PT-15.1* PTT-22.8 INR(PT)-1.3* [2185-12-4] 08:50AM BLOOD Glucose-85 UreaN-8 Creat-1.1 Na-143 K-4.2 Cl-101 HCO3-29 AnGap-17 [2185-12-3] 04:20AM BLOOD Glucose-160* UreaN-8 Creat-0.8 Na-139 K-3.8 Cl-103 HCO3-25 AnGap-15 [2185-12-2] 03:47AM BLOOD Glucose-162* UreaN-11 Creat-0.9 Na-140 K-3.8 Cl-103 HCO3-28 AnGap-13 [2185-12-1] 12:15PM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-142 K-4.2 Cl-104 HCO3-27 AnGap-15 [2185-12-3] 04:20AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0 Brief Hospital Course: Ms. [Known lastname 11468] is a 54 year old female with a history of multiple upper GI bleeds from arteriovenous malformations who was admitted to the ICU for several episodes of melena and decreased HCT. . 1. ACUTE BLOOD LOSS ANEMIA/GI BLEED- patient has a history of multiple upper GI bleeds due to AVMs. There is concern for hereditary telangectasia disorders such as Osler-[Doctor Last Name 11586]-Rendu. She was hemodynamically stable on arrival to the ICU, after receiving one unit of FFP and 10mg Vitamin K in the Emergency department to reverse her therepeutic INR. In the ICU, she was transfused 2units of packed RBCs for a hematocrit of 23.1, with an appropriate increase in her hematocrit to 29.5. Thereafter, the patient's hematocrit remained stable. The patient was called out to the medical floor on [2185-12-3]. She underwent MRA of the brain, which although markedly limited by motion, showed no obvious intracranial AVM. Her Hct remained stable on the floor and she was instructed to follow-up with her PCP [Last Name (NamePattern4) ] [12-8]. . This plan, along with her plan to continue low dose coumadin, was discussed with Dr. [First Name (STitle) 4223] prior to discharge, and the pt will be expected in her [Hospital 11074] clinic on [12-8]. Pt and her daughter understand her ongoing risk for further bleeding in the setting of anticoagulation, and as below, elected to continue with coumadin given her significant DVT. . 2. HYPERTENSION, BENGING: The patient's home lasix, metoprolol, lisinoprl, and isosorbide were initially held due to concerns for hemodynamic instability in the setting of active GI bleed. These were restarted on [2185-12-3]. Her BP remained stable thereafter . 3. HISTORY OF DVT - Prior to admission, the patient was on chronic anticoagulation with Coumadin for history of left lower extremity DVT in [2184-2-20]. Several outpatient providers have recommended she go off anticoagulation given multiple GI bleeds but patient has been reluctant to do so. The patient's Coumadin was discontinued on admission, and her anticoagulation was reversed. Past notes indicate that her goal INR should be 1.6-2.5. Her coumadin was restarted on [2185-12-4] cautiously at a dose of 2.5mg po qdaily (baseline 5-7.5mg), as the patient strongly preferred to continue coumadin, despite a frank discussion of the risks. After discussion with her PCP, [Name10 (NameIs) ] agreed to discharge the patient on low dose coumadin, she will have her INR checked on [10-6], and again during her visit with her PCP [Last Name (NamePattern4) ] [10-8] in her [Hospital 11074] clinic, at which time a repeat HCT will be checked also. . 4. ASTHMA - Stable, Continued albuterol and Flovent. . 5. OBSTRUCTIVE SLEEP APNEA - Continued CPAP with O2 2L/min per home settings. . 6. DIABETES MELLITUS TYPE 2, POORLY CONTROLLED WITH COMPLICATIONS - The patient was treated with glargine twice daily, plus a Humalog sliding scale. . 7. NEUROPATHY - Continued gabapentin, oxycodone, and cymbalta. . 8. CHRONIC PAIN: Continued opiates per home regimen Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs every 4-6 hours as needed BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg Tablet - 1 (One) Tablet(s) by mouth every six (6) hours as needed for headache DULOXETINE [CYMBALTA] - 30 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day FABRICATE - NEW CHANNELS IN NEW SHOES FOR EXISTING KLENZAK BRACE - - use as directed as needed FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 sprays in each nostril twice a day FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs twice a day FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day if gain 2 pounds or more in one day. If you gain over 4 pounds in a day call the health center GABAPENTIN - 800 mg Tablet - 1 Tablet(s) by mouth three times a day HYDROCORTISONE ACETATE [ANUSOL-HC] - 25 mg Suppository - 1 per rectum rectally once per day after BM as needed INSULIN GLARGINE [LANTUS] - 100 unit/mL Cartridge - 75 units at noon and at bedtime sq daily INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - according to sliding scale administer twice a day - No Substitution INSULIN SYRINGES - ULTRA COMFORT 28 - - USE AS DIRECTED ISOSORBIDE MONONITRATE - 30 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth four times a day before meals and at bedtime METOPROLOL TARTRATE - 100 mg Tablet - take one Tablet by mouth twice a day MUPIROCIN CALCIUM [BACTROBAN] - 2 % Cream - apply to each naris with cotton swab twice a day OLOPATADINE [PATANOL] - 0.1 % Drops - 1 gtt OU twice a day OXYCODONE [OXYCONTIN] - 15 mg Tablet Sustained Release 12 hr - 1 Tablet(s) by mouth twice a day OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1 to 2 Tablet(s) by mouth q 6 h PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day Pt would like it delivered to her at her daughter's house at [State 12857]. Apt#3, [Location (un) 686]. SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day UREA [CARMOL 40] - 40 % Cream - apply to both feet twice a day as needed for thickened and dry skin WARFARIN - 5 mg Tablet - 1 Tablet(s) by mouth once a day except on Thursday and Sunday, take 1 1/2 tablets by mouth ZOLPIDEM [AMBIEN] - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth twice a day LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day NICOTINE - 7 mg/24 hour Patch 24 hr - apply 1 patch once a day SENNA - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. 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. 2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [1-21] Tablets PO Q6H (every 6 hours) as needed for headache. 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation DAILY (Daily). 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): or if you gain more than 2 pounds. 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day: with meals. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthough pain: do not use with alcohol or driving. limit 4 grams tylenol total per day. 14. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Oxycodone 15 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day: do not use with alcohol or driving. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constip. 19. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 20. Insulin Glargine 100 unit/mL Solution Sig: Seventy Five (75) units Subcutaneous twice a day: qMorning, qHS. 21. Insulin Lispro 100 unit/mL Solution Sig: 1-20 units Subcutaneous QACHS: According to your home sliding scale. 22. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO once a day: goal INR 1.6-2.5, follow your INR closely and re-dose accordingly. Discharge Disposition: Home Discharge Diagnosis: Acute blood loss anemia/GI Bleed DVT, chronic Asthma Hypertension, benign Type 2 Diabetes Mellitus, poorly controlled no complications Discharge Condition: Good Discharge Instructions: You were admitted with recurrence of your GI bleeding. This was likely due to your AVMS (venous malformations) plus your blood thinning from your coumadin. With supportive care and blood transfusion your bleeding stopped. Please resume your coumadin with caution and have your INR closely monitored. Please follow up with your Gastroenterologist, PCP, [Name10 (NameIs) ] hematologist. . You INR level is still subtherapeutic. You preferred to remain on coumadin, although you should discuss discontinuing this with your primary care doctor. You will need to have your INR and HCT checked with your PCP [Last Name (NamePattern4) ] [12-8]. You should see your PCP in her [Name9 (PRE) 11074] clinic by 8:30AM on [12-8], this plan was discussed with your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 4223], who is expecting you. . Thye following changes were made to your medication regimen: 1. Your coumadin dose was decreased to 2.5mg po qdaily. . Please resume all previous medications as before. Return to the hospital with fevers, chills, recurrence bloody or black stool, or other concerning symptoms. Followup Instructions: Please [Last Name (un) 5511] the [Hospital 11074] clinic on [12-8] with your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 4223], she asks that you arrive prior to 8:30AM, and is expecting you. Please call your PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 7976], if you are unable to make this appointment. . Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2185-12-20] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2185-12-20] 10:30 Provider: [Name10 (NameIs) ] FITTING TECHNICIAN Phone:[Telephone/Fax (1) 612] Date/Time:[2185-12-21] 11:40	[ "311", "280.0", "455.0", "327.23", "355.9", "790.92", "285.1", "537.83", "562.10", "V16.0", "569.85", "789.00", "401.9", "346.90", "V12.51", "493.90", "278.00", "536.8", "E934.2", "V45.89", "250.00", "338.29" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.07", "99.04" ]	icd9pcs	[ [ [] ] ]	15246, 15252	7044, 10170	317, 324	15431, 15438	3919, 7021	16636, 17415	3249, 3415		12883, 15223		15273, 15410		10196, 12860			15462, 16613								3430, 3900																						266, 279														352, 1864													1886, 2873	2889, 3233
49,999	135,281	16896	Discharge summary	report	Admission Date: [2173-7-16] Discharge Date: [2173-7-23] Date of Birth: [2122-7-26] Sex: F Service: MEDICINE Allergies: Rifampin / morphine / ceftriaxone Attending:[First Name3 (LF) 4393] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: R hickman removal L tunneled line placement History of Present Illness: Ms. [Known lastname 47598] is a 50-year-old female with a complicated past medical history including AMA-positive primary biliary cirrhosis with at least stage 3 fibrosis (LBX [5-/2164]), which has been complicated by portal pulmonary hypertension on Treprostinil gtt, non-bleeding esophageal varices, and ascites who is presenting with severe abdominal pain. She developed chills and subjective fevers yesterday, shortly afterwards she noted insidious onset of diffuse abdominal pain. She developed diarrhea, small volume and mucousy discharge [4-1] times overnight accompanied by nausea but not vomiting. She has been excessively fatigued. No recent sick contacts. The pain progressed over the daytime today- it is exacerbated by movement and relents somewhat when still. She noted severe pain during the drive to the hospital when the car hit roadbumps. She has had very poor appetite with decreased PO over the past day. She has held her diuretics. She has no history of SBP per her report. With regard to her liver disease, she has has had diuretic-controlled ascites, and she is currently taking spironolactone 100 mg daily (along with potassium supplementation given history of low K.) Her last upper endoscopy [2172-4-3] noted two cords of grade [11-23] varices. She is on nadolol 10 mg daily. She has never had bleeding esophageal varices. Her last abdominal U/S [2173-4-21] was negative for liver mass lesions. Her main complications has been portal pulmonary hypertension, which has been severe. She was hospitalized [Date range (1) 47599] @ [Hospital1 18] for placement of a central caheter and initiation of treprostinil therapy. She is on a dose escalation schedule and is currently at 106.5. Her repeat right heart cath [2173-5-19] noted PASP 45 mmHg (previously 52 mmHg.) In the ED, initial vs were 100.0F, 93, 95/62, 18. Exam was significant for exquisite abdominal pain diffusely to palpation. CT abd/pelvis showed ?peritonitis, ascites, cirrhosis, and a normal gallbladder. Discussions with liver team raised possibility of SBP, though a paracentesis could not be performed due to an inability to find an accessible pocket. She was given 2g ceftriaxone and was admitted. On arrival to the floor, VS were T99.4 BP93/47 P105 RR18 Sat95RA. She is in pain but feels better while laying still. In discussion with pharmacy given the plans for dose escalation of Treprostinil and the need for frequent vital sign checks, she was transferred to the MICU for close monitoring. On arrival to the MICU, she stated that abdominal pain continued and was improved if she remained still. Review of systems: (+) Per HPI 10lb weight gain in last 1-2 weeks (-) Denies night sweats, recent weight loss. Denies headache. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Past Medical History: -Primary Biliary Cirrhosis -Hepatopulmonary hypertension diagnosed on cardiac cath(unresponsive to sildenafil, recently started on remodulin) -Varices: upper endoscopy in [Month (only) 116] which showed 2 cords of grade [11-23] varices in the esophagus as well as varices in the fundus. -Depression Social History: Patient lives in [Location (un) ] with roommates. She has two grown children who live in TX (31 and 26). She works as a house cleaner. Formerly smoked tobacco 1 pack per three days x 15 years, quit many years ago. She drinks a wine cooler very rarely, as she is sensitive to alcohol (stays in her system a long time). No current or past drug use. Family History: Father: heart disease Mother: heart disease s/p CABG. Denies family history of gastrointestinal or renal problems Physical Exam: On Admission: Vitals: T:98.9 BP:99/60 P:92 R: 18 O2:92% 2LNC General: Middle aged female alert, oriented, appearing uncomfortable though in no acute distress HEENT: Sclera anicteric, MMM, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, S1 + loud S2, loud systolic murumr over right upper sternal border. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, diffusely tender with rebound Ext: warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge PE: Vitals: Tc- 98.5, HR 60-70s, BP 90-100s/40-50s, RR 18, 93-98% RA I/O: 250(PO) + 1548(IV) / 1850 + 4BM General: pleasant woman, A&Ox3, lying in bed, in NAD HEENT: Sclera anicteric. MMM. CARDIAC: RRR, no murmurs LUNGS: bibasilar rales with inspiratory rales up to the mid thorax on the R, otherwise clear CHEST: dressing over R hickman removal site, nontender; L-sided tunnel line without surrounding erythema, mild tenderness ABDOMEN: Distended, soft, diffuse mild tenderness to palpation. +BS. EXTREMITIES: Trace LE edema. Warm and well perfused. NEURO: no asterixis Pertinent Results: Admission Labs: ====================== [2173-7-16] 03:29PM BLOOD WBC-5.4# RBC-3.81* Hgb-11.4* Hct-34.1* MCV-90 MCH-29.8 MCHC-33.3 RDW-16.7* Plt Ct-26# [2173-7-16] 03:29PM BLOOD Neuts-90.1 Lymphs-5.9* Monos-3.9 Eos-0 Baso-0.1 [2173-7-16] 07:38PM BLOOD PT-18.9* PTT-53.5* INR(PT)-1.8* [2173-7-16] 03:29PM BLOOD Glucose-90 UreaN-17 Creat-0.9 Na-132* K-3.4 Cl-105 HCO3-20* AnGap-10 [2173-7-16] 03:29PM BLOOD ALT-36 AST-50* AlkPhos-146* TotBili-3.3* [2173-7-17] 05:18AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8 [2173-7-16] 03:29PM BLOOD Albumin-3.0* CT Abd/pelvis [2173-7-16]: 1. Subtle enhancement of the peritoneal surfaces, raising concern for peritonitis in the appropriate clinical setting. 2. Cirrhosis, with recanalization of the umbilical vein and numerous varices with ascites consistent with portal hypertension. 3. Unremarkable gallbladder, with note again made of a stone adjacent to the gallbladder wall. RUQ U/S [2173-7-17]: 1. Patent portal vein. 2. Evidence of cirrhosis and small volume ascites. 3. Mild circumferential gallbladder wall thickening, likely secondary to third spacing. 4. Massive splenomegaly. Micro: bl cx: NGTD R Hickman catheter culture: WOUND CULTURE (Final [2173-7-23]): No significant growth. URINE CULTURE (Final [2173-7-21]): NO GROWTH. Discharge Labs: ====================== [2173-7-23] 08:05AM BLOOD WBC-1.5* RBC-3.41* Hgb-9.9* Hct-30.6* MCV-90 MCH-29.0 MCHC-32.3 RDW-18.0* Plt Ct-48* [2173-7-23] 08:05AM BLOOD PT-14.5* INR(PT)-1.4* [2173-7-23] 08:05AM BLOOD Glucose-79 UreaN-13 Creat-1.0 Na-137 K-3.5 Cl-104 HCO3-24 AnGap-13 [2173-7-23] 08:05AM BLOOD ALT-24 AST-37 AlkPhos-105 TotBili-2.6* [2173-7-23] 08:05AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1 Brief Hospital Course: Ms. [Known lastname 47598] is a 50yoF with primary biliary cirrhosis (c/b portal pulmonary hypertension, ascites and esophageal varices) who presented with diffuse abdominal pain. # SBP: Exam initially showing rebound and significant tenderness, thought to be SBP given her history of cirrhosis and ascites. There was no evidence of secondary peritonitis seen on CT abdomen. Lipase was normal. Gall bladder stone is seen on CT, which could potentially explain RUQ pain but not the diffuse abdominal pain picture. Tbili decreased, as was Alk phos. All LFTs decreased but Tbili started to uptrend. No ascites fluid pocket was seen on U/S, so she was treated empirically with ceftriaxone and albumin 1.5mg/kg. Fluid resuscitation. Portal Vein patent. Drug rash [7-19] with Ceftriaxone, so switched to therapeutic PO Cipro. Started cipro ppx [7-21]. S/p albumin, received on days 1 and 3. Restarted diuretics and uptitrated spironolactone back to home dose of 50 [Hospital1 ]. Pt slightly volume up from MICU stay, so initially diuresed with IV lasix, and transitioned to PO home lasix of 20 QD. Tramadol for pain management per patient preference. Abdominal pain improved with intermittent abdominal pain throughout the hospital stay, which was controlled with tramadol. Bl cx NGTD. # Hickman with drainage, concern for pocket infection: Nurse reported drainage from Hickman starting [7-19]. Nurses intermittently reporting purulent drainage from around line. Skin pink just adjacent to line insertion site; nontender, no spread of erythema. Concern for tunnel infection. Hickman nurse evaluated and recommended line removal for concern of tunnel infection. R hickman pulled [7-21]. Remodulin run temporarily through peripheral line. New tunneled line placed on L by IR [7-22]. R catheter tip sent for culture, which was negative. Pt put on Vanc [7-21] for tunnel infection, which was transitioned to PO doxy + amoxicillin [7-22]. Pt remained afebrile. No leukocytosis. Bl cx NGTD. Plan for 5d course of ABX total to end [2173-7-25]. # Primary Biliary Cirrhosis: MELD 17 on adm from 13. Followed by Dr [Last Name (STitle) ] with plans to place on transplant list once pulmonary artery hypertension under better control. Home regimen of ursodiol and nadalol continued. No EGD since [3-/2172], will need one as outpatient. # Hypotension: BP 80/50s on [8-15] after remodulin infusion uptitrated (plan was for biweekly dose uptitration managed by pt to get to goal drop in pulm pressures in hopes for liver transplant and this plan confirmed with Dr. [Last Name (STitle) ]. Albumin challenge without much response. Pt asymptomatic. Not much changed from prior baseline of 90-100s/50-60s, but BPs improved back to baseline by time of discharge. # Portal Pulmonary Hypertension: Her repeat right heart cath [2173-5-19] while on Treprostinil showed PASP 45 mmHg (previously 52 mmHg.) Dr. [Last Name (STitle) ] has stated that his target PASP < 40 mmHG to reactivate the transplant evaluation. The plan is for her to gradually increase the dose of Treprostinil. On [7-17] Treprostinil was increased from 106 to 109 nanograms/kg/minute as was previously planned and on [7-21] dose was increased to 111.5, also as planned. Repeat RHC scheduled for [2173-9-3]. # Acute Kidney Injury: Cr 0.9 from 0.6, likely from volume depletion as she was also hyponatremic and mildly acidotic with HCO3 20. Improved with albumin. Diuretics restarted. # Thrombocytopenia: Likely related to chronic liver disease. Platelets have ranged 26-70 in the last 90 days. Trended daily and remained stable. Transitional Issues: - close f/u with Dr.[Name (NI) 47600] clinic. Will need EGD since >1yr since last. - Pt to f/u for repeat RHC in [2173-9-3]. Pt instructed to f/u with Dr. [Last Name (STitle) ] as previously planned. - Team recommended against travel until f/u with Dr. [Last Name (STitle) 10924] when pt asked about travel to visit family in [State 2690]. - Pt discharged on SBP ppx with daily cipro. - Pt discharged with 2 additional days of doxy + amoxicillin for tunnel infection from R-sided hickman. - Pt with rash after ceftriaxone, so allergies updated. - labs pending at time of discharge: Bl cultures pending (NGTD at time of discharge). Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Nadolol 10 mg PO DAILY 2. Pantoprazole 40 mg PO Q24H 3. Spironolactone 50 mg PO BID 4. Potassium Chloride 15 mEq PO BID Duration: 24 Hours 5. Treprostinil Sodium 109 nanograms/kg/minute IV DRIP INFUSION (increased from 106.5 on [2173-7-16]) 6. Ursodiol 600 mg PO BID 7. Furosemide 20 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. Nadolol 10 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Potassium Chloride 15 mEq PO BID Duration: 24 Hours 5. Spironolactone 50 mg PO BID 6. Treprostinil Sodium 111.5 nanograms/kg/minute IV DRIP INFUSION 7. Ursodiol 600 mg PO BID 8. Ciprofloxacin HCl 500 mg PO/NG Q24H RX ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 9. Lactulose 30 mL PO Q8H:PRN constipation Titrate to 3 bowel movements daily. RX lactulose 10 gram/15 mL (15 mL) 30 mL(s) by mouth every 8 hours Disp #1 Liter Refills:0 10. Amoxicillin 500 mg PO Q12H last day [2173-7-25] RX amoxicillin 500 mg 1 tablet(s) by mouth every 12 hours Disp #4 Tablet Refills:0 11. Doxycycline Hyclate 100 mg PO Q12H last day [2173-7-25] RX doxycycline hyclate 100 mg 1 tablet(s) by mouth every 12 hours Disp #4 Tablet Refills:0 12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain hold for sedation or RR<12 RX tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Primary diagnosis: Spontaneous bacterial peritonitis Secondary diagnosis: Primary biliary cirrhosis with portal pulmonary hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 47598], It was a pleasure taking care of you in the hospital. You were admitted with abdominal pain. We were unable to remove fluid from your belly to test for infection, so we treated you for a presumed infection. You did well with antibiotics and felt even better after we gave you pain medications and you had reular bowel movements. You started to drain pus from around your tunneled line, which was concerning for an infection in the tunnel. We had the line on the right removed and you had a new line placed on the left for your Remodulin infusion. Please follow-up at the appointments listed below. Please make an appointment to follow-up with Dr. [Last Name (STitle) ] as planned (([Telephone/Fax (1) 514]). Please see the attached list for changes to your medications. You will complete a course of antibiotics for your soft tissue infection from the Hickman line on the right. These antibiotics will finish on [2173-7-25]. You will also start an antibiotic called ciprofloxacin which will help to prevent infections in your belly in the future; you will take ciprofloxacin long-term. Followup Instructions: Department: [Hospital3 249] With: [Name6 (MD) ] [Name8 (MD) ], MD When: THURSDAY [2173-7-29] at 10:50 AM With: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. After this visit, you will see your regular primary care doctor in follow up. Department: LIVER CENTER When: WEDNESDAY [2173-8-4] at 1:40 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage You will be getting a Right heart catheterization on [2173-9-3]. Please call the catheterization scheduler at ([Telephone/Fax (1) 8668] to find out the time of the procedure. Department: [Hospital3 249] When: [2173-10-1] at 2:35PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36840], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 4407] Completed by:[2173-7-24*]	[ "416.8", "E879.8", "V15.82", "E930.5", "567.23", "584.9", "276.1", "571.6", "285.9", "276.2", "693.0", "311", "287.5", "999.33" ]	icd9cm	[ [ [] ] ]	[ "86.05", "38.97" ]	icd9pcs	[ [ [] ] ]	12968, 13043	7155, 10811	310, 355	13223, 13223	5372, 5372	14538, 16087	4016, 4132		11935, 12945		13064, 13064		11510, 11912			13374, 14515		6717, 7132						4147, 4147															10832, 11484			3037, 3299		4784, 5353		255, 272														383, 3018			13139, 13202		5388, 6701	13083, 13118	4161, 4770	13238, 13350					3321, 3631	3647, 4000
20,071	186,517	47786	Discharge summary	report	Admission Date: [2142-11-25] Discharge Date: [2142-11-26] Date of Birth: [2084-9-7] Sex: F Service: MEDICINE Allergies: Tramadol / Abacavir Attending:[First Name3 (LF) 2297] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname ] is a 58 year-old woman with HCV, HIV CD4 200, ESRD on HD last HD [11-23] and 9 prior admissions this year for abdominal pain and HD access issues last discharge [10-18] presenting with epigastric pain. She reports epigastric pain that began this morning and is associated with nausea and non-bloody non-bilious vomiting. She also reports mild dyspnea and orthopnea with nonproductive cough. She denies any chest pain or pressure. In the ED, initial VS were 100.1 76 221/110 16 97%RA. Labs in the ED were notable for TropT 0.01, K 7, Cr 9.4, BUN 69, WBC 4.6 and BNP 30K. She received 2mg of zofran and 10mg of morphine IV for nausea and abdominal pain in the ED. She also received 2g calcium gluconate IV, 1 amp D50 and 10units of insulin and admitted to the MICU for emergent treatment of her hyperkalemia. Vitals on transfer were 99.6 76 189/96 99% on RA. On arrival to the MICU, patient appears comforatable and is without additional complaints. Past Medical History: - HIV/AIDS on HAART CD4 200 [10-11] - CKD stage V on HD ([1-10] HTN) - RUE AVG, ligated [2142-6-15] - Hep C: Liver biopsy [3-/2137] showed focal mild-to-moderate portal - chronic inflammation with focal periportal extension (grade II) - HTN - Diverticulosis - High-grade adenomatous polyp Social History: No current IV drug use, No current etoh or Smoking Family History: non-contributory Physical Exam: VS: T: 97, P: 87, BP: 142/74, RR: 15, O2 sat 100% on RA General: Alert, oriented, no acute distress HEENT: Swollen face, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated to 12cm H2O, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to ausculation bialreally, no wheezes, rales or ronchi Abdomen: Obese, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: 1+ nonpitting edema bilat LE, 1+ DP pulses bilaterally. Discharge: VS: T: 97, P: 60, BP: 135/71, 95% on RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, no JVD, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to ausculation bialreally, no wheezes, rales or ronchi Abdomen: Obese, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: 1+ nonpitting edema bilat LE, 1+ DP pulses bilaterally. Pertinent Results: Hematology: [2142-11-26] 06:08AM BLOOD WBC-3.5* RBC-3.79* Hgb-11.4* Hct-35.4* MCV-93 MCH-30.1 MCHC-32.3 RDW-17.8* Plt Ct-124* [2142-11-25] 07:49PM BLOOD WBC-4.6# RBC-4.16* Hgb-12.0 Hct-39.4 MCV-95 MCH-28.8 MCHC-30.4* RDW-18.2* Plt Ct-160 [2142-11-25] 07:49PM BLOOD Neuts-70.8* Lymphs-25.1 Monos-3.2 Eos-0.5 Baso-0.5 [2142-11-26] 06:08AM BLOOD PT-11.2 PTT-34.8 INR(PT)-1.0 [2142-11-25] 07:49PM BLOOD PT-10.8 PTT-35.1 INR(PT)-1.0 Chemistries: [2142-11-26] 06:08AM BLOOD Glucose-95 UreaN-40* Creat-6.6# Na-134 K-4.9 Cl-93 HCO3-33* AnGap-13 [2142-11-25] 07:49PM BLOOD Glucose-95 UreaN-69* Creat-9.4# Na-138 K-7.0 Cl-94* HCO3-28 AnGap-23* [2142-11-26] 06:08AM BLOOD ALT-19 AST-27 CK(CPK)-40 TotBili-0.9 [2142-11-25] 07:49PM BLOOD ALT-20 AST-29 CK(CPK)-55 AlkPhos-604* TotBili-1.2 [2142-11-26] 06:08AM BLOOD Albumin-4.3 Calcium-10.4* Phos-4.4 Mg-2.2 [2142-11-25] 07:49PM BLOOD Calcium-10.3 Phos-4.1 Mg-2.4 [2142-11-26] 01:43AM BLOOD Lactate-1.2 [2142-11-25] 08:10PM BLOOD Lactate-2.6* K-6.5* [2142-11-25] CXR IMPRESSION: No evidence of congestive heart failure. Brief Hospital Course: 58 year-old woman with poorly controlled HTN, HIV(last CD4 200 on [10-11]), ESRD on HD presents with acute onset of abodminal pain and is found to have hyperkalemia. . #. Hyperkalemia: Patient was found to be hyperkalemic to 7.0 in the ED and was treated with calcium gluconate, D50 and insulin with follow-up value of 6.5. Patient has a recent baseline potassium 4.3-5 thus this represents an acute increase in her potassium level. She denies missing any HD sessions. Her hyperkalemia may have been related to dietary indiscretion. She underwent emergent hemodialysis and her hyperkalemia corrected. # Abdominal pain: Patient presents after acute onset of nausea, vomiting and abdominal pain. There was no sign if infectious etiology- no leukocytosis, no fever. Her nausea was liked related to her uremia and all her symptoms improved with HD. She was able to tolerate a diet at the time of discharge. # ESRD: CKD Stage V due to HTN. On HD MWF. Patient last received [Month/Day (4) 2286] on 2 days prior to admission. She underwent emergent HD on admission and then had her regularly scheduled [Month/Day (4) 2286] in the morning. She was continued on Sevelemer and Nephrocaps. # HIV/AIDS: On HARRT, last CD4 200 on [2142-10-11]. Continued on atazanavir, raltegravir, ritonavir, lamivudine. # HTN: Patient has poorly contolled HTN with prior admissions for hypertensive emergency, she presented hypertensive again today to the ED. Vitals on admission were slightly improved after her nausea and pain were contolled. She was continued on her home lisinopril, metoprolol and amlodipine. # Shoulder arthritis: Extensive workup as outpatient for shoulder pain, thought to be musculoskeletal. Patient was continued on PO oxycodone as needed for control of symptoms. #CODE: Full Code (confirmed with patient) Medications on Admission: - Sevelamer carbonate 800 mg TID QAC - B complex-vitamin C-folic acid 1 mg daily - atazanavir 300 mg daily - raltegravir 400 mg [Hospital1 ] - ritonavir 100 mg daily - lamivudine 10 mg/mL daily - senna 8.6 mg [Hospital1 ]:PRN - docusate sodium 100 mg [Hospital1 ] - lactulose 10 gram/15 mL daily - polyethylene glycol 3350 17 gram/dose daily - aspirin 81 mg daily - lisinopril 40 mg daily - metoprolol succinate 100 mg daily - oxycodone 5 mg Q4H - amlodipine 2.5 mg daily Discharge Medications: 1. sevelamer carbonate 800 mg Tablet [Hospital1 ]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. B complex-vitamin C-folic acid 1 mg Capsule [Hospital1 ]: One (1) Cap PO DAILY (Daily). 3. atazanavir 300 mg Capsule [Hospital1 ]: One (1) Capsule PO once a day. 4. raltegravir 400 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 5. ritonavir 100 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 6. senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. docusate sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). 8. lactulose 10 gram/15 mL Syrup [Hospital1 ]: Fifteen (15) ML PO DAILY (Daily). 9. polyethylene glycol 3350 17 gram/dose Powder [Hospital1 ]: One (1) PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 11. lisinopril 40 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 12. lamivudine Oral 13. metoprolol succinate 100 mg Tablet Extended Release 24 hr [Hospital1 ]: One (1) Tablet Extended Release 24 hr PO once a day. 14. oxycodone 5 mg Tablet [Hospital1 ]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 15. amlodipine 2.5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Hyperkalemia, ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to the hospital with abdominal pain. We found that your potassium was very high and you were admitted to the intensive care unit for [Known lastname 2286]. Your potassium improved after [Known lastname 2286]. Your abdominal pain also improved and you were discharged home. No changes were made to your medications. Followup Instructions: Please call your primary care doctor at [Telephone/Fax (1) 250] to follow-up in [12-10] weeks. Please keep the following appointments: Department: [Hospital3 249] When: TUESDAY [2143-1-15] at 2:10 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 456], MD [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: OBSTETRICS AND GYNECOLOGY When: THURSDAY [2143-2-14] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 71322], MD [Telephone/Fax (1) 2664] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2143-4-2] at 10:15 AM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 5500], M.D. [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "716.91", "V45.11", "585.6", "403.91", "042", "276.69", "285.21", "070.54", "276.7", "789.00" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	7610, 7616	3884, 5713	297, 304	7688, 7688	2742, 3861	8238, 9350	1731, 1749		6247, 7587		7637, 7667		5739, 6224			7839, 8215								1764, 2723																						242, 259														332, 1318								7703, 7815					1340, 1647	1663, 1715
70,462	149,819	5994	Discharge summary	report	Admission Date: [2169-10-20] Discharge Date: [2169-10-27] Date of Birth: [2107-7-3] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1234] Chief Complaint: Foot swelling, erythema, with blisters for 3 days Major Surgical or Invasive Procedure: OPERATIONS: 1. Ultrasound-guided puncture of the right common femoral artery. 2. Contralateral second-order catheterization of the left external iliac artery. 3. Abdominal aortogram. 4. Serial arteriogram of the left lower extremity. 5. Pressure measurement of the left external and common iliac arteries. Left second and fourth ray amputation and debridement of left foot-open History of Present Illness: 62 year old female PMH DMII poorly controlled with chief complaint of left foot swelling, erythema, with blisters for 3 days. Has been getting progressively worse, had fevers and chills this morning. She has not visited doctor for the last 7 years, is not taking any medication for her DM. Today, her blood pressure was 175/81, temp 100.8, she was referred to ER for left foot cellulitis. In the ED she was seen by podiatry who recommended urgent amputation of L 4th toe and Xray showed osteo. She was tachycardic to 138 and so she was given 2.5L NS HR responded to 110s. Vascular surgery saw pt in ICU and recommended OR in am, did not feel concerning for nec fasc. Her blood glucose was elevated and her gap was 23. Given 8U IV regular insulin. . . In the ED, vs were: T 101 P 118 BP 106/42 R 20 O2 sat 100 RA . On the floor, 97.8, HR 115, BP 108/50, 20, 100% RA Past Medical History: DMII, increase choleseterol Social History: Lives with Son and Daughter Smokes 1/2-1PPD X40yrs, occasional ETOH Poorly controlled diabetes, last hemoglobin A1c was 10.6 in [2162]. She has not seen a doctor since then. She does not check her blood sugar regularly. She is not following any physicians in this regard. Hyperlipidemia, hypertension, and proteinuria. SCREENING TESTS: She never had a mammogram, bone density, or colonoscopy. She has not seen a physician for office visit for the last seven years. IMMUNIZATION: She never received a Pneumovax, flu shot, or tetanus shot Family History: No History of MI or DVT Physical Exam: Vitals- T: 97.8 BP: 108/50 P: 111 R: 20 100% RA Gen- sitting comfortably, AOx 3, well appearing, well nourished, NAD HEENT- NC/AT, EOMI, PERRL, anicteric Neck: supple, JVP not elevated Cor- Tachycardic, normal S1 + S2, no m/r/g, Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular or subcostal retractions Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no organomegaly, negative [Doctor Last Name 515] sign Extremities: L amputation site with VAC, good granulation tissue, no recent signs of infection Neurologic: no focal deficits, CN II-XII grossly intact Pertinent Results: [2169-10-23] 9:02 pm URINE Source: Catheter. URINE CULTURE (Final [2169-10-25]): NO GROWTH. [2169-10-21] 10:35 am FOOT CULTURE LEFT FOOT CULTURE //LEFT TOE (4TH). GRAM STAIN (Final [2169-10-21]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Preliminary): BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. ANAEROBIC CULTURE (Final [2169-10-27]): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. None isolated. FINDINGS: On the right side, triphasic Doppler waveforms were seen at the femoral, popliteal, posterior tibial and dorsalis pedis arteries. The right ABI was 1.24. On the left side, triphasic Doppler waveforms were seen at the femoral, popliteal and posterior tibial arteries. However, monophasic Doppler waveforms were seen at the left dorsalis pedis. Pulse volume recordings showed mildly decreased amplitudes at the left metatarsal level. COMPARISON: None available. IMPRESSION: Mild tibial arterial disease on the left side IMPRESSION: AP chest compared to [10-22]: CXR: Lung volumes have improved, partially responsible for the apparent decrease in mild pulmonary edema and small-to-moderate bilateral pleural effusions. Heart size is normal. The hila are symmetrically enlarged and lobulated suggesting adenopathy. Differential diagnosis includes sarcoidosis and lymphoma, among many other causes. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1022] was paged. [2169-10-20] 4:00 pm BLOOD CULTURE Blood Culture, Routine (Final [2169-10-26]): NO GROWTH. [2169-10-24] 09:30AM BLOOD WBC-10.3 RBC-2.80* Hgb-8.7* Hct-26.1* MCV-93 MCH-30.9 MCHC-33.3 RDW-13.8 Plt Ct-496* [2169-10-24] 09:30AM BLOOD Glucose-146* UreaN-5* Creat-0.4 Na-140 K-3.3 Cl-106 HCO3-25 AnGap-12 [2169-10-24] 09:30AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.6 [2169-10-23] 09:02PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 Brief Hospital Course: 62 yo F w/ DMII p/w DKA and deep tissue infection of L foot. [10-20] - admitted to MICU # Diabetic foot infection: Does not appear to be necrotizing fasciitis per vascular. Tachycardic but good UOP, BP and lactate <2, doubt sepsis. - Bolus IVF to keep UOP>50cc/hr - Unasyn and vanc, ON DC keflex x 10 days. CX data: strep B - Open amp with VAC dressing placed in OR, probable close seconday intention . # DKA: Ketones in urine, VBG w/ pH 7.32 so not severely acidotic. Likely precipitated by acute infection. - Insulin drip 3U/hr until FS <200 then decrease - Q4 lytes until gap closed - IVF switch to D5NS when FS<200 - [Last Name (un) ] consulted, ON DC BS stable new to lantus and humulog # FEN: IVF, replete electrolytes, regular diabetic diet [10-21] - went to OR for 4th toe amputation, had purrulent material from 4th digit metatarsal to sole and 2nd metatarsal to sole - in OR had some ST changes an was tachy and HTN post op, had rigors, in OR given labetolol 20mg IV x 1, on floor BP in 180s-200, and was given labetolol 5mg, NS x 500ml, and demerol 25mg x 1 for rigors - temp spiked to 103.7 post op, then BP dropped to 70s, was given 3 liters of NS and tylenol 1g - later in afteroon temp spiked again and pt was tachy, was given Motrin 600mg, NS x 1 liter - at 10pm BP to 80s, gave 3 L IVF, temp up to 101.9, gave tylenol 1g - had more hypotension at 12:30 AM, gave 2 liters of NS, pressures remained stable afterwards, had brief dyspnea was on 4 liters oxygen, then later off oxygen without intervetion - wound with GPC in pairs and clusters on prelim cx - will need to go to OR on Monday for further debridment and possible further amputation --- [10-22] - vascular would like on Hamdan's service after procedure tomorrow - ordered noninvasives prior to procedure - nicotine patch ordered - increased vanco to 1250 mg q12 due to low trough - metoprolol 12.5 mg [Hospital1 ] given for elevated BP / tachy / periop - lasix 20 IV x 1 given for peripheral edema / HTN with brisk uop [10-23] - patient brought to angiography for lower extremity angiography. Post-operatively she had a fever of 102.1 which blood and wound cultures were sent for. They eventually returned with group-B strep. [10-24] - the patient was seen by the [Last Name (un) ] diabetes consult service who recommended a sliding scale and that the patient be started on lantus. [10-25] surgical deridement of plantar facia performed on floor and placement of wound VAC [10-27]: VAC dressing taken down, Good wound bed. To be discharged on keflex Medications on Admission: Advil Discharge Medications: 1. Glucometer Dispense: 1 2. Wheelchair with elevating leg rests 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 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 for constipation. 6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q4H (every 4 hours) as needed for tachycardia. 10. Ampicillin-Sulbactam 3 gram Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours). 11. Insulin Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Breakfast Glargine 8 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-70 mg/dL 4 oz. J 71-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 3 Units 3 Units 3 Units 0 Units 161-200 mg/dL 4 Units 4 Units 4 Units 0 Units 201-240 mg/dL 5 Units 5 Units 5 Units 1 Units 241-280 mg/dL 6 Units 6 Units 6 Units 2 Units 281-320 mg/dL 7 Units 7 Units 7 Units 3 Units 321-360 mg/dL 8 Units 8 Units 8 Units 4 Units 361-400 mg/dL 9 Units 9 Units 9 Units 5 Units > 400 mg/dL Notify M.D. 12. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Discharge Disposition: Extended Care Facility: [Hospital1 4860] - [Location (un) 4310] Discharge Diagnosis: Left lower extremity ischemia with necrotizing infection of the left foot DKA - treated Hyperlipidemia protienuria Discharge Condition: Stable Discharge Instructions: WOUND CARE: Please change VAC every 3 days PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your wound(s). New pain, numbness or discoloration of your lower or upper extremities (notably on the side of the incision). Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2169-11-7] 11:15 Please make an appointment with her PCP [Name9 (PRE) 6431], [Month (only) ] ([Month (only) ]) MD Location: [Hospital1 ] HEALTH CARE [Location (un) 2352] - ADULT MEDICINE Address: 1000 [Last Name (LF) ], [First Name3 (LF) 2352],[Numeric Identifier 9121], she shpould be seen in one to two weeks, Phone: [Telephone/Fax (1) 1144] Please call to schedule an appointment with the plastic surgery clinic in one week to see Dr. [Last Name (STitle) 23606] ([Telephone/Fax (1) 4652]) Completed by:[2169-10-27]	[ "E878.8", "401.1", "250.82", "707.15", "038.9", "785.52", "995.92", "E849.7", "458.29", "041.89", "440.24", "730.28", "511.9", "731.8", "682.7", "599.0", "250.12", "041.02" ]	icd9cm	[ [ [] ] ]	[ "88.42", "86.22", "84.11", "88.48" ]	icd9pcs	[ [ [] ] ]	9483, 9557	5220, 7797	365, 758	9716, 9725	2948, 3341	10273, 10979	2290, 2315		7853, 9460		9578, 9695		7823, 7830			9749, 9749								2330, 2929																						276, 327				3370, 5197								9761, 10250		786, 1653													1675, 1704	1720, 2274
20,528	195,702	48956	Discharge summary	report	Admission Date: [2144-9-29] Discharge Date: [2144-10-9] Date of Birth: [2079-8-23] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Cortisporin / Bactrim / Levofloxacin / Sertraline / Ceftriaxone / Adhesive Tape / Keflex / Bee Sting Kit Attending:[Doctor First Name 2080] Chief Complaint: Fever, multiple other complaints Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 65yo female with multiple medical problems including Type 2 diabetes mellitus, hypertension, and PE was admitted from the ED with fever and multiple other complaints. She reports that she felt well until the afternoon of admission. She went to orthopedics clinic where she had a steroid injection into the shoulder. Later that afternoon, she suddenly developed weakness, fevers, and shaking chills. Associated symptoms include persistent nonproductive cough, shortness of breath nausea, vomiting, and loose stools x 2. Regarding her cough, she has had cough for the last 4-6 weeks, which she attributes to changing of the seasons. Her nausea and vomiting began on the afternoon of admission and she vomited a very small amount of nonbloody, nonbilious emesis. She had two episodes of loose stools which she describes as nonbloody and primarily water. Additional symptoms include crampy abdominal pain. When EMS came to take her into the hospital, she felt right sided flank pain when the ambulance drivers tried to raise the right sided railing of the stretcher. Upon arrival in the ED, temp 101.1, HR 115, BP 121/108, RR 18, and pulse ox 98% on 4L NC. Exam was notable for morbid obesity, epigastric tenderness, right flank tenderness, and erythematous pannus surrounding right flank. Labs are notable for WBC 15.4 with 8 percent bands. CXR was unremarkable. CT Abd/Pelvis was of poor quality due to body habitus. She received 2L IVF, benadryl, and vancomycin / clindamycin for coverage of colitis and panniculitis. Review of systems: (+) Per HPI. fevers, shaking chills, weakness, rhinorrhea, cough, shortness of breath, nausea, vomiting, abdominal pain, loose stools (-) Denies night sweats, weight loss, headache, sinus tenderness, rhinorrhea, congestion, chest pain or tightness, palpitations, constipation, abdominal pain, change in bladder habits, dysuria, arthralgias, or myalgias. Past Medical History: 1. Morbid obesity making her wheelchair bound 2. Chronic pain [1-20] osteoarthritis of bilateral knees and shoulders 3. PE for which she is anticoagulated 4. Type 2 diabetes - previously on insulin, currently diet controlled, but per pt on regular diet when admitted to hospital 5. Obstructive sleep apnea - on BiPAP, 4L O2 at night 6. Hyperlipidemia 7. Hypothyroidism 8. Hypertension 9. Recurrent UTIs - followed by ID and urogynecology, has estrogen ring/pessary in place. Urinary pathogens have included pseudomonas, Klebsiella, Proteus, and E. coli (which has been highly resistant in the past). 10. h/o panniculitis - Previous episode [7-22] with infected hematoma and complications resulting in ICU stay afterwards. 11. Anxiety 12. h/o Anemia - hemolytic anemia after Keflex 13. COPD 14. Gout - managed with daily allopurinol Social History: Home: single, lives at home on disability; perform her ADLs, goes shopping, and gets around in her wheelchair. Has a weekly housemaker who helps w/ laundry/shopping/cleaning. Occupation: on disability; previously employed as an administrative assistant at School of Nursing at [Hospital3 1196] EtOH: Rare Drugs: Denies Tobacco: quit smoking > 40 years ago Family History: Father - deceased - MI in his 40s, died in his 60s. Mother - deceased at age 65 - diabetes mellitus, leukemia Physical Exam: Admission Gen: very pleasant, no acute distress, fatigued appearing, comfortable, speaking clearly, frequent coughing, morbidly obese [Hospital3 4459]: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. 2/6 systolic murmur heard best at LUSB LUNGS: CTA, BS BL, No W/R/C ABD: + BS, morbidly obese, soft, NT, ND, no rebound or guarding; right flank with focal area of erythema, tenderness but no discharge or fluctuance EXT: trace bilateral edema SKIN: left labia majora with ulceration without discharge, bleeding, or drainage; scattered areas of erythema and associated fungal infection in the setting of large amounts of pannus; right flank with focal area of erythema and tenderness NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. moving all four extremities Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2144-9-29] Na 143 / K 4 / Cl 104 / CO2 26 / BUN 32 / Cr 1.4 / BG 196 CK 111 / MB 5 / Trop T .04 ALT 25 / AST 26 / Alk Phos 112 / TB .6 / Lipase 22 WBC 15.4 / Hct 39 / Plt 185 / MCV 103 N 82 / Bands 9 / L 1 / M 7 / E 0 / B 0 / Metas 1 Lactate 2.7 UA - yellow, clear, 1.025, pH 5, urobili .2, neg lueks, neg blood, neg nitr, 30 prot, neg gluco, trace ket, 0 RBCs, 0-2 WBCs, no bacteria, no yeast, [2-20] epis INR 1.7 . Baseline Cr 1.4-1.6 . MICROBIOLOGY: [2144-9-29] Blood Cx pending [2144-9-29] Urine Cx pending . STUDIES: [2144-9-29] CXR - No acute cardiopulmonary abnormality. Minimal bibasilar atelectasis. . [2144-9-29] ECG - NSR at ~100bpm, left axis deviation, normal intervals, TWI in III (unchanged from prior) . [2144-9-29] 05:00PM BLOOD CK-MB-5 [2144-9-29] 05:00PM BLOOD cTropnT-0.04* [2144-10-1] 04:40PM BLOOD CK-MB-5 cTropnT-0.02* proBNP-4809* [2144-10-1] 11:52AM BLOOD Type-ART pO2-94 pCO2-55* pH-7.27* calTCO2-26 Base XS--2 [2144-10-2] 07:44AM BLOOD Type-ART pO2-37* pCO2-59* pH-7.30* calTCO2-30 Base XS-0 [2144-10-2] 08:22AM BLOOD Type-ART pO2-86 pCO2-47* pH-7.38 calTCO2-29 Base XS-1 . [2144-10-2] URINE URINE CULTURE-FINAL INPATIENT [2144-9-30] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT [2144-9-29] URINE URINE CULTURE-FINAL INPATIENT [2144-9-29] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [Hospital1 ] . CT abd/pelvis IMPRESSION: 1. Partially occluded portal vein thrombosis which is new when compared to prior exam. 2. Cirrhotic-appearing liver with ascites, recanalized umbilical vein, splenomegaly. 3. Gallbladder sludge and wall thickening, the latter is likely due to chronic liver disease. No evidence of acute cholecystitis. 4. No intrahepatic or extrahepatic biliary dilatation. . CXR Right PICC tip is in the right brachiocephalic vein. There is no evident pneumothorax. No other interval change. . CXR: FINDINGS: The cardiac silhouette is enlarged. The prominence of the upper zone blood vessels seen on yesterday's examination shows improvement. CONCLUSION: No definite pneumonia identified. . EKG: Sinus rhythm. Left atrial abnormality. Baseline artifact. Lead V1 is not recorded. Compared to the previous tracing of [2144-9-29] the rate has slowed. Otherwise, no diagnostic interim change. Brief Hospital Course: 65yo female with multiple medical problems including Type 2 Diabetes mellitus, morbid obesity, and pulmonary embolism was admitted with fevers of unclear etiology. . Panniculitis: Source of fever was found to be ride sided panniculitis. She was started on clinda/vanco and ID was consulted. Her antibiotics were narrowed to vancomycin/ A PICC was placed in the midline position. As she continued to improve, she completed a 10 day course of vancomycin. . Hypercarbic respiratory failure/COPD exacerbation: During the admission, she was found to be wheezy and was started on nebulizers, azithromycin, and was given a course of steroids in addition to her regular home COPD inhalers. She was ruled out for influenza. In follow up, pt began to appear very somnolent, and patient was transferred to the ICU for hypoxemic and hypercarbic respiratory failure. She was managed with Bipap, and was nearly intubated. Her BNP was found to be severely elevated, and she was diuresed with IV lasix with some improvement in respiratory function. Her respiratory failure was felt to be multifactorial with elements of COPD exacerbation, reactive airway disease, bronchitis, CHF, OSA, and obesity hypoventilation syndrome. . h/p PE: Patient's INR was subtherapeutic and was started on heparin gtt. Her warfarin was increased until her INR was therapeutic between [1-21]. INR 2.8 at discharge. Patient instructed to resume home warfarin with close INR follow up. . Paroxysmal Afib: Near the end of her hospital stay, she was found to be in rapid afib to the 140s. She improved with IV metoprolol. She had additional paroxysms requiring low dose oral metoprolol. She was asymptomatic. Her afib may likely be related to her acute infection and COPD. She was on warfarin for her PE. . Gastroenteritis Patient's symptoms of nausea, vomiting, and diarrhea are most suggestive of viral gastroenteritis. Her reported diarrhea resolved on admission. . Gout: Stable; continued allopurinol per home regimen . Hyperlipidemia: Stable. continued statin . Depression: continued citalopram and anxiety . Urinary Incontinence: Stable. - continued home regimen with fesoterodine, vesicare - continued nitrofurantoin for urinary tract infection prophylaxis . Hypothyroidism: continued home regimen of levothyroxine supplementation . Type 2 Diabetes Mellitus, controlled and without complications: Stable, transitioned to insulin sliding scale. Metformin was held in house . Chronic Pain: Stable. continued MS contin, percocet, and tylenol prn . GERD: Stable. Continued home regimen with PPI and H2 blocker . Seasonal Allergies: Stable - continued loratadine and benadryl . Cholelithiasis: Stable. Continued ursodiol . CKD stage III: fluctuated but remained overall stable during this admission. Medications on Admission: 1. Albuterol 1-2 puffs inh q4-6h SOB / wheeze 2. Allopurinol 100mg PO daily 3. Atorvastatin 30mg PO daily 4. Citalopram 40mg PO daily 5. Fesoterodine 8mg PO daily 6. Fluticasone [12-20] sprays per nostril daily 7. Advair 250-50 1 puff [Hospital1 ] 8. Folate 1mg PO daily 9. Lasix 20mg PO daily 10. Levothyroxine 125mcg PO daily 11. Ativan .5mg PO bid 12. Metformin 500mg PO q AM / 1000mg PO q PM 13. MS Contin 30mg PO bid 14. Nitrofurantoin 100mg PO bid 15. Percocet [12-20] tab PO q4h prn pain 16. Pantoprazole 40mg PO bid 17. Ranitidine 300mg PO qhs 18. Solifenacin (Vesicare) 20mg PO qhs 19. Travodone 150-300mg PO qhs prn insomnia 20. Ursodiol 250mg PO bid 21. Coumadin per coumadin clinic 22. Tylenol prn 23. Vitamin C 1000mg PO bid 24. Calcium 25. Vitamin D 26. Vitamin B12 27. Benadryl daily 28. Ferrous Sulfate 325mg PO daily 29. Loratadine 10mg PO daily 30. Magnesium Oxide 400mg PO daily 31. Miconazole cream 32. Multivitamin daily Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day) as needed for nasal congestion. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 13. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 19. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 21. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 22. Warfarin 5 mg Tablet Sig: 0.5-1 Tablet PO Once Daily at 4 PM: take 2.5mg friday [10-9], then resume your home dosing. Please check your INR on [2144-10-12]. 23. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 24. Fesoterodine 8 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 25. Vesicare 10 mg Tablet Sig: Two (2) Tablet PO at bedtime. 26. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 27. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. [Date Range ]:1 bottle Refills:0 28. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [Date Range ]:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Panniculitis Hypercarbic Respiratory Failure COPD exacerbation/bronchitis Chronic kidney disease stage III Paroxysmal atrial fibrillation Depression Hypothyroidism Hyperlipidemia Obesity Type 2 diabetes mellitus, poorly controlled with complications Discharge Condition: Good, afebrile, hemodynamically stable Discharge Instructions: You were admitted with an infection of your right side, as well as increased carbon dioxide/difficulty breathing. You completed a course of vancomycin for infection, as well as prednisone and azithromycin for your breathing difficulty. Your warfarin was also continued. Additionally, you were found to briefly have a heart rhythm called atrial fibrillation. . Please resume all home medications. New medications include: Metoprolol 25mg twice daily. Robitussin as needed for cough - you will need your INR checked on [2144-10-12], resume your home dosing of warfarin. . You will need to follow up with [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 3817] in the next 2 weeks. Your warfarin/INR will need to be monitored closely to ensure it remains in the therapeutic range. . return to the hospital with fevers, chills, chest pain, shortness of breath, or other concerning symptoms. Followup Instructions: MD: [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 3817], NP Specialty: PCP Date and time: Tuesday, [10-20] at 11:40am Location: [Hospital1 18] [Hospital Ward Name 516], [Hospital Ward Name 23] Bldg [Location (un) ], Atrium Suite Phone number: [Telephone/Fax (1) 250] . Provider: [Name10 (NameIs) ] NURSE Phone:[Telephone/Fax (1) 9316] Date/Time:[2144-10-13] 7:20 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2144-10-19] 8:00 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2144-10-19] 8:20	[ "244.9", "V12.51", "272.4", "530.81", "427.31", "278.01", "574.20", "V85.4", "008.8", "250.00", "493.22", "285.29", "715.96", "300.00", "518.81", "403.90", "428.33", "585.3", "715.91", "278.8", "338.29", "466.0", "428.0", "729.39", "V58.61", "327.23", "788.39", "274.9", "V46.3" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	13435, 13493	7080, 9862	415, 432	13787, 13828	4675, 7057	14790, 15418	3613, 3724		10866, 13412		13514, 13766		9888, 10843			13852, 14767								3739, 4656																		2000, 2355				343, 377														460, 1981													2377, 3219	3235, 3597
46,305	152,478	42547	Discharge summary	report	Admission Date: [2157-4-14] Discharge Date: [2157-4-21] Date of Birth: [2084-5-15] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1481] Chief Complaint: Splenomagaly with intractable pain and pressure due to myelofibrosis Major Surgical or Invasive Procedure: splenectomy laparotomy for post op bleeding History of Present Illness: Ms. [Known lastname 1645] saw Dr. [Last Name (STitle) ] in surgical consultation for a massive splenomegaly in the setting of myelofibrosis. She is a 71-year-old woman who has a long history of myelofibrosis and has had a spleen which has increased in size over the past 12 to 15 years. She had received blood transfusions in the past, but is now not transfusion dependent, but has increasing amounts of pain and early satiety. She gets nauseated after eating and feels weak. Her bowels have been normal. Her platelet counts have evidently been relatively stable. She has sought surgical consultation for question of a splenectomy and two surgeons have seen her in the past and thought her to be too high risk. She has had evaluation by a hepatologist who finds her liver risk to be quite relatively low. Of interest is that she has had radiation therapy to the area one and a half years ago. Past Medical History: PMH: congenital deafness, myelofibrosis, chronic anemia [1-20] myelofibrosis, hepatosplenomegaly, hypothyroidism PSH: total abdominal hysterectomy, appendectomy, exploration for infertility Social History: NC Family History: NC Physical Exam: AVSS she is a well-developed woman. Head, eyes, ears, nose, and throat are normal. The neck is supple, without mass, nodes, or thyromegaly. Chest is clear to percussion and auscultation. Heart sounds are regular without murmurs or gallops. The abdomen is soft with well-healed scars. She has massive splenomegaly with the spleen going over past the midline on the right as well as down close to the pelvis. Pertinent Results: [2157-4-14] 10:56PM HCT-29.4* [2157-4-14] 04:50PM TYPE-ART PO2-84* PCO2-44 PH-7.31* TOTAL CO2-23 BASE XS--4 [2157-4-14] 04:50PM LACTATE-0.9 [2157-4-14] 04:47PM GLUCOSE-135* UREA N-14 CREAT-0.7 SODIUM-142 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-22 ANION GAP-15 [2157-4-14] 04:47PM estGFR-Using this [2157-4-14] 04:47PM ALT(SGPT)-30 AST(SGOT)-44* ALK PHOS-112* TOT BILI-0.7 [2157-4-14] 04:47PM LIPASE-40 [2157-4-14] 04:47PM ALBUMIN-3.3* CALCIUM-7.7* PHOSPHATE-5.2* MAGNESIUM-1.8 [2157-4-14] 04:47PM WBC-60.1* RBC-3.27* HGB-9.9* HCT-32.8* MCV-101* MCH-30.2 MCHC-30.0* RDW-19.0* [2157-4-14] 04:47PM NEUTS-43* BANDS-13* LYMPHS-10* MONOS-3 EOS-2 BASOS-0 ATYPS-0 METAS-2* MYELOS-21* NUC RBCS-20* OTHER-6* [2157-4-14] 04:47PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ BURR-OCCASIONAL TEARDROP-OCCASIONAL ACANTHOCY-OCCASIONAL [2157-4-14] 04:47PM PLT SMR-LOW PLT COUNT-99* [2157-4-14] 04:47PM PT-15.8* PTT-32.2 INR(PT)-1.5* [2157-4-14] 04:47PM CD5-DONE CD33-DONE CD41-DONE CD56-DONE CD64-DONE CD71-DONE CD117-DONE CD45-DONE HLA-DR[Last Name (STitle) 7735] [Name (STitle) 31151] A-DONE KAPPA-DONE CD2-DONE CD7-DONE CD10-DONE CD11c-DONE CD13-DONE CD14-DONE CD15-DONE CD19-DONE CD20-DONE LAMBDA-DONE [2157-4-14] 04:47PM CD34-DONE CD3-DONE CD4-DONE CD8-DONE [2157-4-14] 04:47PM IPT-DONE [2157-4-14] 03:56PM GLUCOSE-134* LACTATE-0.9 [2157-4-14] 03:56PM TYPE-ART TEMP-36.6 PO2-122* PCO2-40 PH-7.35 TOTAL CO2-23 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED [2157-4-14] 03:56PM GLUCOSE-134* LACTATE-0.9 [2157-4-14] 03:56PM freeCa-1.05* [2157-4-14] 03:56PM HGB-7.7* calcHCT-23 [2157-4-14] 03:44PM TEMP-36.5 TIDAL VOL-500 O2-50 PO2-113* PCO2-37 PH-7.35 TOTAL CO2-21 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED [2157-4-14] 03:44PM GLUCOSE-120* LACTATE-0.8 NA+-136 K+-3.6 CL--114* [2157-4-14] 03:44PM freeCa-1.03* [2157-4-14] 01:58PM WBC-62.8# RBC-2.83 HGB-8.9* HCT-28.2* MCV-100* MCH-31.6 MCHC-31.7 RDW-19.9* [2157-4-14] 01:58PM PLT COUNT-103* [2157-4-14] 01:58PM PT-15.3* PTT-32.8 INR(PT)-1.4* [2157-4-14] 01:58PM FIBRINOGE-285 [2157-4-14] 01:58PM OTHER BODY FLUID CD34-DONE CD3-DONE [2157-4-14] 01:58PM OTHER BODY FLUID IPT-DONE [2157-4-14] 01:47PM TYPE-ART PO2-100 PCO2-53* PH-7.29* TOTAL CO2-27 BASE XS--1 [2157-4-14] 01:47PM GLUCOSE-78 LACTATE-0.6 NA+-137 K+-3.9 CL--107 [2157-4-14] 01:47PM HGB-9.5* calcHCT-29 O2 SAT-92 [2157-4-14] 01:47PM freeCa-1.14 Brief Hospital Course: The patient was taken to the operating room for splenectomy. Please see the operative note for complete details. She tolerated the procedure well and was taken extubated in stable condition to the ICU for post-operative monitoring. Post operatively she had mild tachycardia with soft pressrue in the low 90s. Due to continued transfusion requirements, she was reoperated for concern of post op bleeding. Intraabdominal bloood and clot was found around the area for friability of the diaphragm from her radiation, but no active bleeding site was found.She was maintained on fluid and given extra volume with PRBC and FFP and platelets for her nedical coagulopathy as well. Her hematocrit and INR responded appropriately. Her UOP dropped to 5cc/hour for one hour but she responded to the fluid and her UOP picked up. She never required pressors and her creatinine stabilized to her baseline. After adequate rescucitation she was transferred out of the ICU to the floor, where she was monitored. She did well on the floor and advanced her diet and urinated on her own. We spoke with her PCP and her hematologist to discuss pre-splenectomy vaccinations- she had received pneumovax. We gave the patient the hemophilus and neisseria vaccinations. The patient was evaluated by physical therapy to ensure her safety. Medications on Admission: aranesp (darbepoetin alfa, unknown dosage), levothyroxine 100mcg', omeprazole 20', calcium + vitamin D3' Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain for 3 days. Disp:5 Tablet(s) Refills:0 4. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). Disp:30 Refills:2 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Myelofibrosis s/p splenectomy Postoperative bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 1645], You were admitted to the West 3 General surgery service for your splenectomy. Post operatively you had some bleeding into your abdomen and you were taken back for an exploratory laparotomy. The procedure went well. We spoke extensively with your personal hematologist, who requested that you be started on lovenox to prevent clotting. We would like you to follow with him closely. We had physical therapy evaluate you to ensure your safety. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call ([Telephone/Fax (1) 1483] upon discharge to schedule an appointment in the office of Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ] in [1-22] weeks, or with any questions/concerns. Clinic is located in the [Hospital ] Medical Office Building, [Location (un) ], [Hospital1 18]. Please follow up with your hematologist on Thursday [2157-4-28], at 11:30 am. Completed by:[2157-4-22*]	[ "789.2", "285.29", "269.0", "288.60", "998.11", "287.49", "V15.82", "E878.8", "238.76", "571.8", "530.81", "V15.3", "244.9", "V03.82", "389.9", "458.9", "780.94", "785.0", "V05.8", "285.1", "V03.81", "V88.01", "286.9" ]	icd9cm	[ [ [] ] ]	[ "54.12", "41.5" ]	icd9pcs	[ [ [] ] ]	6610, 6685	4701, 6014	373, 418	6781, 6781	2064, 4678	8724, 9173	1611, 1615		6170, 6587		6706, 6760		6040, 6147			6931, 7410						8212, 8701		1630, 2045																					7442, 8197	264, 335														446, 1356								6796, 6907					1378, 1575	1591, 1595
44,601	127,665	15871	Discharge summary	report	Admission Date: [2157-5-17] Discharge Date: [2157-6-2] Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2777] Chief Complaint: right lower leg ischemia with 1st toe ulcer Major Surgical or Invasive Procedure: [2157-5-19] diagnostic RLE angiogram [2157-5-25] R Fem to PT bypass with NRSVG History of Present Illness: 88M presents with 3 days of red discoloration of forefoot and increased intermittent foot pain at night. Patient was in USOH, when it was noted by his wife helping him from his shower, that his right foot appeared red. He was brought in to his PCP who noted an absence of pulses and signals in the distal foot and sent him to the ED. Per the patient he currently has no pain. The foot has been warm throughout and never cyanotic. He still is able to walk 100ft without stopping and denies any pain with ambulation, although at night he notes increased discomfort. He also noted that 3 days ago the ulcer on the first great toe peeled a scab , he is uncertain how long the ulcer has been in place. He denies chest pain, sob, fevers, chills. HE denies sensory or motor changes. He gives no history of trauma. Past Medical History: PMH: prostate Ca, melanoma back s/p excision and lymphadenectomy, Waldernstroms macroglobulenemia, Diabetes, third degree heart block, paroxsymal atrial fibrillation, not anticoagulated, Skin cancer nose PSH: Pacer placement, Cryo surgery for the prostate, Melanoma excision with flap, Right axillary lymphadenopathy. Social History: Former smoker quit 30 years ago, no ETOH, NO Drug use Family History: Cancer in father Physical Exam: on admission T 99.2 HR 95 BP 118/62 RR 16 SpO2 99% RA GEN: NAD, A&Ox3 CVS: RRR no m/r/g/ CTAB anteriorly on exam Soft NT/ ND abdomen, Palpable aorta nontender,no masses Ext: Rubor of right forefoot and toes, but warm to touch. Sensory-motor intact, but no Doppler signals. 1 cm dry eschar on tip of first digit, no evidence of drainage or cellulitis LLE with Doppler signals. Bilateral fem pulses palp. Pertinent Results: [2157-5-17] 02:30PM PT-14.0* PTT-30.7 INR(PT)-1.2* [2157-5-17] 02:30PM PLT SMR-NORMAL PLT COUNT-408 [2157-5-17] 02:30PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL SCHISTOCY-1+ TEARDROP-1+ [2157-5-17] 02:30PM NEUTS-78* BANDS-0 LYMPHS-10* MONOS-9 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2157-5-17] 02:30PM WBC-10.9 RBC-3.31* HGB-8.7* HCT-29.2* MCV-88 MCH-26.4* MCHC-29.9* RDW-16.2* [2157-5-17] 02:30PM GLUCOSE-95 UREA N-28* CREAT-1.2 SODIUM-139 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-22 ANION GAP-14 [2157-5-17] 08:54PM URINE MUCOUS-RARE [2157-5-17] 08:54PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [2157-5-17] 08:54PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2157-5-17] 08:54PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2157-5-17] 08:54PM PT-14.6* PTT-31.0 INR(PT)-1.3* [2157-5-17] 08:54PM BLOOD WBC-9.2 RBC-3.10* Hgb-8.2* Hct-27.5* MCV-89 MCH-26.5* MCHC-29.9* RDW-16.4* Plt Ct-361 [2157-5-18] 03:11AM BLOOD Hct-27.0* [2157-5-18] 11:17AM BLOOD Hct-28.6* [2157-5-18] 07:37PM BLOOD Hct-28.3* [2157-5-19] 03:54AM BLOOD Hct-29.3* [2157-5-20] 05:00AM BLOOD WBC-9.5 RBC-3.42* Hgb-9.0* Hct-29.9* MCV-87 MCH-26.2* MCHC-30.0* RDW-15.8* Plt Ct-338 [2157-5-21] 04:50AM BLOOD WBC-10.0 RBC-3.37* Hgb-9.0* Hct-29.3* MCV-87 MCH-26.7* MCHC-30.6* RDW-15.8* Plt Ct-321 [2157-5-22] 06:00AM BLOOD WBC-11.2* RBC-3.48* Hgb-9.3* Hct-30.6* MCV-88 MCH-26.8* MCHC-30.5* RDW-16.3* Plt Ct-351 [2157-5-23] 05:58AM BLOOD WBC-12.1* RBC-3.44* Hgb-9.1* Hct-30.6* MCV-89 MCH-26.5* MCHC-29.8* RDW-15.7* Plt Ct-311 [2157-5-25] 05:32AM BLOOD WBC-8.5 RBC-3.17* Hgb-8.5* Hct-28.1* MCV-89 MCH-26.9* MCHC-30.3* RDW-16.0* Plt Ct-278 [2157-5-25] 10:29PM BLOOD Hgb-7.4* Hct-24.7* Plt Ct-294 [2157-5-26] 03:48AM BLOOD WBC-19.4# RBC-3.22 Hgb-8.5* Hct-28.6* MCV-89 MCH-26.5* MCHC-29.8* RDW-16.4* Plt Ct-357 [2157-5-27] 04:19AM BLOOD Hct-25.9* Plt Ct-206 [2157-5-27] 02:30PM BLOOD WBC-14.4* RBC-3.02* Hgb-8.4* Hct-27.3* MCV-90 MCH-27.8 MCHC-30.8* RDW-16.1* Plt Ct-254 [2157-5-28] 05:16AM BLOOD WBC-7.4 RBC-3.26* Hgb-10.8# Hct-31.3 MCV-96 MCH-33.2# MCHC-34.5# RDW-13.6 Plt Ct-260 [2157-5-28] 06:29PM BLOOD WBC-17.9 RBC-2.08* Hgb-5.8* Hct-18.8* MCV-91 MCH-27.8 MCHC-30.6* RDW-17.1* Plt Ct-362 [2157-5-28] 11:24PM BLOOD Hct-25.6# [2157-5-29] 03:28AM BLOOD WBC-15.3 RBC-2.80# Hgb-8.0# Hct-24.7* MCV-88 MCH-28.4 MCHC-32.3 RDW-16.6* Plt Ct-304 [2157-5-29] 09:52AM BLOOD Hct-27.1* [2157-5-29] 01:53PM BLOOD Hct-29.1* [2157-5-29] 05:19PM BLOOD Hct-27.8* [2157-5-29] 09:24PM BLOOD Hct-28.8* [2157-5-30] 02:28AM BLOOD WBC-11.0 RBC-3.52# Hgb-10.1# Hct-29.7* MCV-84 MCH-28.6 MCHC-33.9 RDW-16.7* Plt Ct-249 [2157-5-30] 01:11PM BLOOD Hgb-10.4* Hct-31.3* [2157-5-31] 03:14AM BLOOD WBC-10.6 RBC-3.35* Hgb-9.7* Hct-29.2* MCV-87 MCH-28.9 MCHC-33.2 RDW-17.0* Plt Ct-273 [2157-6-1] 06:03AM BLOOD WBC-9.8 RBC-3.27* Hgb-9.5* Hct-28.5* MCV-87 MCH-29.0 MCHC-33.2 RDW-16.9* Plt Ct-284 [2157-5-31] 03:14AM BLOOD WBC-10.6 RBC-3.35* Hgb-9.7* Hct-29.2* MCV-87 MCH-28.9 MCHC-33.2 RDW-17.0* Plt Ct-273 [2157-6-1] 06:03AM BLOOD WBC-9.8 RBC-3.27* Hgb-9.5* Hct-28.5* MCV-87 MCH-29.0 MCHC-33.2 RDW-16.9* Plt Ct-284 [2157-6-2] 04:59AM BLOOD Hct-28.9* [2157-5-29] 12:26AM BLOOD Fibrino-558* [2157-5-29] 03:28AM BLOOD Fibrino-568* [2157-5-27] 02:30PM BLOOD CK(CPK)-20* [2157-5-28] 05:16AM BLOOD CK(CPK)-141 [2157-5-28] 05:10PM BLOOD CK(CPK)-10* [2157-5-29] 03:28AM BLOOD CK(CPK)-10* [2157-5-29] 09:52AM BLOOD CK(CPK)-10* [2157-5-27] 02:30PM BLOOD CK-MB-4 cTropnT-0.03* [2157-5-28] 05:16AM BLOOD CK-MB-3 [2157-5-28] 05:10PM BLOOD CK-MB-3 cTropnT-0.02* [2157-5-29] 03:28AM BLOOD CK-MB-3 cTropnT-0.02* [2157-5-29] 09:52AM BLOOD CK-MB-3 cTropnT-0.02* [2157-5-28] 05:16AM BLOOD TSH-0.94 [2157-5-28] 05:16AM BLOOD T4-6.9 [5-18] b/l LE U/S: IMPRESSION: Patent great and small saphenous veins bilaterally, with diameters as described above. [5-18] noninvasive vasc: On the right side, monophasic Doppler waveforms were seen at the femoral and popliteal arteries. Doppler signal was absent in the right posterior tibial and dorsalis pedis arteries. IMPRESSION: Severe inflow arterial insufficiency to the lower extremities, worse on the right. [5-20]: IMPRESSION: No anginal type symptoms or objective EKG evidence of myocardial ischemia. Normal myocardial perfusion. The calculated left ventricular ejection fraction is 65%. [5-20] b/l carotid U/S: 1. Findings consistent with right 60-69% stenosis. 2. Findings consistent with left 60-69% stenosis. 3. Diminished diastolic flow in the right vertebral artery waveform suggests downstream stenosis/occlusion. [5-23] ECHO: EF > 55%. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic valve stenosis. Mild mitral regurgitation. Pulmonary artery hypertension. [5-28] EGD: At least 2 ulcers were found in the body of the stomach. One of the ulcers was actively bleeding during the procedure (although not initially) and therefore 3 hemoclips were placed with resolution of bleeding. The other ulcer had no obvious visible vessel and did not show any evidence of bleeding throughout the procedure. It was unclear if this ulcer was the sole source of bleeding or if there were other ulcers more proximally in the stomach, as this area was obscured by blood during the procedure. [5-30] EGD: Two non-bleeding ulcers in the stomach body, with two previously-placed clips on one of them Two ulcers at the gastroesophageal junction, with stigmata of recent bleeding A single small ulcer in the pre-pyloric region No active bleeding or old blood No duodenual ulcers Small hiatal hernia Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Patient was admitted to the vascular surgery service for right leg ischemia, started on a heparin drip, and scheduled for vein mapping/noninvasives/angiography in preparation for possible intervention. He was started on vancomycin, ciprofloxacin, and metronidazole for his ulcer. On [5-19] patient underwent a diagnostic angiogram, which demonstrated flow-limiting R CFA calcifications, flush occlusion of R SFA, no visible AK popliteal w/ BK popliteal recon, complete occlusion of R AT with distal recon, complete occlusion of R peroneal, and complete occlusion of R PT with recon at midcalf. Refer to Dr.[Name (NI) 1720] operative note for further details. Patient tolerated the procedure well and was returned to the floor in stable condition. A bypass procedure was recommended. Preoperative cardiac workup consisting of stress testing and echocardiography was negative. Carotid ultrasound was performed for evaluation of bruits and revealed 60-69% bilateral stenosis. On [5-25] patient underwent right common femoral, profunda femoral, and external iliac endarterectomy, and patch angioplasty using the donor SFA graft, right common femoral to PT bypass using nonreversed greater saphenous vein, and angioscopy. Refer to Dr. [Name (NI) 43011] operative note for further details. Patient was transferred stable and extubated to the PACU, where he was maintained on a phenylephrine drip, which was weaned. Dopplerable signals were noted in his right PT and DP post-op. Heparin drip was discontinued after surgery and patient was continued on prophylactic subcutaneous heparin. He was then transferred to the VICU for monitoring. On [5-27] patient had an episode of atrial fibrillation with rapid ventricular response, which responded to IV metoprolol. Cardiac enzymes were checked and were negative. On [5-28] patient had an upper GI bleed, requiring transfusion of 3 units of pRBCs for an HCT of 18. He was transferred to the SICU and started on a Protonix drip, where he underwent endoscopy, during which a bleeding ulcer was clipped. On [5-29] patient required transfusion of an additional 4 units of pRBCs. Repeat endoscopy was performed demonstrating additional ulcers not previously visualized but no active bleeding. On [5-31], patient tolerated a clear liquid diet and was transitioned to oral PPI and sucralfate. Patient was hemodynamically stable and transferred to the floor. On [6-1] vanco/cipro/flagyl were discontinued and Bactrim DS was started. On [6-2] patient was tolerating a regular diet, had good pain control, and was working with PT to improve mobility. On [6-2] patient was discharge to rehab. He will continue high-dose PPI treatment for 8 weeks and follow-up with GI in 2 weeks. Medications on Admission: Digoxin 125 mcg ferrous sulfate 325 mg omeprazole 40 mg Cap" Cozaar 50 mg Tab Oral glyburide 2.5 mg Tab Oral cyanocobalamin (vitamin B-12) 1,000 mcg/mL Discharge Medications: 1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. insulin regular human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED). 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed) as needed for yeast. 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 6. aspirin 325 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. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. 9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 10. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. 11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 12. Cozaar 50 mg Tablet Sig: One (1) Tablet PO once a day. 13. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 14. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 8 weeks. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: RLE ischemia right 1st toe ischemic ulcer upper 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: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [1-20] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? 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: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2157-6-10] 11:00 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD (Gastroenterology) Phone:[Telephone/Fax (1) 1983] Date/Time:[2157-6-14] 11:00 Provider: [Name10 (NameIs) ] [Apartment Address(1) 871] (ST-3) GI ROOMS Date/Time:[2157-7-18] 10:00	[ "V10.82", "440.4", "707.15", "440.23", "250.00", "V10.46", "531.40", "273.3", "426.0", "V45.01", "V70.7", "427.31", "V10.83", "285.1" ]	icd9cm	[ [ [] ] ]	[ "39.29", "88.42", "38.18", "00.41", "88.48", "44.43", "45.13" ]	icd9pcs	[ [ [] ] ]	12497, 12594	8119, 10872	293, 382	12718, 12718	2114, 8096	15689, 16116	1655, 1674		11074, 12474		12615, 12697		10898, 11051			12869, 15256	15282, 15666							1689, 2095																						210, 255														410, 1224								12733, 12845					1246, 1567	1583, 1639
71,825	149,167	46637	Discharge summary	report	Admission Date: [2117-2-5] Discharge Date: [2117-2-18] Service: MEDICINE Allergies: Percocet / Lisinopril / Zetia / [Year/Month/Day ] / Lovastatin / Doxepin / Boniva / Gleevec / Ciprofloxacin Attending:[First Name3 (LF) 689] Chief Complaint: Dizziness, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: H/P reviewed and verified. Please see original HPI for details. In brief, Ms. [Known lastname 1617] is an 87yo woman with h/o CAD, Afib on dofetalide and coumadin, sCHF (EF 40%), h/o v tach s/p PPM/ICD, CML on Gleevec but not taking, CKD (baseline Cr 1.6), who initially presented to the BMT service with vertigo and vomiting on [2117-2-5], and a white count of 173 thought to be due to untreated CML. Of note, she had not been taking her Gleevec for 6 weeks because of side effects of malaise and GI discomfort. Her hospital course was notable for starting Gleevec with more GI symptoms which caused a decrease in her WBC count. They also discontinued dofetilide due to worsening renal failure on [2-12]. On [2-13], she developed intractable V tach in the 130s with pressures in the 90s/50s that was not easily amenable to pacer override by EP. She was transferred to the CCU for further management of her v tach. In the CCU, she complains of mild dyspnea at rest, palpitations. She denies CP or light-headedness. She was in sinus prior to transfer, but en route returned into v tach in the 130s with pressures in the 90s/50s. EP was called again who tried again to override pace the v tach successfully. However, v tach recurred and this needed to be repeated 2 more times. Amiodarone 100mg IV ONCE bolus plus 1mg/min drip x 6 hours, then 0.5mg/min bolus x 18 hours was started. Electrolyte panel returned showing hypokalemia of 3.2 and hypomagnesemia of 1.7. This was repleted immediately with K 10mg IV ONCE, and K 40mg PO ONCE and magnesium 4gm IV ONCE. Because the v tach developed at a sinus rate of 78, the pacer was set to 85bpm to override the ventricular ectopic focus with an automated 8 time override mechanism. . On review of systems, she denies any prior joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies nause, vomitting, diarrhea, constipation. 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 (except on presentation). Past Medical History: 1. Hypertension / CAD / CHF, [2094] IWMI cardiogenic shock. Cath: LVEF 0.40, INFERIOR AKINESIS, 1+ MR, LMCA, LAD AND LCX -- NO SIGNIFICANT DISEASE, RCA -- 100% PROX. [2110-1-6] ETT modified [Doctor Last Name 4001], 3.5 min, 55% age pred max heart rate, MIBI LVEF 48%, large inf fixed defect. Echocard [5-/2113]: mild sym LVH, EF only 30%, 2+ MR. s/p mi [2094], cath [2103] one vessel dz RCA, LVEF 40%; [4-13] ETT fixed defect inf/lat and apical EF 42%, [12-17] new septal moderate, parially reversible defect 2. Type 2 diabetes, diet controlled. 3. Atrial fib / flutter and wide complex tachycardia, rx pacemaker / defibrillator [2108], anticoag, followed by Dr. [Last Name (STitle) ]. 4. CML, stable on Gleevec despite side effects incl eye discomfort and occasional gassiness, dry heaves 5. Hyperlipidemia, discontinued pravachol due to myalgias which then promptly resolved. Had liver problems on [Name2 (NI) 17339], zocor so intolerant to multiple statins. 6. COPD, FEV1 1.13 [2112]. Stopped smoking in [2094], pulmonary eval [2112]: deconditioning and wt is contributing to dyspnea. 7. Depression, 8. Eczema / psoriasis, pruritis improved with Sarna. 9. GERD, ? asymptomatic. 10. Gout, treated. 11. Hypothyroidism. 12. Mesenteric ischemia, without abdominal sx after eating. Positive angiogram 13. Osteporosis. stopped Fosamax due to heartburn. 14. Renal insufficiency, creat 1.4. Social History: Social History: Pt lives alone in her own apartment. She has a homemaker and someone who helps buy her groceries. She ambulates with a walker. She was a previously smoker, 2ppd x 40 years, quit in [2094]. No ETOH or recreational drugs. Family History: Family History: Mother, brother, and [Name2 (NI) 802] with DM. Sister, brother with heart disease. Sister with breast cancer, who has now passed. Physical Exam: VS: No temp measured, 97/63 136 17 94% 2L GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. NECK: Supple with JVP flat CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. bibasilar crackles, no wheezes or rhonchi. ABDOMEN: Soft, NTND, obese. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION LABS: [2117-2-5] 09:52AM BLOOD WBC-181.0# RBC-3.25 Hgb-10.7* Hct-32.7* MCV-101* MCH-32.9* MCHC-32.7 RDW-16.7* Plt Ct-195 [2117-2-5] 01:40PM BLOOD WBC-173.6* RBC-3.42* Hgb-10.8* Hct-32.8* MCV-96 MCH-31.7 MCHC-33.0 RDW-17.6* Plt Ct-160 [2117-2-6] 06:25AM BLOOD WBC-142.0* RBC-2.97* Hgb-9.8* Hct-29.6* MCV-99* MCH-33.0* MCHC-33.2 RDW-16.9* Plt Ct-157 [2117-2-7] 06:10AM BLOOD WBC-122.7* RBC-2.86* Hgb-9.0* Hct-28.9* MCV-101* MCH-31.3 MCHC-31.2 RDW-17.0* Plt Ct-134* [2117-2-5] 01:40PM BLOOD Glucose-145* UreaN-68* Creat-2.0* Na-141 K-4.7 Cl-107 HCO3-22 AnGap-17 [2117-2-6] 06:25AM BLOOD Glucose-94 UreaN-71* Creat-2.3* Na-143 K-4.7 Cl-108 HCO3-25 AnGap-15 [2117-2-5] 09:52AM BLOOD LD(LDH)-877* [2117-2-5] 01:40PM BLOOD Calcium-9.8 Phos-4.6* Mg-2.8* UricAcd-7.6* DISCHARGE LABS: [2117-2-18] 06:30AM BLOOD WBC-49.7* RBC-2.97* Hgb-10.0* Hct-29.7* MCV-100* MCH-33.5* MCHC-33.6 RDW-18.7* Plt Ct-114* [2117-2-18] 06:30AM BLOOD PT-13.6* INR(PT)-1.2* [2117-2-18] 06:30AM BLOOD Glucose-94 UreaN-44* Creat-1.7* Na-140 K-4.2 Cl-105 HCO3-22 AnGap-17 [2117-2-18] 06:30AM BLOOD LD(LDH)-351* [2117-2-17] 05:25AM BLOOD ALT-36 AST-33 LD(LDH)-389* AlkPhos-92 TotBili-0.6 [2117-2-18] 06:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.6 UricAcd-10.1* [2117-2-18] 06:30AM BLOOD TSH-2.1 [2117-2-15] 08:30PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.010 [2117-2-15] 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG [2117-2-15] 08:30PM URINE RBC-<1 WBC-61* Bacteri-NONE Yeast-NONE Epi-1 MICROBIOLOGY: Blood Cx [2-5], [2-6] No growth Urine Cx [1-27] negative Urine Cx (Final [2117-2-17]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING/STUDIES: NCHCT [2117-2-5]: There is no acute hemorrhage, large areas of edema, large masses or mass effect. Periventricular white matter hypodensities consistent with [Month/Day/Year ] small vessel ischemic changes. Additional hypodensities noted within the basal ganglia bilaterally are likely due to old lacunar infarcts. There is preservation of normal [Doctor Last Name 352]-white matter differentiation. Prominence of the ventricles and sulci is likely due to age-related parenchymal atrophy. Visualized paranasal sinuses and mastoid air cells are clear. Soft tissues of the orbits and nasopharynx are within normal limits. Mild calcification of the cavernous portions of both internal carotid arteries is noted. IMPRESSION: No acute intracranial process. . Abd U/S [2117-2-8]: 1. Nodular liver, compatible with cirrhosis, and splenomegaly indicative of portal hypertension. 2. Stable hepatic hemangioma. 3. Cholelithiasis, without evidence of acute cholecystitis. 4. Simple bilateral renal cysts. . CT Abd/Pel [2-9]: FINDINGS: Small bilateral pleural effusions are new on this study. Heart size is enlarged with pacer leads noted within the right ventricle. Atelectasis is also noted in the lower lung lobes. ABDOMEN: In segment VII of the liver, there is a 14 x 13 well-circumscribed hypodensity that is of a fat density, this is increased in size from previous study; however, microscopic fat suggests a benign lesion. No intrahepatic biliary dilatation is seen. Large gallstones are seen within the gallbladder, but there is no gallbladder distention or wall thickening. The spleen is enlarged, measuring 13.6 mm in its longest axis. Pancreas is normal appearing showing no masses, cysts or calcifications. In the right adrenal gland, there is a 6 x 9 mm nodule with macroscopic fat most consistent with myelolipoma. The left adrenal gland is normal appearing. The kidneys enhance with and excrete contrast symmetrically without evidence of masses. The small and large intesting demonstrate no evidence of obstruction, wall thickening, or masses. Diverticulosis without evdience of diverticulitis is seen in the sigmoid colon. No lymphadenopathy is seen. The aorta, IVC, portal vein, and their major branches appear patent. BONES: An L4 vertebroplasty is seen. Severe degenerative changes are seen throughout the lumbar spine. No lytic or sclerotic lesions are seen. IMPRESSION: 1. Small new bilateral pleural effusions. 2. Cholelithiasis without evidence of cholecystitis. 3. Diverticulosis without evidence of diverticulitis. 4. Enlarged spleen. . CXR [2-10]: PA and lateral upright chest radiographs were compared to [2117-2-5]. Cardiomegaly is unchanged. Pacemaker leads terminate in right atrium and right ventricle, the right ventricular lead being pacemaker defibrillator. There is interval progression of vascular engorgement, upper zone redistribution of the vasculature and bilateral perihilar opacities in conjunction with increased pleural effusion, findings consistent with interval development of interstitial pulmonary edema. No pneumothorax is demonstrated. Brief Hospital Course: BMT COURSE: Ms [Known lastname 1617] was admitted to BMT for her uncontrolled CML, as she had been off Gleevec secondary to side effects. She was prescribed dasatinib in the interval, but she never filled this prescription. She described her side effects as having nausea, abdominal discomfort, and periorbital edema. While on the BMT service, we restarted her Gleevec at 400 mg daily but given as 4 100 mg pills rather than the larger 400 mg tablet, she was better able to tolerate the smaller pills. On one occasion, we tried the larger pill and she had severe abdominal pain. We did obtain a CT scan with PO contrast to evaluate for any obstruction but no significant abnormalities were seen. On Gleevec, her WBC continued to improve considerably from 170 -> below 90. Tumor lysis labs remained negative. Coumadin was initially held because of its interaction with Gleevec. Due to her initial renal failure, her lasix dose, which she takes 40 mg PO daily, was held. Over the course of her hospitalization on BMT, her renal function improved, and secondary to hydration, she developed pulmonary edema, presenting with orthopnea and shortness of breath. She was restarted on lasix and given IV diuresis over [2-10] - [2-12] with significant improvement with a return of her oxygen status to baseline. Her dofetilide was also contraindicated at admission secondary to renal failure and was held. She remained in normal sinus rhythm for the first week on the BMT service. She then went into a slow, sustained ventricular tachycardia on [2-13], during which she was asymptomatic. The ventricular tachycardia lasted for 60 beats with a duration of ~ 20-30 seconds. Her defibrillator/pacer managed to bring her back into a regular sinus rhythm and rate after several attempts to pace. However, upon repeat instance of asymptomatic, slow, sustained VT the next day, she was transferred to the CCU for further management of her VT. CCU COURSE: In the CCU, the pt came in Vtach in the 130s (probably converting in the field) with pressures in the 90s/50s. EP was called, and tried to override pace the v tach successfully. However, v tach recurred and this needed to be repeated 2 more times. Amiodarone 100mg IV ONCE bolus plus 1mg/min drip x 6 hours, then 0.5mg/min bolus x 18 hours was started. Electrolyte panel returned showing hypokalemia of 3.2 and hypomagnesemia of 1.7. This was repleted immediately with K 10mg IV ONCE, and K 40mg PO ONCE and magnesium 4gm IV ONCE. Because the v tach developed at a sinus rate of 78, the pacer was set to 85bpm to override the ventricular ectopic focus with an automated 8 time override mechanism. The override pacer function was set to override pace at 128bpm, with shocking after 8 attempts. Amio was continued. The patient's v tach was thought to be triggered by electrolyte abnormalities and stopping dofetelide [12-15] renal failure. On [2117-2-15] just past midnight, the patient developed V tach again while on amio. She remained hemodynamically stable (only has sx of palpitations) Lidocaine was started with a bolus then a drip with successful conversion. Gtt stopped on [2117-2-15]. Of note, pt had WBCs in urine and was started on ceftriaxone for UTI on [2117-2-15]. Lasix restarted [2117-2-16], and electrolytes checked twice daily thereafter without significant derangement. The patient was then transferred to the medicine service to coordinate discharge planning. . MEDICINE WARDS COURSE: VTach: Patient had no further episodes of ventricular tachycardia. She was instructed to continue with her new cardiac regimen of amiodarone and metoprolol, and follow-up with EP as an outpatient. Her prior cardiac regiment included dofetolide, atenolol, digoxin and irbesartan. Irbesartan was stopped secondary to renal failure on admission, and digoxin was stopped on transfer to CCU; these medications were not restarted on discharge, and should be discussed with outpatient cardiologist. UTI: Patient was initially started on ceftriaxone, which was transitioned to oral cefpodoxime when species and sensitivities from urine culture returned. The patient was instructed to complete a 7 day course of antibiotics to end on [2117-2-22]. Atrial Fibrillation: As noted above, patient had stopped dofetolide and was started on amiodarone during her course in the CCU. She will consequently need periodic monitoring of TFTs, LFTs and repeat PFTs as an outpatient. Additionally, coumadin was stopped during her hospitalization and restarted several days prior to discharge. At discharge her INR was 1.2. She was instructed to have VNA draw INR on Monday [2-22], and the results faxed to her PCP. CML: The patient was discharged on [Month/Year (2) 99026] 300 mg daily. The patient's pharmacy was contact[Name (NI) ] and stated they would have the medication ready for pickup on the day after discharge. The patient was instructed to take her dose of [Name (NI) 99026] prior to leaving on the day of discharge, but refused, stating that she would only take the medication at dinner time, when consuming a full dinner (this was not available at the time of discharge). Consequently, she missed her dose of [Name (NI) 99026] on the day of discharge, but was given detailed instructions for obtaining and taking her medication thereafter. Medications on Admission: ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth every day - gout ATENOLOL - 25 mg Tablet - [11-14] Tablet(s) by mouth in AM and 1 tab in PM per Dr.[Name (NI) 71235] note - prevent heart attack, blood pressure DASATINIB [SPRYCEL] - 100 mg Tablet - 1 Tablet(s) by mouth once a day DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day DOFETILIDE [TIKOSYN] - 250 mcg Capsule - one Capsule(s) by mouth twice a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day - diuretic GLIPIZIDE - (Dose adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth once a day before breakfast INSULIN GLARGINE [LANTUS SOLOSTAR] - 300 unit/3 mL Insulin Pen - 23 Units every night IRBESARTAN [AVAPRO] - 75 mg Tablet - 1 Tablet(s) by mouth 1 po qd LEVOTHYROXINE - 88 mcg Tablet - 1 Tablet(s) by mouth once a day, take separately from calcium - thyroid NITROGLYCERIN - 400 MCG (1/150 GR) TABLET - ONE UNDER THE TONGUE AS NEEDED ONDANSETRON HCL - 4 mg Tablet - 1 Tablet(s) by mouth qd prn POTASSIUM CHLORIDE [K-DUR] - 20 mEq Tab Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth twice a day WARFARIN - 2 mg Tablet - 2 - 3 Tablet(s) by mouth once a day as directed (Coumadin 4 mg daily, apart from Tue & [Doctor First Name ] when she takes 5 mg) ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (OTC) - 500 mg Tablet - 2 Tablet(s) by mouth four times a day as needed for pain ASPIRIN [ENTERIC COATED ASPIRIN] - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day with food - heart protection CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D MAXIMUM] - (OTC) - 315 mg-250 unit Tablet - 1 Tablet(s) by mouth twice a day with food NAPHAZOLINE [CLEAR EYES] - (OTC) - 0.012 % Drops - 1 - 2 drops both eyes four times a day as needed for irritation NASAL MOISTURIZER - (OTC) - 0.65 % Aerosol, Spray - 2 sprays each nostril twice a day as needed for dryness Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day: 1 tab once daily before breakfast. 6. Lantus Solostar 300 unit/3 mL Insulin Pen Sig: Twenty Three (23) units Subcutaneous at bedtime. 7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual prn as needed for chest pain. 8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:30 Tablet, Rapid Dissolve(s) Refills:0 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Imatinib 100 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). Disp:90 Tablet(s) Refills:0 11. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: Take 4 mg daily, except Tue and [Doctor First Name ] take 5 mg. 13. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO four times a day as needed for pain. 14. Citracal + D Maximum 315-250 mg-unit Tablet Sig: One (1) Tablet PO twice a day: With food. 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:30 Tablet(s) Refills:0 17. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 4 days: Last day [2117-2-22]. Disp:8 Tablet(s) Refills:0 18. Outpatient Lab Work Please draw INR on Monday [2117-2-22] and fax results to PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] at fax [Telephone/Fax (1) 6443]. Tel [Telephone/Fax (1) 1144] Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary Diagnoses: Uncontrolled [Location (un) 8304] Myelogenous Leukemia Acute on [Location (un) ] renal failure Ventricular Tachycardia Urinary Tract Infection . Secondary Diagnoses: CHF CAD HTN COPD Depression/Anxiety 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 to the hospital for dizziness and nausea thought to be related to untreated CML. During the course of your hospitalization, you were restarted on [Location (un) 99026] and your CML improved. However, some of your cardiac medications were stopped and you experienced several episodes of ventricular tachycardia. You have started on a new medication for this rhythm, which will hope will continue to control your heart rate. . We made the following changes to your home medications: -Restart [Location (un) 99026] 300 mg daily (and stop Sprycel) -START cefpodoxime for 4 more days for your urinary tract infection -STOP dofetolide and START Amiodarone to control your arrhythmia -CHANGE Atenolol to Metoprolol twice daily -STOP Digoxin and irbesartan until you see your PCP or cardiologist [Name9 (PRE) ] Lorazepam as needed for anxiety or sleep Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please have VNA draw an INR on Monday [2-22] (or go to the location where you normally have INRs drawn) and fax the results to your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 1683] at fax [Telephone/Fax (1) 6443]. Tel [Telephone/Fax (1) 1144]. Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2117-2-26] at 10:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9052], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 1935] CENTER When: WEDNESDAY [2117-3-3] at 1:30 PM With: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2334], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital1 18] [Location (un) 2352] - ADULT MED WITH DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] When: FRIDAY [2117-3-5] at 11:30 AM With: 9471 [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "V58.61", "530.81", "733.00", "V45.02", "414.01", "427.31", "428.22", "585.9", "244.9", "275.2", "274.9", "412", "205.10", "427.1", "V45.01", "428.0", "V15.82", "041.6", "692.9", "696.1", "584.9", "276.8", "783.7", "599.0", "300.4", "427.32", "496" ]	icd9cm	[ [ [] ] ]	[ "99.25" ]	icd9pcs	[ [ [] ] ]	19934, 19991	10579, 15945	336, 342	20264, 20264	5074, 5074	21438, 22749	4347, 4482		17896, 19911		20012, 20184		15971, 17873			20447, 20935		5894, 10556						4497, 5055	20205, 20243		20953, 21415																			278, 298														370, 2569					5090, 5878			20279, 20423					2591, 4057	4089, 4315
82,393	195,032	54340	Discharge summary	report	Admission Date: [2190-10-5] Discharge Date: [2190-10-27] Date of Birth: [2110-9-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 663] Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: none History of Present Illness: 80F NH resident with L MCA CVA, CAD, AFib on coumadin, and recent admission [Date range (1) 111287] for LGIB [3-16] ischemic colitis who was evaluated in [Hospital ] clinic today for melena then referred to ED for hypothermia, tachycardia, tachypnea, and hypoxemia. According to the GI note in OMR from today, referred to [Hospital ] clinic for 1 week of melena in the setting of an elevated INR. Hct down to 28% on [9-30] from 36.6 on discharge. INR 1.8 on [9-30].4 on [9-26]. V/S in clinic T 94.5 HR 110's 85%RA. In ED initial VS 98.7 98 122/55 24 98%6L. Brown stool, guaiac positive, NG lavage negative. Hct 28.0 INR 1.2. CXR showed worsening bibasilar airspace opacities (compared with [2190-9-21]) with small bilateral pleural effusions, secondary to atelectasis or pneumonia. Given vancomycin 1 g, ceftriaxone 1 g, levofloxacin 750 mg, tylenol 650 mg, 1L NS. Family reportedly revoked DNR status when her respiratory status worsened. Vital signs prior to transfer 101.1 102 107/47 24 100%NRB. Upon arrival to the ICU, denies fever, chills, sweats, chest pain, cough, shortness of breath, abdominal pain, nausea, hematochezia, or melena. Past Medical History: -AFib -Tachy-brady syndrome s/p PPM [3-24] -CAD s/p PCI to LAD [2181], RCA [2179] -L MCA stroke [7-22] with residual aphasia/R-sided weakness while anticoagulation on hold for EGD -Chronic diastolic CHF -PUD -Ischemic colitis -Depression Social History: Resident of [Hospital3 9475] Care Center in [Location (un) 3146]. Former 40 pack-year smoker. Family History: Non-contributory Physical Exam: Admission Physical Exam V/S: T 96 HR 100 BP 132/64 RR 25 O2sat 100%3L GEN: Appears comfortable HEENT: PERRL NECK: No JVD CV: irreg irreg no m/r/g PULM: coarse rhonchi bilat no wheeze/rales ABD: soft nondistended mildly tender to deep palpation RLQ>RUQ no rebound, guarding normoactive BS EXT: warm, dry no edema Neuro/Psych: awake, alert, speaks in one-word phrases . Discharge Physical Exam Vital signs not recorded as she is CMO Gen: female in no acute distress HEENT: Supple neck without lymphadenopathy Chest: Clear to auscultation anteriorly. Heart: Irregularly irregular. Tachycardic Abdomen: Soft, nontender and nondistended External: 1+ pitting edema to the knee. Appropriate temperature Neuro: Awake and alert to person and place. Speaks in one-word phrases Pertinent Results: Admission labs: [2190-10-5] 05:15PM WBC-13.5* RBC-3.44* HGB-8.8* HCT-27.6* MCV-80* MCH-25.6* MCHC-31.9 RDW-20.4* [2190-10-5] 05:15PM NEUTS-83* BANDS-3 LYMPHS-8* MONOS-4 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2190-10-5] 05:15PM PLT COUNT-553* [2190-10-5] 05:15PM GLUCOSE-111* UREA N-14 CREAT-0.6 SODIUM-134 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15 [2190-10-5] 05:15PM CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-1.7 [2190-10-5] 05:15PM cTropnT-<0.01 [2190-10-5] 03:35PM PT-14.3* PTT-31.4 INR(PT)-1.2* [2190-10-21] 06:55AM BLOOD WBC-11.1* RBC-2.87* Hgb-7.5* Hct-24.6* MCV-86 MCH-26.1* MCHC-30.5* RDW-21.7* Plt Ct-738* [2190-10-19] 07:00AM BLOOD Neuts-88.0* Lymphs-6.2* Monos-4.4 Eos-1.1 Baso-0.3 [2190-10-21] 06:55AM BLOOD Glucose-82 UreaN-28* Creat-0.8 Na-139 K-5.6* Cl-103 HCO3-28 AnGap-14 [2190-10-11] 06:55AM BLOOD calTIBC-161* Ferritn-494* TRF-124* [2190-10-12] 05:41PM BLOOD Type-ART pO2-69* pCO2-35 pH-7.52* calTCO2-30 Base XS-5 [2190-10-19] 05:12PM BLOOD Type-ART pO2-71* pCO2-38 pH-7.49* calTCO2-30 Base XS-5 Comment-UNLABELLED [2190-10-21] 04:59PM BLOOD Type-ART pO2-71* pCO2-52* pH-7.32* calTCO2-28 Base XS-0 [2190-10-5] 08:58PM BLOOD Lactate-1.4 [2190-10-5] 10:33PM BLOOD Lactate-1.5 [2190-10-19] 05:12PM BLOOD Lactate-1.5 [2190-10-21] 04:59PM BLOOD Lactate-1.3 [2190-10-5] UPRIGHT AP VIEW OF THE CHEST: Left sided dual-chamber pacemaker leads terminating in the right atrium and right ventricle is in unchanged position. There is mild to moderate cardiomegaly which is stable. Aortic knob calcifications are redemonstrated. Pulmonary vascularity does not appear markedly engorged. There are bibasilar airspace opacifications, slightly worse in the interval, which could represent atelectasis, but infection is not excluded. Trace bilateral pleural effusions persist. No pneumothorax. No acute osseous findings are otherwise demonstrated. IMPRESSION: Worsening bibasilar airspace opacities with small bilateral pleural effusions, which may be secondary to atelectasis, but infection is not excluded. . [2190-10-5] EKG: Probable "fine" atrial fibrillation. Diffuse ST-T wave abnormalities are non-specific. Since the previous tracing of [2190-7-5] ST-T wave changes are less prominent. . CXR ([2190-10-19]): Pulmonary edema with stable left pleural effusion and decreased right pleural effusion. Right perihilar atelectasis stable in size with increased density. . CXR ([2190-10-21]): 1. Bilateral pleural effusions, left more than right, stable since [2190-10-12]. 2. Pulmonary hypertension. Brief Hospital Course: 80F NH resident with L MCA CVA, CAD, AFib on coumadin, and recent hospitalization for LGIB with admitted with fever, hypoxemia, and report of melena. . 1. Comfort measures only: After extensive discussion with family, decision was made to make her as comfortable as possibe. She appears comfortable and clinically seems to be improving. On morphine concentrated solution 1-5mg po Q2prn respiratory discomfort. Also on hysocyamine, xopenex/ipratroprium nebs prn. . 2. Fever and hypoxia - Initial differential included aspiration pneumonitis, HCAP, ateletasis, or pulm edema. With fever, leukocytosis, and bandemia, she was empirically started for HCAP with vanc/levo/cefepime. Blood and urine culture were negative with no pneumonia on CXR. She was continued on levofloxacin while vancomycin and cefepime were discontinued. She continued to be afebrile. Levofloxacin was discontinued on [10-8]. She was noted to have low grade temperature of 100.4 and leucocytosis on [10-11] with normal hemodynamics. Blood and urine cultures were negative with unchanged CXR. Stool studies were negative as well. Levofloxacin was restarted with improvement in her leucocystosis. She continued to be afebrile. Levofloxacin was discontinued on [2190-10-19]. . 3. Melena/Diarrhea - Recent hospitilization for lower GI Bleed. Likely from her ischemic colitis. Continued on pantoprazole 40 mg once a day. Stool brown guaiac positive on admission. Her hematocrit had been stable throughout her hospital stay. She was given one unit of PRBCs for drop in her hematocrit to 22.1 from baseline of 25.2 on [10-14]. Rectal tube was continued. Iron was continued as well during her hospital stay. She continued to have diarrhea/melena > 800 cc a day from rectal tube. Clostridium difficile toxin x 3 were negative. Stool studies x 2 were negative. CMV viral load negative. TTG-IgA for celiac disease was negative. Loperamide 2 mg po QID was started which seemed to have decreased her stool output. Rectal tube was discontinued. Chromogranin A level was elevated which Gastroenterology agreed did not require workup as she is currently comfort measures only. . 4. LLQ pain: Likely from her ischemic colitis. Has been same for past few months. No change in intensity or characteristics per her. . 5. AFib- Rate well controlled with metoprol 12.5 mg po TID and diltiazem 60 mg po QID. CHADS2 score of 5. Anticoagulated with Lovenox during her hospital stay. Her metoprolol and diltiazem were discontinued once she was made comfort measures only. . 6. CAD: Was not on aspirin on admission with concern for LGIB. Continued on simvastatin during the hospital which was eventually discontinued for the same reason aspirin not started after weighing in the mortality benefit of aspirin in relation to her prognosis. . 7. Acute on chronic diastolic heart failure: Home bumetanide was held due to concern for hypotension. She required intermittent IV lasix for volume overload. Her peripheral edema seemed to have improved once all the medications were stopped for comfort measures. . 8. Depression: Venlafaxine 75 mg po qdaily was continued until she was made comfort measures only. . 9. Communication: [Name (NI) 6818], [Name (NI) ], husband, [Telephone/Fax (1) 111286]; [First Name5 (NamePattern1) ] [Known lastname ] [Telephone/Fax (3) 111288] . Medications on Admission: 1. Simvastatin 40 mg Tablet [Telephone/Fax (3) ]: One (1) Tablet PO DAILY (Daily). 2. Diltiazem HCl 30 mg Tablet [Telephone/Fax (3) ]: 2.5 Tablets PO QID (4 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Telephone/Fax (3) ]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr [Telephone/Fax (3) ]: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [Telephone/Fax (3) ]: One (1) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Telephone/Fax (3) ]: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 7. Multivitamin Tablet [Telephone/Fax (3) ]: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr [Telephone/Fax (3) ]: 0.5 Tablet Sustained Release 24 hr PO once a day. 9. Warfarin 4 mg Tablet daily (on hold) 10. Enoxaparin 60 mg Q12H 11. Bumetanide 0.5 mg Tablet [Telephone/Fax (3) ]: One (1) Tablet PO DAILY . Discharge Medications: 1. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [Telephone/Fax (3) ]: One (1) Tablet, Sublingual Sublingual QID (4 times a day) as needed for PRN secretions. 2. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [Telephone/Fax (3) ]: One (1) ML Inhalation q4 () as needed for PRN SOB. 3. Ipratropium Bromide 0.02 % Solution [Telephone/Fax (3) ]: One (1) Inhalation Q4H (every 4 hours) as needed for PRN SOB. 4. Enoxaparin 60 mg/0.6 mL Syringe [Telephone/Fax (3) ]: One (1) Subcutaneous Q12 (). 5. Loperamide 2 mg Capsule [Telephone/Fax (3) ]: Two (2) Capsule PO QID (4 times a day). 6. Morphine Concentrate 20 mg/mL Solution [Telephone/Fax (3) ]: One (1) PO Q2H (every 2 hours) as needed for respiratory distress/discomfort. 7. Diltiazem HCl 30 mg Tablet [Telephone/Fax (3) ]: One (1) Tablet PO QID (4 times a day). 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr [Telephone/Fax (3) ]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Lighthouse Discharge Diagnosis: Primary Diagnosis 1. Ischemic Colitis 2. Atrial fibrillation 3. Reactive airway disease . Secondary Diagnosis 1. Left MCA stroke Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted because you had fever and difficulty breathing. You were treated for pneumonia. Your hospital course was complicated by worsening diarrhea, uncontrolled heart rate with your atrial fibrillation and worsening shortness of breath from your reactive airway disease. After extensive discussion with your family, decision was made to make your care comfort measures only. . You were discharged on following medications Enoxaparin Sodium 60 mg subcutaneously twice a day Hyoscyamine 0.125 mg sublingually four times a day as needed for secretions Ipratropium Bromide Nebulizer every four hours as needed for wheezing Levalbuterol Neb NF 0.63 mg/3 mL Inhalation every four hours for wheezing Loperamide 4 mg by mouth four times a day Morphine Sulfate (Concentrated Oral Soln) 1-5 mg by mouth every two hours for respiratory distress/discomfort Diltiazem 30 mg by mouth four times a day Metoprolol succinate 25 mg by mouth once a day Iron supplement qod OK to try small bites of simple foods as tolerated such as rice, oatmeal, bread. [Month (only) 116] advance only as tolerated as long as no increase in abdominal pain or diarrhea. Call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] -- [Telephone/Fax (1) 111289] or [Telephone/Fax (1) 111290] for any urgent issues or clarifications. Followup Instructions: None	[ "285.9", "428.33", "557.9", "311", "V45.01", "438.11", "V58.61", "401.9", "486", "438.89", "414.01", "427.31", "428.0", "780.79", "V45.82", "424.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10956, 10993	5415, 8795	325, 331	11166, 11166	2772, 2772	12665, 12673	1949, 1967		9932, 10933		11014, 11145		8821, 9909			11303, 12642								1982, 2753																						276, 287														359, 1536					2788, 5392			11181, 11279					1558, 1813	1829, 1933
4,785	132,155	43007	Discharge summary	report	Admission Date: [2199-1-25] Discharge Date: [2199-2-1] Date of Birth: [2139-12-11] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: SOB Major Surgical or Invasive Procedure: intubation History of Present Illness: Briefly, this is a 59 yo lady with severe COPD on 4L home O2, s/p several hospitalizations for exacerbations in the recent past at [Hospital1 2177] with intubation, who now presented from [Hospital 5346] with yet another COPD exacerbation most likely due to infection. The pt was intubated in the MICU for hypercarbic respiratory failure after inital trial of BIPAP. She received Azithromycin as well as Prednisone, Fluticasone-Salmeterol, Albuterol and Tiotropium. Extubation on [2199-1-26] with subsequent BIPAP. Now on 3L nasal cannula saturating at 91%, but still with desaturation on ambulation to 85%. Past Medical History: 1. COPD (intubated in the past) 2. Asthma 3. DM type 2 4. Depression 5. hx of + PPD treated 6. history of MVA Social History: h/o of tobacco abuse, 40pyrs, quit this year, no ETOH, lives alone, has one daughter Family History: no heart and lung disease Mother died of CVA Physical Exam: VS 97.7, HR 101/ 78-108, BP 131/67, 25, 91% 3L Gen: mild respiratory distress, stops to breath in between words, pursed lip breathing HEENT: MMM, OP clear, PERRL Lungs: CTA bilaterally, decreased BS bilaterally, no wheezes, use of accessory muscles CV: RRR, nl S1S2, no murmurs Abd: soft, ND, positive BS, pain on palpation in R upper quadrant, + [Doctor Last Name ] sign Ext: no edema Neuro: moving all extremities, 2+ reflexes bilaterally, AAOx3 Pertinent Results: [2199-1-25] 11:43AM freeCa-1.23 [2199-1-25] 11:43AM LACTATE-0.8 K+-4.0 [2199-1-25] 11:43AM TYPE-ART TEMP-36.7 O2-95 O2 FLOW-4 PO2-71* PCO2-93* PH-7.27* TOTAL CO2-45* BASE XS-11 AADO2-513 REQ O2-86 INTUBATED-NOT INTUBA [2199-1-25] 12:00PM PT-12.0 PTT-22.7 INR(PT)-1.0 [2199-1-25] 12:00PM PLT COUNT-238 [2199-1-25] 12:00PM NEUTS-87.2* LYMPHS-9.9* MONOS-1.8* EOS-0.9 BASOS-0.2 [2199-1-25] 12:00PM WBC-11.9* RBC-3.58* HGB-10.3* HCT-32.9* MCV-92 MCH-28.9 MCHC-31.4 RDW-13.2 [2199-1-25] 12:00PM CALCIUM-9.4 PHOSPHATE-4.8* MAGNESIUM-1.8 [2199-1-25] 12:00PM GLUCOSE-123* UREA N-10 CREAT-0.5 SODIUM-139 POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-37* ANION GAP-13 Brief Hospital Course: # Hypercarbic respiratory Failure - Pt was intubated initially for hypercarbic respiratory failure after a failed trial of BIPAP. Nebulizers albuterol and Ipratropium Q6h were continued, as well as fluticasone and spiriva. High dose prednisone 60mg was started. Azithromycin was started. Rapid improvement on intubation. Hypercarbia at baseline with PCO2 of around 70-80, bicarbonate of around 36. Pt extubated [2199-1-27]. Sputum culture with gram-neg rods, sparse growth, no further specification possible. Azithromycin was stopped and Levofloxacin was started on [1-28] and should be continued for 10 days. The pt continued to have a tenous respiratory status on the floor but slowly improved with continued therapy. She was back to her baseline on the day of discharge. Dr. [Last Name (STitle) 52730] at [Hospital1 2177] was informed about the pt's stay at the [Hospital1 18]. . # New finding of nodule on inital CXR. Chest CT: Multiple small, less than 5 mm, noncalcified pulmonary nodules, which are likely of benign etiology, and a followup CT could be obtained in one year. 4 Calcified granuloma seen in the left upper lobe. . # Tachycardia: supraventricular tachycardia consistent with multilocal atrial tachycardia. Also component of Albuterol and anxiety. Started on Diltiazem, short acting, then switched to 120mg QD. Also started on Clonazepam. Will need outpatient ECHO to look for structural heart disease. Lasix po 10mg was started for clinically suspected right sided heart failure. . # Diabetes, usually controlled with diet, hemoglobin A1c 6.5. Will need FS QID while on steroids. Covered with ISSC while on steroids. Also started on Glyburide 1.25mg [Hospital1 ]. The pt should receive diabetes training at Rehab. . # Anemia: Low iron with normal TIBC and low normal Ferritin. Component of anemia of chronic disease and iron deficiency. Iron supplements were started. Hct stable. Vit B12/Folate wnl. . # Depression, Anxiety: Continue Seroquel, Trazadone, and Zoloft at out-patient doses. Started on CLonazepam TID in addition. . Medications on Admission: MEDS at rehab: Seroquel Senna Advair Albuterol Calcium Vitamin D Zoloft Trazadone Spiriva Flonase . Meds on tranfer from MICU: Insulin SC Azithromycin 500 mg PO Q24H Prednisone 60 mg PO Fluticasone-Salmeterol (250/50) 1 INH IH [Hospital1 ] Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Haloperidol 1-2 mg IV BID:PRN Pantoprazole 40 mg IV Q24H Heparin 5000 UNIT SC TID Hydrocodone-Acetaminophen [1-28] TAB PO Q4-6H:PRN Acetaminophen 325-650 mg PO Q4-6H:PRN Lorazepam 0.5 mg PO Q4-6H:PRN Beclomethasone Dipro. AQ (Nasal) 1 SPRY NU [Hospital1 ] 12 Tiotropium Bromide 1 CAP IH DAILY traZODONE HCl 50 mg PO HS Sertraline HCl 150 mg PO DAILY Vitamin D 400 UNIT PO DAILY Calcium Carbonate 500 mg PO TID W/MEALS Albuterol [1-28] PUFF IH Q4H:PRN Albuterol [1-28] PUFF IH Q6H Bisacodyl 10 mg PO DAILY:PRN Senna 1 TAB PO BID:PRN Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(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:2 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet, Chewable(s) Refills:2 5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:30 Cap(s) Refills:2 8. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). Disp:qs Refills:2 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed: do not exceed 4g/d. Disp:30 Tablet(s) Refills:0 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): continue until ambulating > 3x/d. Disp:qs Refills:2 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:2 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-28] Sprays Nasal QID (4 times a day) as needed. Disp:qs Refills:0 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:qs Refills:2 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:qs Refills:2 16. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 18. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 20. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 21. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:15 Tablet(s) Refills:2 22. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:2 23. Pantoprazole 40 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 Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: 1 severe COPD 2 hypercarbic respiratory failure 3 Multiple small, less than 5 mm, noncalcified pulmonary nodules, which are likely of benign etiology, and a followup CT could be obtained in one year. 4 Calcified granuloma seen in the left upper lobe Discharge Condition: stable Discharge Instructions: Please come back to the hospital or see your primary care physician if you experience worsening shortness of breath, chest pain, fever, chills or any other concerns. . Please take all medications as instructed. Followup Instructions: Please f/u with Dr. [Last Name (STitle) 52730] at the [Hospital6 ]. . Please make sure that a copy of the discharge summary is forwarded to Pulmonary Fellow, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 52730] at [Hospital 2082] Doctor's Office Building. He will need copy of reports documenting pulmonary nodule for follow-up. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472]	[ "250.00", "285.29", "427.89", "428.0", "518.89", "493.22", "515", "518.81", "276.2" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	8315, 8370	2491, 4567	318, 331	8664, 8673	1765, 2468	8932, 9420	1232, 1278		5454, 8292		8391, 8643		4593, 5431			8697, 8909								1293, 1746																						275, 280														359, 980													1002, 1114	1130, 1216
46,093	139,857	54646	Discharge summary	report	Admission Date: [2134-7-26] Discharge Date: [2134-7-31] Date of Birth: [2111-1-25] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 301] Chief Complaint: bilateral pulmonary embolism Major Surgical or Invasive Procedure: [2134-7-31] - pulmonary artery catheterization without tPa infusion History of Present Illness: 23F s/p laparoscopic appendectomy on [2134-7-20]. Patient was discharged the next day in good condition. Pt was ambulating without any difficulty. She reports feeling tired yesterday and this morning feeling lightheaded, sweating, and some chest pain. Pt went to [Hospital ] hospital where CT scan revealed bilateral PEs. She was hypotensive to 76/52 and she was given fluid bolus as well as heparin bolus, followed by heparin gtt. Pt was then transferred to [Hospital1 18] for further management. In the TSICU, her O2 sat is 100 on 3L NC. She does not complain of shortness of breath, lightheadedness, or LE pain or swelling. Denies Fever/Chill/Nausea/Vomiting. Last BM was yesterday and it was normal. Pt reports minimal chest pain. Past Medical History: hypothyroidism, and ADHD Social History: No tobacco, occasional alcohol. No illicit substances. Family History: non-contributory Physical Exam: Vitals: T98.3 P91 BP96/58 RR16 100% 3L NC GEN: NAD. Alert, oriented x3. HEENT: No scleral icterus. Mucous membranes moist. Neck supple CV: RRR, normal S1/S2 PULM: Unlabored breathing, CTAB ABD: Soft, nondistended, NTTP, No R/G. No masses. normal active bowel sound, port sites are D/C/I EXT: Warm without LE edema/c/c Pertinent Results: [2134-7-26] 05:00PM PLT COUNT-218 [2134-7-26] 05:00PM WBC-14.4* RBC-4.23 HGB-12.6 HCT-37.5 MCV-89 MCH-29.7 MCHC-33.5 RDW-13.4 [2134-7-26] 05:00PM HCG-<5 [2134-7-26] 05:00PM TSH-3.2 [2134-7-26] 05:00PM D-DIMER-3821* [2134-7-26] 05:00PM CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.8 [2134-7-26] 05:00PM CK-MB-3 cTropnT-0.09* proBNP-275* [2134-7-26] 05:00PM CK(CPK)-46 [2134-7-26] 05:00PM estGFR-Using this [2134-7-26] 05:00PM GLUCOSE-83 UREA N-10 CREAT-0.6 SODIUM-139 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-11 [2134-7-26] 05:16PM FIBRINOGE-493* [2134-7-26] 05:16PM PT-11.3 PTT-141.7* INR(PT)-1.0 [2134-7-26] 05:23PM LACTATE-1.3 [2134-7-26] 06:35PM HEPARIN-0.64 [2134-7-26] 06:35PM PT-11.6 PTT-82.4* INR(PT)-1.1 Brief Hospital Course: 23F admitted [2134-7-26] for bilateral pulmonary embolisms s/p laparoscopic appendectomy on [2134-7-20]. She underwent a CTA of her chest, which showed extensive bilateral pulmonary emboli. She was started on a heparin drip and transferred to the ICU. Cardiology and Vascular Surgery were consulted. They recommended therapeutic enoxaparin, which was given. To assess the strain on the heart, an echocardiogram was performed, which showed right free wall hypokinesis, 2+ tricuspid regurgitation, and dilation of the right ventricle. On [7-27], heme was consulted, and they recommended lifelong discontinuation of her oral contraceptive pills. They also advised a six-month course of warfarin. She underwent a repeat echo, which showed no change. On [7-28], a repeat CTA/CTV of th echest was performed as well as a CT of the pelvis to evaluate thrombus burden and to evaluated for iliofemoral clot, respectively. A repeat echo was unchanged. She was put on a regular diet, which she tolerated well. On [7-29], she was advanced to PO pain meds. Given her experience, she had anxiety, and so social work was consulted to evaluate for therapy options. From a cardiovascular standpoint, catheter directed thorombolysis was planned for the next morning, so she was switched over to a heparin drip. On [7-30], catheter directed thrombolysis was attempted but ultimately aborted before tPa was given secondary to her right pulmonary artery pressures being found to be normal. A repeat echo showed minimal dilation of the ventricle. She was transferred to the floor in stable condition. Cardiology recommended 3 weeks of fondaparinux (7.5 mg SC daily) every day with a transition to warfarin as an outpatient. On [7-31], she was doing well and discharged home in stable condition. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever/pain 2. Fondaparinux Sodium 7.5 mg SC DAILY TO START [6-30]. PLEASE GIVE AS CLOSE TO 0600AM AS POSSIBLE. RX fondaparinux 7.5 mg/0.6 mL inject one syringe daily Disp #21 Syringe Refills:0 3. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX oxycodone 5 mg [12-14] tablet(s) by mouth every 6 hours Disp #40 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID Discharge Disposition: Home Discharge Diagnosis: pulmonary embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: Test for consideration post-discharge: Factor V Leiden	[ "787.02", "415.11", "244.9", "458.9", "V45.89", "564.00", "314.01", "V45.79", "429.9" ]	icd9cm	[ [ [] ] ]	[ "37.21" ]	icd9pcs	[ [ [] ] ]	4854, 4860	2522, 4355	331, 405	4923, 4923	1693, 2499	5524, 5582	1321, 1339		4410, 4831		4881, 4902		4381, 4387			5074, 5501								1354, 1674																						263, 293														433, 1182								4938, 5050					1204, 1231	1247, 1305
55,772	146,419	32504	Discharge summary	report	Admission Date: [2153-2-13] Discharge Date: [2153-2-19] Date of Birth: [2085-12-29] Sex: F Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 668] Chief Complaint: End stage renal disease, here for kidney transplant Major Surgical or Invasive Procedure: Kidney transplant Transplant nephrectomy Hemodialysis History of Present Illness: Ms. [Known lastname 15942] is a very pleasant 66-year-old female with end-stage renal disease who has been currently on dialysis for approximately one year. She is currently dialyzing through a left upper extremity fistula. She presents for living related renal transplant from her son. She currently denies any signs / symptoms of infection. No fever, chills, URI symptoms, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, dysuria, hematuria, bright red blood per rectum, diarrhea. She has not had dialyisis in six days due to missing one round during a holiday period. Past Medical History: ESRD due to long standing HTN Diabetes mellitus type II; diet controlled Hypertension Hemodialysis T/Th/S AV Fistula right upper extremity Hypercholesterolemia Social History: Pt lives with son and has many family members near home No tobacco, etoh, drugs Family History: Noncontributory Physical Exam: 95.6 56 149/83 16 100RA Alert and oriented x 3 NAD Mucus membranes moist CTAB, no C/W/R RRR, no murmurs Abdomen soft nontender, nondistended RUE AV fistula Pertinent Results: Admission Labs SODIUM 141 POTASSIUM 7.0 CHLORIDE 106 Bicarb 21 BUN 71 Cr 11.3 Glucose 99 Brief Hospital Course: The patient was admitted on [2153-2-13] for living related renal transplant; however, on admission it was noted that the patient's potassium level was 7.0. She therefore underwent hemodialysis prior to receiving her renal transplant. She then underwent a right renal transplant in the iliac fossa, resection of segment of external iliac artery and an interposition graft with an 8-mmEPTFE. Almost immediately after her transplant the patient was anuric. A renal ultrasound showed no flow in the renal artery. The patient therefore returned to the OR where an arteriotomy was performed. The renal artery was obstructed by white clot. The artery was thrombectomiezed. Subsequent to this procedure, the patient still did not make any urine. Serial renal ultrasounds over the coming days still did not show renal artery blood flow. During this time, the patient remained on hemodialysis. On the 16th the patient underwent renal transplant nephrectomy. The patient tolerated the proceedure well. Over the coming days her diet was advanced without complication, she passed flatus and had a bowel movement, nursing and physical therapy were comfortable with her ambulation. During her transplant nephrectomy it was noted that the patient had developed an infiltrated right hand iv with phlebits. She developed a 2 cm ulcer. She was instructed to keep her hand elevated, and over her stay here her hand continued to improve. Also, post operatively, the patient had uncontrolled hypertension requiring multiple antihypertensive medication changes. She is being instructed to f/u with her nephrologist within a week to reevaluate her medication changes. She is to follow up with us within a week to have her jp removed, evaluate improvement in her right hand, and perform a hypercoaguability workup. She will resume hemodialysis as before admission. She will also receive nystatin, valcyte, and bactrim prophylaxis for the coming weeks as the patient already received anti thymocyte globulin. Medications on Admission: Allopurinol 300 qday, Lipitor 20 qday, Nephrocaps qday, Clonidine 0.1 qday, Lasix 20 [Hospital1 ], Nifedipine XL 90 qday, Renagel 800 tid, Colace 100 [Hospital1 ] Discharge Medications: Allopurinol 100 daily, Atorvastatin 20 daily, Clonidine 0.2 [Hospital1 ], Furosemide 20 [Hospital1 ], Nifedipine XL 120 daily, Sevelamer 800 with meals, Colace 100 [Hospital1 ], Protonix 40 daily, Renagel daily, Oxycodone 5 q4prn, Valganciclovir 450 2X/WEEK ([Doctor First Name ],TH), Bactrim SS 3X/WEEK ([Doctor First Name ],TU,TH), Nystatin suspension 5ml 4x/day Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: End stage renal disease s/p renal transplant s/p transplant nephrectomy for arterial thrombosis and transplant kidney failure Diabetes mellitus Hypertension Thrombophlebitis Discharge Condition: Good Discharge Instructions: please follow low potassium diet activity as tolerated you may shower but know pools or tub baths for 2 wks you will go home with the drain and should strip it and empty it twice daily or as needed you are going with some medication changes because your blood pressure has been elevated; you should make an appointment with your nephrologist in the next week to go over your medications you should call the clinic or come to ER if you have a fever > 101.5 (although there is no need to check it if you don't feel poorly), you have pus or redness around wound, you develop nausea and vomiting please keep you right arm elevated as much as possible; call clinic if worsens you may drive when not taking narcotic pain medication your dialysis unit is expecting you tomorrow at your usual time Followup Instructions: You should call the clinic in the am to arrange a follow appt within the next week You should make an appointment with your nephrologist to review your medications within the next week	[ "272.0", "403.91", "996.81", "451.84", "997.5", "585.6", "999.2", "250.00", "584.5" ]	icd9cm	[ [ [] ] ]	[ "55.69", "55.23", "00.91", "38.66", "38.06", "55.53", "39.27", "39.95" ]	icd9pcs	[ [ [] ] ]	4270, 4325	1633, 3640	326, 382	4543, 4550	1520, 1610	5396, 5585	1312, 1329		3861, 4247		4346, 4522		3666, 3838			4574, 5373								1344, 1501																						235, 288														410, 1016													1038, 1199	1215, 1296
49,599	140,810	1140	Discharge summary	report	Admission Date: [2148-7-18] Discharge Date: [2148-7-24] Date of Birth: [2067-11-16] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5790] Chief Complaint: Left upper lobe lung cancer. Major Surgical or Invasive Procedure: [2148-7-18] Left pneumonectomy, mediastinal lymph node dissection, intercostal muscle flap buttress. History of Present Illness: Ms. [Known lastname 7324] is an 80-year-old woman with a biopsy-proven left upper lobe cancer. She presents for exploratory thoracoscopy and possible resection. Past Medical History: PMR Hypertension Hyperlipdemia Hypothyroidism BL cataract surgery Glaucoma Zoster Bilateral knee surgery lap chole Social History: Lives alone. Tobacco: 7.5 pack-year. Quit 50 years ago Family History: non-contributory Physical Exam: VS: 98.5 HR: 86 SR BP: 136/55 Sats: 95% RA General: no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRRR Resp: absent BS on left, clear on right GI: benign Extr: warm no edema Incision: Left thoracotomy site clean, dry Neuro: non-focal Pertinent Results: [2148-7-17] 01:20PM BLOOD WBC-5.5# RBC-4.00* Hgb-11.1* Hct-33.6* MCV-84 MCH-27.7 MCHC-33.0 RDW-14.2 Plt Ct-412 [2148-7-19] 02:53AM BLOOD WBC-9.4# RBC-3.26* Hgb-8.7* Hct-27.3* MCV-84 MCH-26.8* MCHC-32.0 RDW-14.3 Plt Ct-318 [2148-7-20] 02:24AM BLOOD WBC-14.0* RBC-4.07* Hgb-10.8* Hct-35.4# MCV-87 MCH-26.5 MCHC-30.4* RDW-14.8 Plt Ct-274 [2148-7-21] 09:00PM BLOOD WBC-10.9 RBC-3.54* Hgb-9.5* Hct-28.6* MCV-81* MCH-26.7* MCHC-33.1 RDW-14.8 Plt Ct-403 [2148-7-18] 04:40PM BLOOD Creat-0.8 K-3.8 [2148-7-19] 02:53AM BLOOD Glucose-143* UreaN-15 Creat-0.8 Na-139 K-4.2 Cl-108 HCO3-23 AnGap-12 [2148-7-23] 07:05AM BLOOD Glucose-136* UreaN-9 Creat-0.6 Na-135 K-4.0 Cl-98 HCO3-29 AnGap-12 [2148-7-19] 02:53AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0 [2148-7-23] 07:05AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.1 [2148-7-22] CXR: Partial filling of left pneumonectomy space with fluid. Small right pleural effusion. Brief Hospital Course: Mrs. [Known lastname 7324] was admitted on [2148-7-18] for Left pneumonectomy, mediastinal lymph node dissection, intercostal muscle flap buttress. She was extubated in the operating room transferred to the SICU for further management. Respiratory: Aggressive pulmonary toilet with nebs were continued. Her respiratory status remained stable. She weaned off the oxygen with saturations in the high 90's. She was followed by serial CXR with slow filling on the left. The chest tube was removed on [2148-7-19]. She transferred to the floor on [2148-7-21]. Cardiac: Episode of hypotension immediately postoperative which responded to a fluid challenge. She remained in sinus rhythm. GI: no issues Bowel regime Renal: Renal function remained stable with good urine output. She was diuresed with small amounts of IV Lasix to keep euvolemic or mildly negative. Her lytes were replete as needed. The Foley was removed on [2148-7-23]. Nutrition: She was seen by Speech and Swallow on [2148-7-19] who recommended a regular diet with thin liquids which she tolerated. Pain: She was followed by acute pain service for the Bupivacaine and Dilaudid epidural. This was contributing to her hypotension therefore was removed on [2148-7-20]. She was started on PO pain medications requiring Tylenol initially for pain. With increased activity she tolerated a small dose of Roxicet without difficulty. Heme: She was transfused 1 Unit PRBC for a HCT of 25. Consults: She was seen by the Geriatric team for delirium prevention and management. They recommend no Benadryl. Use Trazodone 12.5 mg HS for sleep as needed, Start Tylenol standing 650mg Q6H, Please keep in mind non-pharmacologic delirium prevention: a) Remove all lines and catheters as soon as possible, esp Foley b) Avoid sedatives, especially antihistamines and benzodiazepines c) Encourage family to be at bedside, with familiar home objects d) Explore and encourage baseline religious/spiritual coping mechanisms for illness. e) Preserve sleep wake cycle by minimizing overnight interruptions and allowing for stimulation and activity during the day ie cancelling midnight vitals unless medically ndicated f) OOB for meals if/when eating TID g) Reorient frequently h) Ensure BM at least once every other day, if not daily. i) Providing hearing aids as needed glasses and dentures to maximize sensory input Disposition: She was followed by physical therapy who recommended rehab. She continued on her home medications and was discharged to rehab. Medications on Admission: Levoxyl 88 mcg daily, lisinopril 10 mg daily, ASA 81 mg daily, Multivit citrudel w/D daily, timolol 0.5 OU qam zalden OU hs aculor OD [Hospital1 ] Discharge Medications: 1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic QAM (once a day (in the morning)) as needed for glaucoma. 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Oxycodone 5 mg/5 mL Solution Sig: [12-15] mL PO Q4H (every 4 hours) as needed for pain: sensitive to narcotics give 2.5 mL. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ketorolac 0.5 % Drops Sig: One (1) drop Ophthalmic [Hospital1 ] (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for puritis. 12. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: give with food & water. Discharge Disposition: Extended Care Facility: [Last Name (un) 1687] - [Location (un) 745] Discharge Diagnosis: Left Upper Lobe Cancer Discharge Condition: deconditioned Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if experience: -Fever > 101 or chills. -Increased shortness of breath, cough or sputum production -Incision develops drainage -You may shower. No tub bathing or swimming for 4 weeks Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [8-1] at 2:30 on the [Hospital Ward Name 5074] Clinical Center [Location (un) 24]. Report to the [Location (un) 861] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[2148-7-24]	[ "292.81", "E933.0", "725", "162.3", "E935.2", "244.9", "365.9", "401.9", "458.29", "426.2" ]	icd9cm	[ [ [] ] ]	[ "86.74", "34.20", "40.29", "32.59" ]	icd9pcs	[ [ [] ] ]	6118, 6196	2188, 4732	352, 460	6263, 6279	1230, 2165	6575, 6859	882, 900		4934, 6095		6217, 6242		4758, 4911			6303, 6552								915, 1211																						283, 314														488, 655													677, 794	810, 866
11,341	185,234	3057	Discharge summary	report	Admission Date: [2145-7-1] Discharge Date: [2145-7-7] Date of Birth: [2082-1-26] Sex: F Service: MICU/GREEN HISTORY OF PRESENT ILLNESS: This is a 63 year-old female with a history of Prednisone dependent sarcoid, cirrhosis, ascites with SBP who presented with one day of nausea, vomiting, diarrhea and change in mental status. She was discharged to nursing home on [2145-6-28] after admission for back pain. She has had multiple admissions including three day admissions for compression fracture of the spine, which was complicated by pneumonia and ascites with a 7 liter tap. She also had azotemia and hypophosphatemia as well as urinary tract infection, right tibia fibula fracture and that admission date was from [5-22] until [6-11]. The patient was doing well at nursing home, eating well and comfortable one night prior to admission when this morning had nausea, vomiting and diarrhea, initially presented to [Hospital3 1442] and was transferred to [Hospital1 188]. She received enema twice yesterday and had diarrhea since then. In the Emergency Department her vital status was heart rate 120, blood pressure 100/68, respirations 18, and then she became hypotensive. Her blood pressure dropped down to the 80s. Her regular blood pressure ranging between 90s to 110. She was given Phenergan and her abdominal x-ray was concerning for obstruction. We recommended to have an abdominal CT, but the patient did not tolerate NG tube placement. Her blood culture was sent and we also gave her 1 liter of normal saline. She was seen by surgery who recommended broad spectrum antibiotics. CT scan was later done without any contrast. PAST MEDICAL HISTORY: Cirrhosis, sarcoid, osteoporosis, hyperlipidemia, hypertension, portal hypertension, thrombocytopenia, esophageal varices and aortic stenosis. PAST SURGICAL HISTORY: Total abdominal hysterectomy, total right hip placement. ALLERGIES: She has multiple allergies including Penicillin, Oxacillin, Percocet, Keflex, intravenous iodine, Oxycontin, Flagyl, and Codeine. SOCIAL HISTORY: The patient is divorced with many children. She currently lives with children prior to being at rehabilitation. She denies tobacco and alcohol. LABORATORY: Ascites fluid white blood cell is [Pager number 14569], red blood cell equal to 7700, poly 95%, band 1%. Urinalysis large amount of blood, positive nitrites, moderate leukocytes, few bacteria. CT of the abdomen with intravenous contrast, there is extensive ascites with severely shrunken nodular cirrhotic liver. The pancrease is atrophic. There is a diffused wall thickening of the colon as well as several loops of small bowel. This is not evident on the previous examination. Extensive vascular calcifications are again noted, however, in the interval there has been development of extensive clot within the SMV. No free air or pneumoptosis is identified. HOSPITAL COURSE: 1. SMV/thrombosis: CT of the abdomen on [Month (only) 205] the 4th, showed diffuse thickening of loops of large and small bowel in the setting of extensive clots within SMV. These findings are concerning for venous ischemia. Also showing clots within the protal venous confluents as previous CT scan [2145-3-30]. Heparin was started. Repeated abdominal CT on [2145-7-3] shows no growth change in the clots within the SMV and portal venous confluence. Heparin therapy continues. 2. Respiratory: The patient's respiratory deteriorated since admission, became progressively labored and tachypneic. Chest x-ray shows lung volumes are extremely low due to massive ascites pushing up on diaphragm. CT showed atelectasis at the lung bases. On [7-3] the patient's respiratory status worsened with mental status change. Arterial blood gas showed 7.09/68/78. The patient's proxy did not wish to intubate the patient. Therapeutic paracentesis was done to remove 6 liters of fluid. The patient received three bags of albumin, however, still developed hypotensive episodes and became unresponsive afterwards. 3. Cirrhosis: The patient had end stage renal disease with cirrhosis and massive ascites. The patient received albumin 75 grams on [2145-7-2] and another 50 grams on [2145-7-4]. (per liver consult suggestion to decrease motility in people with ascites). 4. Infectious disease: Paracentesis on [7-2] showed white blood cell of more then 5000 and gram negative rods, which was later identified to be Pseudomonal and urinalysis was consistent with urinary tract infection. The patient was initially put on Vancomycin and Cipro, but later changed to Flagyl and Aztreonam per ID consult suggestion. 5. Code: The patient was initially on full code, however, on [7-5] after taping the patient had a discussion with the patient's proxy and family members and decision was made to keep the patient on comfort measures only. O line was discontinued and medications stopped except for morphine drips to keep the patient pain free. The patient expired on the evening of [2145-7-7] at 7:30 p.m. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4561] Dictated By:[Doctor Last Name 14570] MEDQUIST36 D: [2145-7-9] 05:17 T: [2145-7-14] 08:55 JOB#: [Job Number 14571]	[ "789.5", "996.64", "557.0", "599.0", "785.59", "567.2", "135", "424.1", "571.5" ]	icd9cm	[ [ [] ] ]	[ "54.91", "38.93" ]	icd9pcs	[ [ [] ] ]														2953, 5362									1887, 2088																																					166, 1696													1719, 1863	2105, 2935
8,339	107,515	29024	Discharge summary	report	Admission Date: [2122-1-14] Discharge Date: [2122-2-6] Date of Birth: [2057-2-17] Sex: F Service: MEDICINE Allergies: Penicillins / Fentanyl / Oxycodone / Meperidine Attending:[First Name3 (LF) 11040] Chief Complaint: ARDS seconrday to septic shock Major Surgical or Invasive Procedure: Tracheostomy and G-tube placement. History of Present Illness: Ms. [Known lastname 69940] is a 64 year old woman with HTN, RA, Type 2 DM admitted to OSH on [1-10] with confusion, chills, fevers to 103 and a week of green sputum found to have PNA on CXR, hypotension, and hypoxic respiratory failure. She was intubated in ED, started on dopamine, and transfered to the ICU. She ruled in for NSTEMI. She was switched to Norepinephrine (per cards) and hydrocort. She also received Xigris. Within 24 hours her HCT dropped from 35% to 28% and Xigris was stopped. Pt was initially on Ceftriaxone and Azithro which was changed to Levoquin Vanco and Clinda which was stopped on [1-14]. Due to possible [Location (un) ] exposure, Doxycycline was also started. She went into A flutter with RVR and was cardioverted once unsuccessfully at the OSH. She was started on Diltiezem drip for rate control. For ? PCP PNA, she was started on high dose Bactrim as well. Throughout her OSH course she developed an increasing O2 requirment, and there was concern for ARDS with increasing difficulty in ventilation. Her last ABG on transfer was 7.30/45/51 sating 88% on 100%FiO2; IMVO 14; PEEP 8; Tv 700. She was transfered here for further management. . PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Past Medical History: RA- Stopped Methotrexate 5 months ago for a "reverse effect" according to notes. Maintained on 20mg Prednisone daily HTN NIDDM GERD Social History: Lives with husband, quit smoking 23 years ago, occasional wine, no drug use. Family History: Non-contributory Physical Exam: PE: Admitted intubated, on rotating bed T:36.9 HR:104 BP:133/51 (off pressors) RR:19 90% O2 Sats Wt:98.6kg AC Tv:400 FiO2:100% Peep:15 PP:24 Gen: intubated, sedated HEENT: ET tube in place NECK: unable to asses JVP 2/2 habitus CV: Regular Rate and rhythym, occasional PVCs. LUNGS: course BS anteriorly/laterally ABD: Soft, NT, ND. NL BS. EXT: No edema. 2+ DP pulses BL SKIN: No lesions Pertinent Results: [2122-1-14] 11:03PM PT-12.9 PTT-27.2 INR(PT)-1.1 [2122-1-14] 11:03PM PLT COUNT-268 [2122-1-14] 11:03PM WBC-15.9* RBC-3.81* HGB-11.4* HCT-31.7* MCV-83 MCH-30.1 MCHC-36.1* RDW-16.8* [2122-1-14] 11:03PM CALCIUM-5.9* PHOSPHATE-1.9* MAGNESIUM-2.1 [2122-1-14] 11:03PM estGFR-Using this [2122-1-14] 11:03PM GLUCOSE-275* UREA N-30* CREAT-0.9 SODIUM-138 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-22 ANION GAP-12 [2122-1-14] 11:09PM freeCa-0.72* [2122-1-14] 11:09PM LACTATE-2.3* [2122-1-14] 11:09PM TYPE-ART PO2-69* PCO2-45 PH-7.38 TOTAL CO2-28 BASE XS-0 . OSH MICRO DATA: Mycoplasma IgG - posative Blood Cx [1-10] - Gm posative cocci, speciation/sensis pending Legionella - negative Strep Pneumo antigen - negative RSV - negative Influenza A/B - negative . STUDIES: CXR - has large left pulmonary infiltrate . [1-21] CT abd/pelvis: 1. Uncomplicated pancreatitis with no evidence of abscess or fluid collection. 2. Pleural effusions, left greater than right, with consolidation in the right lower lobe consistent with pneumonia. 3. Old fractures of the pelvis. Brief Hospital Course: # Hypoxic Respiratory Failure - Secondary to mycoplasma PNA for which she completed 14 day course of levofloxacin, evolved to ARDS from sepsis. Subsequently complicated by likely ventilator associated pneumonia, culture and bronchial lavage negative, empirically treated with a course of Vancomycin and Cefepime. Also, complicated by severe polyneuropathy from likely critical care neuropathy. NIF was measured and was in the 30s range. Pt was weaned to PS 5/0 on the 13th day of hospitalization and extubation was attempted. However the patient became increasingly tachypneic and agitated about 12 hours after extubation and was reintubated. Failure was thought to be due to respiratory muscle fatigue, poor underlying lung function in the context of pneumonia, possible component of volume overload. A tracheostomy was placed the next day as well as a PEG tube. She was successful with trach mask trials several days after trach placement on high flow O2. She was successful for > 12hours daily, but on several occasions became tachypneic in the evening, thought to be influenced largely by anxiety rather than fatigue, requiring placement back on PS overnight. She was, however, trialed for 24 hours on trach mask and was fatigued the following day requiring full 24 hours back on PS. This was likely [3-6] to true respiratory muscle fatigue. . # PNA: From mycoplasma, treated with 14 day course of levofloxacin. Subsequently complicated by likely ventilator associated pneumonia, culture and bronchial lavage negative, empirically treated with a course of Vancomycin and Cefepime. . # Septic shock: Lactate on admission 2.3, hypotension, elevated WBC with 2 bands, tachypnea and tachycardia. Initially with pressor requirement. Initial broad spectrum Abx were discontinued once source of sepsis was found to be due to mycoplasma and a course of 14 days of Levofloxacin was completed. The patient also was treated with stress dose steroids initially, which were subsequently weaned to baseline Prednisone dose for chronic RA of 20mg. . # Clostridium difficile infection: diagnosed on [1-22]. Pt. will complete a 7 day (post other antibiotics) course of flagyl (flagyl course to be completed on [2122-2-6] after receiving her tid dosing that day). Diarrhea is much improved. . # Pancreatitis: Thought [3-6] to propofol originally with elevated amylase and lipase. Once her propofol was d/c'd, her amylase normalized. Her lipase decreased, but remained elevated in the 150s. Other LFTs were normal. Her tube feeds were held transiently when her lipase failed to completely resolve and she had mild epigastric discomfort. Given that her epigastric discomfort was post G tube placement, it resolved and tube feeds were reinitiated. She did have high residuals so was not originally at goal. Reglan was started and tube feeds were advanced. She is now tolerating tube feeds at goal without reglan. . # Critical illness neuropathy: severe distal weakness, slight improvement towards the end of her hospital stay. EMG and nerve conduction studies showed mild, proximal myopathy with a superimposed geneneralized polyneuropathy, predominantly axonal. The picture is consistent with critical illness polyneuropathy and myopathy. Her strength has been consistently increasing, but deficit remains. She will need continued physical therapy for this. . # Rash, eosinophilia: During her course of cefepime and vancomycin she developed a rash and eosinophilia. Once her 7 day course of cefepime and vanco was complete, her rash resolved although she remained mildly subjectively itchy requiring fexofenadine. Her eosinophils remained elevated, but this also started to resolve. There was no other clear drug source and suspiscion for infective cause was very low. . # Low grade fever: Intermittent low grade fever to Tmax of 100.2. She has BAL, Urine and blood cultures pending from [2122-2-5], but suspiscion for infection is low given normal WBC count and no left shift on diff. These cultures should be followed up. . # Rheumatoid arthritis: Patient was transiently on stress dose steroids in the setting of sepsis. Steroids were reduced to her home dose of 20mg PO prednisone with the resolution of sepsis. The need for PCP prophylaxis was discussed given chronically on 20mg prednisone daily. The need for this dose in the setting of her RA and PCP prophylaxis was discussed with her rheumatologist and her dose of prednisone was decreased to 15mg po prednisone as she is not currently complaining of joint symptoms. She was not started on bactrim while inpatient and if her chronic prednisone dose requirement increases, this should be readdressed. Additionally, given her age, sex and chronic prednisone, she was started on vitamin D and calcium. . # Anemia with hct drop: HCT has been stable 24-26 from original drop from 29-31. Anemia w/u included abd CT not revealing for bleed. LDH is elevated, haptoglobin elevated as well, but this is in the setting of inflammation and, thus may not reflect accurately hemolysis. Stools were guaiac negative. Iron revealed normal iron, elevated ferritin, and low TIBC c/w ACD. . # Depression: Patient has a history of depression and was on elavil previously. She is not sure why this was discontinued originally. While hospitalized, she was experiencing low mood and general anxiety. Thus, celexa was started at 20mg daily on [2122-1-31]. This can be titrated as appropriate upon discharge. . # Hypertension: after hypotension in the context of sepsis has resolved, the patient hypertension which was controlled with Labetalol and Captopril. She did require occasional fluid bolus in setting of negative fluid status and low UOP and transient hypotension, to which her BP responded well. . # A-Flutter: transient episodes in the context of high adrenergic state after acute sepsis resolved. Hemodynamically stable and was in NSR for > 1week prior to discharge, continued on BB. . # Steroid induced hypergylcemia: transiently on glargine, then changed to Regular SS only as steroids were weaned. Her blood sugars have been well controlled. She has not been requiring SS coverage, but this should be initiated if glucose control worsens. # FEN: PEG tube in place. Tube feeds restarted after PEG tube placement on [2122-1-29]. . # PPx: Heparin SQ, PPI . # CODE: Full Code Medications on Admission: MEDS on Transfer: Doxycycline 100mg [Hospital1 ] Lopressor 2.5mg IV q4' and 5mg IV q6' ASA 81mg daily Zithromax 500mg IV Daily (started [1-14]- one dose given) Bactrim 400mg IV q8' (started [1-14]- one dose given) Solumedrol 60mg IV q6' (was 125mg IV q6hour until [1-13]) Fludrocortisone 0.1mg NGT Daily Reglan 5mg IV q8' Vancomycin 1gm IV q12' (started [1-14]- got one dose) Digoxin 0.125mg Daily NG since [1-12] Lovenox 40mg SC Daily Nexium 40mg Daily Lantus 20u SC daily Lopid 300mg via NG [Hospital1 ] RISS Ativan PRN Tylenol ORN Morphine PRN Levaquin 500mg IV Daily (started [1-10]) Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO QID (4 times a day) as needed. 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [Last Name (STitle) ]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for when on vent. 4. Albuterol 90 mcg/Actuation Aerosol [Last Name (STitle) ]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for when on vent. 5. Insulin Regular Human 100 unit/mL Solution [Last Name (STitle) ]: See sliding scale for appropriate dosing Injection ASDIR (AS DIRECTED). 6. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection TID (3 times a day). 7. Trazodone 50 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO HS (at bedtime) as needed. 8. Captopril 12.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 9. Labetalol 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 10. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Acyclovir 5 % Ointment [Last Name (STitle) ]: One (1) Appl Topical 6X/D (6 times a day). 12. Citalopram 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 13. Albuterol Sulfate 0.083 % Solution [Last Name (STitle) ]: [2-3] Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheeze. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). 15. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [Month/Day (2) ]: Ten (10) ML PO TID (3 times a day). 16. Metronidazole 500 mg Tablet [Month/Day (2) ]: One (1) Tablet PO TID (3 times a day) for 2 doses: to complete 3 doses on [2122-2-6] and then to be discontinued. 17. Prednisone 5 mg Tablet [Date Range ]: Three (3) Tablet PO DAILY (Daily). 18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Date Range ]: [2-3] MLs Intravenous DAILY (Daily) as needed. 19. Ativan 1 mg Tablet [Month/Day (2) ]: 0.5-1 Tablet PO every 4-6 hours as needed for anxiety. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: Primary: 1. Hypoxic respiratory failure requiring intubation now s/p tracheostomy and PEG 2. Community acquired pneumonia 3. Ventilator associated pneumonia 4. ARDS 5. Pancreatitis 6. Depression 7. Rheumatoid arthritis 8. Polyneuropathy and myopathy of critical illness 9. Anemia 10. Clostridium difficile colitis Discharge Condition: Stable, had been tolerating trach mask, currently on pressure support and tolerating well. Discharge Instructions: Return to the emergency room if you develop fever, chills, if diarrhea persists or worsens post antibiotic course, worsening abdominal pain, nausea, inability to advance tube feeds. . Please take your medications as prescribed. Please note we have started you on the antidepressant celexa. Additionally, we have decreased your prednisone for rheumatoid arthritis to 15mg daily. If your dose increases chronically from this, you should discuss with your doctor the need for PCP [Name Initial (PRE) 1102]. Followup Instructions: Please follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 69941]t when appropriate from rehab.	[ "483.0", "401.9", "577.0", "785.52", "486", "714.0", "995.92", "693.0", "518.81", "E930.5", "E930.8", "285.29", "251.8", "E932.0", "359.81", "511.9", "V58.65", "008.45", "428.0", "038.8", "357.82", "519.4", "530.81", "584.9", "410.71", "311", "427.32" ]	icd9cm	[ [ [] ] ]	[ "96.6", "43.11", "99.04", "31.1", "96.72", "33.24", "38.93" ]	icd9pcs	[ [ [] ] ]	12833, 12913	3534, 9907	339, 376	13271, 13364	2401, 3511	13923, 14061	1961, 1979		10578, 12810		12934, 13250		9933, 9933			13388, 13900								1994, 2382																						269, 301														404, 1695													1717, 1851	1867, 1945		9951, 10555
32,049	168,588	3858	Discharge summary	report	Admission Date: [2112-9-29] Discharge Date: [2112-10-6] Date of Birth: [2052-3-25] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [2112-9-29] Exploratory laparotomy & splenectomy [2112-9-29] Left chest thoracosotmy [2112-9-30] Epidural catheter placement (removed on [10-4]) History of Present Illness: 60 yo female s/p rollover motor vehicle collision; ?LOC She was taken to an area hospital and was transferred to [Hospital1 771] for further care. Initially she was hemodynamically stable with normal pulse and pressure. However, she developed hemodynamic instability and apparent blood loss anemia. A left sided thoracostomy tube was placed for a hemothorax. Attempt at DPL revealed no return of fluid on aspiration and the guidewire and catheter could not be advanced. CT scan of her abdomen confirmed splenic injury. She was emergently taken to the operating room by Dr. [Last Name (STitle) ]. Past Medical History: GERD Depression Social History: Married Family History: Noncontributory Pertinent Results: [2112-9-29] 09:40PM GLUCOSE-165* UREA N-11 CREAT-0.5 SODIUM-136 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-23 ANION GAP-8 [2112-9-29] 09:40PM CK(CPK)-811* [2112-9-29] 09:40PM CK-MB-55* MB INDX-6.8* cTropnT-<0.01 [2112-9-29] 09:40PM WBC-14.5* RBC-4.21# HGB-13.5# HCT-37.1 MCV-88 MCH-32.1* MCHC-36.3* RDW-14.4 [2112-9-29] 09:40PM PLT COUNT-86* [2112-9-29] 09:40PM PT-14.7* PTT-29.5 INR(PT)-1.3* [2112-9-29] 06:38PM GLUCOSE-131* LACTATE-1.2 NA+-137 K+-3.8 CL--108 TCO2-25 [2112-9-29] 06:35PM UREA N-16 CREAT-0.7 HEAD CT WITHOUT CONTRAST, [2112-9-29] AT 19:19 HOURS. HISTORY: Trauma. TECHNIQUE: Serial transverse images were acquired sequentially through the brain and reconstructed at stacked 5 mm increments. No intravenous contrast was administered. COMPARISON: None. FINDINGS: The extracalvarial soft tissues are unremarkable. The calvarium and skull base are intact. The included paranasal sinuses and mastoid air cells are clear. The globes are intact with lenses in place. The patient is intubated. Intracranially, the ventricles are midline and normal in size and configuration. The cortical sulci and subarachnoid cisterns are unremarkable. The [Doctor Last Name 352] matter-white matter interface is well defined. There is no intracranial hemorrhage or CT evidence of acute cortical stroke. IMPRESSION: No traumatic injury to the skull or brain. CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: trauma Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 60 year old woman with mvc REASON FOR THIS EXAMINATION: trauma CONTRAINDICATIONS for IV CONTRAST: None. CT OF THE TORSO WITH INTRAVENOUS CONTRAST CLINICAL HISTORY: Motor vehicle collision trauma. COMPARISON: None. TECHNIQUE: MDCT of the chest, abdomen, and pelvis from thoracic inlet to upper thighs utilizing IV 130 cc of Optiray. Multiplanar reformations were obtained. CHEST FINDINGS: Endotracheal tube is noted with its tip approximately 3.5 cm above the carina. The thoracic aorta demonstrates normal contour, caliber, adn course. The main pulmonary artery is within normal limits. The heart size is normal with no pericardial effusion. There is no mediastinal, hilar or axillary lymphadenopathy. The central airways are patent. There is a small left pneumothorax. Left-sided chest tube is seen, tracking within the left major fissure. There is massive contusion of the left lower lobe and to a lesser extent peripherally in the anterior left upper lobe. Air- space opacities are also noted in the posterior right upper and lower lobes, which likely represent atelectasis. Other smaller ill-defined patchy opacities are noted in the right apex. The left sixth through eleventh ribs demonstrate fractures at multiple points likely resulting in a flail segment. There is also fracture of the left posterior twelfth rib. There is associated subcutaneous emphysema along the left lateral chest wall. Large amount of high-density fluid is noted within the peritoneal cavity consistent with large hemoperitoneum. The spleen is shattered with a focus of high attenuation in its superior pole compatible with active extravasation. There is a 1.1 cm rim calcified chronic splenic arterial aneurysm (2:57). The liver, pancreas, adrenal glands and kidneys are within normal limits. There is no hydronephrosis or hydroureter. Multiple small layering gallstones are noted wihtout evidence for acute cholecystitis. The small bowel loops demonstrate hyper-enhancement of their walls, compatible with "shock bowel". There is no bowel obstruction. The abdominal aorta is within normal limits. PELVIS FINDINGS: Again seen is the free intraperitoneal fluid. Foley catheter is seen with its balloon inflated in the urinary bladder. The uterus is grossly unremarkable. Umbilical fat stranding, with subcutaneous emphysema is noted. There is a small amount of free intraperitoneal air. These findings are presumed to be a result of deep peritoneal lavage, however such a history is not provided. There is grade 1 spondylolisthesis of L5 on S1 associated with spondylolysis. Vertebral body hemangiomas are seen. IMPRESSION: 1. Shattered spleen with large hemoperitoneum. Active extravasation noted. 2. Shock bowel. 3. Massive left lower lobe and to a lesser extent left upper lobe contusion. 4. Intrafissural placement of left chest tube, which should be replaced. 5. Small left pneumothorax. 6. Multiple left rib fractures, consistent with flail chest. 7. Umbilical wound and small amount of free intraperitoneal air. These findings are presumably due to deep peritoneal lavage, however such a history has not been provided. 8. Chronic 1.1 cm splenic arterial aneurysm. 9. Cholelithiasis. Cardiology Report ECG Study Date of [2112-9-29] 11:15:14 PM Sinus rhythm. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 130 76 394/415 72 58 68 CHEST (PA & LAT) Reason: please evaluate for pneumothorax and eval chest tube [Hospital 93] MEDICAL CONDITION: 60 year old woman s/p chest tube placement for pneumothorax REASON FOR THIS EXAMINATION: please evaluate for pneumothorax and eval chest tube These results were communicated to Dr. [Last Name (STitle) 17296] approximately 12:30 pm the day of the study. HISTORY: 60-year-old female status post rollover MVC with chest tube for pneumothorax. Evaluate pneumothorax. TWO VIEWS OF THE CHEST: The right lung is clear. In comparison to previous chest x-rays, the most recent of which is [2112-10-2], there has been improvement in the contusion previously seen on the left side. There remains a left-sided residual tiny pneumothorax as well as left basilar atelectasis and possible left basilar pleural effusion. A vertical linear lucency projected over the left scapula appears to be a fracture of the left scapula. CAROTID SERIES COMPLETE Reason: evaluate for carotid stenosis [Hospital 93] MEDICAL CONDITION: 60 year old woman with single accident MVC, s/p ex-lap with splenectomy REASON FOR THIS EXAMINATION: evaluate for carotid stenosis CAROTID ULTRASOUND EXAMINATION: INDICATION: 60-year-old woman with status post MVA, possible TIA. FINDINGS: RIGHT SIDE: No significant atherosclerotic changes are seen. The internal carotid artery is tortuous and elevated. Peak systolic velocities in its distal segment could be related to marked tortuosity. The peak systolic velocity in the common carotid artery 98 cm/sec, proximal ICA 78 cm/sec, mid ICA 60 cm/sec, and distal ICA 132 cm/sec. ICA/CCA ratio 1.16. The flow in the vertebral artery is in antegrade direction. LEFT SIDE: There is minimal plaque at origin of the internal carotid artery with peak systolic velocity approximately 97 cm/sec, mid ICA 127 cm/sec, and distal ICA 94 cm/sec. The peak systolic velocity in the common carotid artery 142 cm/sec and external carotid artery 83 cm/sec. ICA/CCA ratio is 0.85. The flow in the vertebral artery is in antegrade direction. IMPRESSION: 1. Tortuous right internal carotid artery with less than 40% stenosis. 2. Less than 40% stenosis of the proximal left internal carotid artery. Brief Hospital Course: She was admitted to the Trauma service and taken directly to the operating room for exploratory laparotomy and splenectomy. She required 4 units packed cells and 2 units fresh thawed plasma. There were no intraoperative complications. Postoperatively she was taken to the Trauma ICU where she remained for a few days. She was weaned from the ventilator and later transferred to the regular nursing unit. Serial enzymes were cycled and were flat, her troponin was <0.01; ECG - normal sinus rhythm. The Acute Pain Service was consulted because of her rib fractures for epidural catheter placement. This was placed and remained for several days. She was later changed to oral narcotics (Dilaudid) and reports adequate pain control. She was also started on a bowel regimen because of the narcotics. The left chest thoracostomy tube was removed on [10-3]; post chest film was stable. She has been instructed on continuing to use the incentive spirometer because of her rib fractures in order to avoid any complications associated with this injury. She complained of dysuria on day of discharge; no hematuria noted. A urinalysis was obtained. She was started on Bactrim DS and Pyridium prn for the dysuria. Her abdominal incision is clean and without any erythema, induration. The staples will be removed within 10-14 days of surgery ([9-29]) when she follows up with Dr. [Last Name (STitle) ]. Because of her injuries and deconditioned status Physical therapy was consulted; she did have some dizziness during the initial evaluation, but no orthostasis. Fluids were encouraged; these symptoms did improve over the next several days and she was cleared for discharge to home. She was given the appropriate vaccinations given the splenectomy (Meningococcal, Pneumovax and Hb). her home medications were restarted; diet advanced which she is tolerating; although full appetite not returned as yet. Case management involved in her care and have made referral to the VNA on [Location (un) ] for skilled nursing care at home. She has requested that a copy of her discharge summary be sent to her primary care doctor, Dr. [First Name8 (NamePattern2) 3551] [Last Name (NamePattern1) 6930], in [Hospital1 1562]. Medications on Admission: Wellbutrin Celexa Omeprazole Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-26] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:1 Refills:1 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [3-27] as needed for pain. Disp:75 Tablet(s) Refills:0 10. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:6 Tablet(s) Refills:0 11. Pyridium 100 mg Tablet Sig: One (1) Tablet PO three times a day as needed for dysuria for 3 days. Disp:9 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA [Hospital3 ] Discharge Diagnosis: s/p Motor vehicle crash 1. Left flail chest (ribs [7-5]) 2. Left pneumothorax with pulmonary contusions 3. AAST Grade V splenic injury 4. Uncomplicated UTI Discharge Condition: Stable Discharge Instructions: Please call your doctor if you develop increased chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Activity: No heavy lifting of items [11-7] pounds until the follow up appointment with your doctor. Medications: Resume your home medications prescribed by your doctor. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. You should take a stool softener (colace) twice daily as needed to prevent narcotic-induced constipation. PLEASE do not take if you are having loose stools Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 1 week. Call his office at ([Telephone/Fax (1) 2047] to set up an appointment. Follow up with your primary care doctor (Dr. [First Name8 (NamePattern2) 3551] [Last Name (NamePattern1) 6930] in [Hospital1 1562]) in [1-26] weeks. You will need to call for an appointment. A copy of your discharge summary will be sent to her per your request. Completed by:[2112-10-6]	[ "958.7", "868.03", "958.4", "860.0", "E812.0", "574.20", "807.06", "861.21", "285.1", "959.12", "865.02", "807.4", "599.0" ]	icd9cm	[ [ [] ] ]	[ "34.09", "41.5", "03.90" ]	icd9pcs	[ [ [] ] ]	11941, 11992	8416, 10651	338, 501	12196, 12205	1252, 2741	13135, 13583	1216, 1233		10730, 11918	7207, 7279	12013, 12175		10677, 10707			12229, 13112																														275, 300	7308, 8393													529, 1136													1158, 1175	1191, 1200
13,351	163,327	5695+5720+5721+55692	Discharge summary	report+report+report+addendum	Admission Date: [2162-2-4] Discharge Date: Date of Birth: [2107-3-22] Sex: F Service: CHIEF COMPLAINT: Chest pain and shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 54 year old female with end-stage renal disease on peritoneal dialysis due to diabetes mellitus, peripheral vascular disease, coronary artery disease status post non-Q wave myocardial infarction in [2162-1-2] with a troponin peak of 40, who presents to the Emergency Room with chest pain and shortness of breath. The patient reports that her substernal chest pain/pressure began at rest the evening prior to the admission. She denied radiation of the pain and described the pain as 6 out of 10, without associated shortness of breath, nausea, vomiting or diaphoresis. The pain did not subside until arrival into Emergency Department in the morning before any medications were given. She reports the symptoms of her last myocardial infarction were mostly respiratory. She also reports that for the last two to three weeks, she has been having mild intermittent chest pain at night. She does not take Nitroglycerin at home. The patient denies palpitations, orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema. She reports no recent illnesses. She denies cough, fevers, chills, change in her bowel movement. She states that occasionally she experiences dizziness with standing up and reports that her blood pressure has been on the lower side. The patient was given Nitroglycerin in the Emergency Department with decrease in her blood pressure which responded to fluids. Currently the patient was chest-pain free with no EKG changes, however, her troponin was noted to be 6.1 and the patient was admitted to rule out myocardial infarction. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus for 20 years with last hemoglobin A1C in [2162-1-2], of 7.5%. 2. End-stage renal disease on peritoneal dialysis for two years. 3. Gastroparesis - on Reglan. 4. Peripheral vascular disease status post right femoral-popliteal bypass. 5. History of supraventricular tachycardia. 6. Status post appendectomy. 7. Status post right carotid endarterectomy. 8. Status post breast reduction. 9. Coronary artery disease status post non-Q wave myocardial infarction on [2162-1-13]. Her last echocardiogram was done on [1-12] of [2161], which showed an ejection fraction of 55%, mitral valve, three plus mitral regurgitation. Her EP performed on that admission showed largely reversible defect in distal anterior wall involving the apex and the lateral wall. Her cardiac catheterization performed on [2162-1-15], showed 30% middle right coronary artery lesion, 90% distal left anterior descending lesions with good collaterals from right to left. 10. Anemia. 11. Hypercholesterolemia. SOCIAL HISTORY: The patient lives with her husband. She quit smoking in [2145]. She does not drink alcohol and denies use of any drugs. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg p.o. q. day. 2. NPH insulin, 24 in the morning and 36 in the evening. 3. Elavil 25 mg twice a day. 4. Prilosec 20 mg q. day. 5. Reglan 5 mg three times a day half an hour before meals. 6. Regular insulin sliding scale. 7. Hexadrol 2.5 mg twice a day. 8. Lopid 600 mg p.o. twice a day. 9. Epogen 6000 units three times a week. 10. Renagel 3,200 mg three times a day. 11. Colace 100 mg p.o. twice a day. 12. Nephrocaps one tablet q. day. 13. Avapro 75 mg q.o.d. and 150 mg q.o.d. 14. Coumadin 1 mg every three days. 15. Atenolol 25 mg p.o. q. day. 16. Lipitor which has been held. PHYSICAL EXAMINATION: On admission, afebrile; blood pressure 107/53; pulse of 75; respiratory rate 12; O2 saturation 98% on two liters. Generally, the patient was a comfortable middle-aged female lying in bed in no apparent distress. HEENT: Pupils equally round and reactive to light. Extraocular movements were intact. Sclerae anicteric. Mucous membranes were moist. Neck was supple. No lymphadenopathy and no jugular venous distention noted. Lungs are clear to auscultation bilaterally. Heart was regular rate and rhythm; no murmur, rub or gallop was appreciated. Abdomen was soft, nontender, nondistended with good bowel sounds. Extremities showed no edema. There was trace dorsalis pedis pulses bilaterally. There was a small ulcer with scabbed skin on the right great toe. Neurologic: Alert and oriented times three. Cranial nerves II through XII were intact. There was decreased sensation bilaterally on both feet. The neurological examination was nonfocal. LABORATORY: On admission, white count 9.2 with a differential of 75 neutrophils, 15 lymphocytes, 3 monocytes, and 6 eosinophils, hematocrit of 39.2. Chem-7 revealed a sodium of 140, potassium of 3.8, chloride of 98, bicarbonate of 21, BUN 58, creatinine of 12, glucose of 283. Her calcium was 10.2, magnesium 1.4, phosphate 5.4. TSH was 1.8 in [2162-1-2]. INR was 1.5. PT 29.3. Troponin was 6.1 with a last troponin seen in [Month (only) 1096] being 23. Her first CK was 124. Chest x-ray with cardiomegaly, no congestive heart failure, no infiltrate. EKG normal sinus rhythm at 74, normal intervals, poor R wave progression, no acute changes from [2162-1-15]. HOSPITAL COURSE: In summary, the patient is a 54 year old female with a history of diabetes mellitus and end-stage renal disease on peritoneal dialysis with coronary artery disease, presenting with chest pain, pressure, suspicious for myocardial ischemia. During this hospitalization, the patient's issues included: 1. Cardiac: It was unclear if the troponin of 6.1 in the setting of end-stage renal disease on peritoneal dialysis was remnant of the troponin from the last event two weeks ago or did it represent an ischemia. Because the patient's symptoms of this event were different from the mostly respiratory symptoms associated with the last myocardial infarction the patient initially was not heparinized and treatment with beta blocker, aspirin and Avapro was continued. However, her second troponin came back as 12, indicating new cardiac ischemia, at which point the patient was started on heparin. Cardiology consultation was called to evaluate for possibility of intervention. Based on the results of cardiac catheterization performed in [2162-1-2], the patient was judged not to be a candidate for percutaneous revascularization due to the fact that the left anterior descending lesion was very distant and not amenable to stenting in the diabetic patient. The patient remained chest pain free and her heparin was discontinued. To optimize her medical management, the patient was started on Imdur with slight increase in her beta blocker, however, her blood pressure was not able to tolerate all of the medications and Avapro as well as Imdur were discontinued. She was continued on her beta blocker as well as aspirin. 2. Renal: The patient initially was admitted on peritoneal dialysis. However, on the fourth hospitalization day, the patient's PD catheter was noted to be clotted. Repetitive attempts at unclotting the catheter with use of TPN were unsuccessful. The patient was noted to be severely constipated and her constipation was treated with enemas as well as laxatives. TSH was checked which revealed severe hypothyroidism and the patient was started on Synthroid replacement. Hard constipation resolved, however, the PDA catheter was persistently clotted and the patient was transitioned into hemodialysis. Initially, the left artery line was used for hemodialysis followed by placement of a Perma-Cath by Surgery. The patient's Peroneus was noted to be leaking, leading to decrease of hematocrit to 24. The patient was transfused two units of packed red blood cells with appropriate increase in her hematocrit. Her PD catheter was surgically replaced. The patient is to continue hemodialysis rather than peritoneal dialysis. 3. Infectious Disease: Just prior to the clotting of the peritoneal dialysis, the patient noted that the peritoneal dialysis fluid that was draining was cloudy. Additionally, she developed some abdominal tenderness and voluntary guarding. She was begun on antibiotic treatment for bacterial peritonitis with Keflex and Ceptaz. Fluconazole was added to prevent super-infection with yeast. The patient's dialysis fluid was sent out for Microbiology testing. Blood cultures were also obtained. All of the cultures have been negative for any growth. Because the peritoneal dialysis catheter was clotted and the patient was transitioned to hemodialysis, her PD catheter was removed. At that time, cultures were also obtained and were negative for any bacterial growth. The patient's antibiotics are to be continued for two weeks following discharge. 4. Gastrointestinal: In addition to the diffuse abdominal tenderness associated with presumed peritonitis, the patient developed localized right lower quadrant pain. She is status post appendectomy. A CT scan was obtained to evaluate possible reasons of her abdominal discomfort and revealed: 1) large cystic pelvis located in the right lower quadrant concerning for ovarian cancer; 2) air in the sigmoid colon wall with adjacent thickening of the sigmoid and descending colonic wall with differential diagnoses including pseudomembranous colitis and ischemia colitis; 3) small amount of ascites. Because of these findings, a transvaginal pelvic ultrasound was obtained to evaluate the pelvic right lower quadrant finding and revealed a complex fluid collection which may represent an abscess with ovarian mass being unlikely. The patient is status post total hysterectomy and unilateral oophorectomy with a remaining ovary not visualized on the transvaginal ultrasound. Based on these findings, ultrasound guided drainage of the complex fluid collection in the right lower quadrant was performed. The drained fluid was chalked with color and cytology analysis revealed no malignant cells, deformed red blood cells and macrophages. A pigtail catheter was left in place for complete drainage of the complex fluid collection and was removed once the drain was draining less than 5 cc. of fluid per day. A GI consultation was obtained to evaluate sources of patient's abdominal cramping. The patient described her cramping was intermittent and provoked by touching her abdomen. The patient's laxatives were discontinued and to control her pain she was started on Fentanyl patch. Her GI consult and recommendation, an MRI of the bowel was attempted to look for mesenteric ischemia, however, the patient was too claustrophobic to tolerate the MRI. Instead, CT scan angiogram of her abdomen was performed which showed no mesenteric ischemia with all vessels being patent, complete drainage of the right lower quadrant fluid collection and decrease in the amount of air in the sigmoid colon wall. The air in the sigmoid colon wall was thought to be due to enemas. The thickening of the bowel wall was felt to be due to Clostridium difficile colitis and the patient was started on Flagyl. Serial C. difficile were obtained and were negative. The patient completed a course of Flagyl. 5. Diabetes mellitus: The patient's sugar was reasonably controlled with her regular dose of NPH and sliding scale regular insulin. 6. Nutrition: During this hospitalization, the patient's p.o. intake was very poor due to her abdominal complaints. She was not able to take adequate amount of calories and in the setting of questioning of mesenteric ischemia, she was placed on total parenteral nutrition. The need for TPN needs to be re-evaluated prior to the patient's discharge. On [2162-3-4], the care of this patient was transferred to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 805], who will dictate an addendum to this discharge summary upon the patient's discharge. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3598], MD [MD Number(1) 3599] Dictated By:[Last Name (NamePattern1) 1762] MEDQUIST36 D: [2162-3-4] 19:13 T: [2162-3-8] 14:58 JOB#: [Job Number 22740] Admission Date: [2162-2-4] Discharge Date: [2162-4-1] Date of Birth: [2107-3-22] Sex: F Service: INT MED This is an addendum to the previous one done up to [3-4]. HOSPITAL COURSE: 1. Cardiovascular: On [3-12], the patient became suddenly hypotensive, hypoxic, with decreased oxygen saturations. Blood pressure was 70/30, and not responsive to fluid boluses. A code was called on the floor. She was intubated and started on a dopamine drip, and transferred to the Medical Intensive Care Unit. Her initial arterial blood gas was 7.53/20/191 on AC ventilator. The patient was ruled out with three negative CKs, however, her troponin rose to 12.1, then 10.7, then 13.7 on [3-14]. It was unclear whether she had undergone and acute ischemic event, or whether her troponin was still elevated from her prior myocardial infarction. A transthoracic echocardiogram was done, showing no vegetations, global left ventricular hypokinesis, with an ejection fraction of 30%, and decreased right ventricular systolic function. She was continued on aspirin. After returning to the regular medicine floor on [3-16], the patient had no cardiovascular issues until [3-30], when she felt acutely short of breath. This reminded her of her previous myocardial infarction, despite having stable vital signs and good oxygen saturation. She received Ativan for her anxiety, as well as some morphine, with some relief of her shortness of breath. An electrocardiogram was done, showing tachycardia as well as more prominent T waves in the precordial leads, and it was decided to rule her out. Again her troponin was elevated at 3, and her CKs were all negative, as well as her MBs. 2. Pulmonary: The patient underwent a chest x-ray on [3-12], which showed no pneumothorax, and her right internal jugular was tipped in the mid-subclavian. Abdominal CT which was done on [3-12] showed small residual pelvic fluid in the area of previously large fluid collection, no free air, persistent abnormal short segment of sigmoid colon, new splenic infarcts, two of them, left basilar consolidation, small bilateral pleural effusions, small amount of ascites anterior to the liver, and extensive vascular calcifications with patent vessels to the intestines. There was also left basilar consolidation which was questionable on the last chest x-ray, although it was unclear whether this was pneumonia. Because of her new right ventricular dysfunction, pulmonary embolism was in the differential for her acute decompensation, and the patient was started on a heparin drip. Both the CTA and a V/Q scan were done, which ruled out pulmonary embolism and, after a few days on the floor, the heparin drip was stopped. A repeat abdominal CT done on [3-24] showed a new lung nodule which should be followed as an outpatient. 3. Infectious Disease: The patient remained afebrile in the Medical Intensive Care Unit, with negative cultures. A few days prior to going to the Medical Intensive Care Unit, she had her [Location (un) 1661]-[Location (un) 1662] drain removed, as well as her pigtail catheter, and it was after that that she started to complain of increased abdominal pain, eventually leading to her decompensation and transfer to the Intensive Care Unit. When she was transferred back to the floor on [3-16], she spiked a temperature to 103 degrees, and she was pan cultured. She had been on Ceptaz, Flagyl, levofloxacin and vancomycin in the Intensive Care Unit. It was decided to continue the Ceptaz, Flagyl and levofloxacin and to slowly remove these. An Infectious Disease consultation was requested. The patient had several blood cultures from different sites, which grew budding yeast and, on identification, this was found to be [Female First Name (un) ] Torulopsis. A transesophageal echocardiogram on [3-22] showed no vegetations in her heart, and then we proceeded to remove all of her lines as possible sources for her candidemia. She had her PICC line removed on [3-19], her hemodialysis catheter removed on the same day. On [3-22], a temporary femoral hemodialysis triple-lumen line was placed. An Ophthalmology consult was requested to rule out endophthalmitis, which they did. We also requested a Plastic Surgery consult for her sacral decubitus, and they recommended no debridement and treatment with constant rotations and wound care. A blood culture was taken from her temporary groin line on [3-23] and, after 48 hours of no growth, it was decided it was safe to place a new PICC line and hemodialysis tunneled Perma-Cath on [3-26]. However, on [3-29], it was noted that the blood culture from [3-23] was indeed growing [Female First Name (un) ] Torulopsis, however, at this point in time, she had been on almost two weeks of ambazone treatment, and it was decided to repeat an abdominal CT to look at the splenic lesions and to repeat a surveillance blood culture. Abdominal CT was without change of the splenic lesions, and again showed some pneumatosis and thickening of her bowel wall. As of today, blood cultures from the [3-29] are without growth. On [3-31], she was switched from ambazone to amphotericin without event. On [3-30], Clostridium difficile toxin in her stool was positive, and she was therefore started on Flagyl orally. 4. Renal: On the day prior to her transfer to the Intensive Care Unit, the patient started to complain of increasing right lower quadrant abdominal pain. She was noted to have a raised, erythematous, extremely tender area and, at this point, she decompensated and had to be transferred to the Medical Intensive Care Unit. The Renal team, which continued to follow her in the Medical Intensive Care Unit, decided that the lesion on her abdomen represented possible calciphylaxis, and that her calcium phosphorus product had been elevated, putting her at increased risk of development of this. She started to be hemodialyzed every day to bring down her phosphorus, and she was placed on both RenaGel and amphojel. The goal was to keep her phosphorus less than 4, and her calcium phosphorus product less than 40. Her calcitriol was held. PTH was checked, and was found to be in the 700s. Prior PTH a few months ago was over 1000. A Dermatology consult was requested and, although they indicated interest in biopsying the lesion, this was held off due to the risk of infection. With frequent hemodialysis and keeping her phosphorus low, the pain and tenderness in the right lower quadrant has improved, although still causes the patient much discomfort, especially with moving. She may benefit from a parathyroidectomy in the future. A Surgery consult was not requested during this hospital stay because of her multiple other issues. She was continued on Epogen three times a week with dialysis. 5. Gastrointestinal: Up until [3-30], all stools were negative for Clostridium difficile, however, after the positive toxin on [3-30], she was started on oral Flagyl. She was continued on Reglan and Prevacid. She was found to be trace guaiac positive and then guaiac negative on multiple samples. Her [Location (un) 1661]-[Location (un) 1662] drain from drainage of her abdominal abscess was removed during the week prior to her transfer to the Intensive Care Unit, as was her pigtail drain at the site of her previous peritoneal dialysis catheter. The sites of these have healed well. The patient continues to complain of worsening constipation, although she has had loose bowel movements during her whole stay, however, subjectively she feels bloated, with much pressure in her abdomen. Her multiple abdominal CT scans have shown continued thickening of her bowel wall, which may represent infectious vs. ischemic vs. malignant etiologies. It should be followed up as an outpatient. The Gastroenterology team determined the patient was not a candidate for a colonoscopy given her recent myocardial infarction and her pneumatosis, but she may benefit from one as an outpatient. 6. Endocrine: The patient was followed by [Last Name (un) ] team throughout her hospital stay. She was continued on Synthroid, which dose was changed several times during the hospital stay. She was also on twice a day NPH and sliding scale insulin, which was adjusted based on her inconsistent oral intake vs. tube feeds vs. total parenteral nutrition. At one point in the hospital stay, her regular insulin sliding scale was changed to a Humalog sliding scale for better control of her sugars. 7. Pain: The patient continued to be placed on a fentanyl patch. She was also on as needed morphine and twice a day Ultram. Ativan was started as needed for her anxiety component. For several days after transferring back to the floor on [3-16], the patient had change in mental status, with lethargy and confusion. This was felt to be secondary to her multiple pain medications, and they were slowly weaned off. 8. Fluids, electrolytes and nutrition: For the week prior to her admission to the Intensive Care Unit on [3-12], the patient had been refusing total parenteral nutrition because of its inconvenience, not allowing her to freely move around. Calorie counts were done and found the patient to be very nutritionally deficient, with intake of less than 300 calories a day. Multiple conversations were had with the patient and her husband about the importance of improving her nutritional intake to improve her medical status. While she was in the Intensive Care Unit, total parenteral nutrition was restarted, and she came to the floor on [3-16] with total parenteral nutrition. On [3-19], the patient agreed to have a Dobbhoff feeding tube placed, and she was started on tube feeds. At this time, she had no access for total parenteral nutrition, given her candidemia. The tube feeds bothered her, and she had the Dobbhoff tube removed on [3-29]. She has since tried to improve her oral intake, and has done reasonably well. A further addendum will be added by the next intern taking care of her from [4-2] onward. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7576] Dictated By:[Last Name (NamePattern1) 7069] MEDQUIST36 D: [2162-4-1] 20:40 T: [2162-4-2] 00:00 JOB#: [Job Number 22828] Admission Date: [2162-2-4] Discharge Date: [2162-4-15] Date of Birth: [2107-3-22] Sex: F Service: DISCHARGE ADDENDUM COVERING DATES [4-2] THROUGH [4-15]: HOSPITAL COURSE: Renal: The patient continued on hemodialysis for end stage renal disease. She had developed calciphylaxis and had this initially managed with daily hemodialysis and AntaGel to reduce her phosphate levels. She did not have a biopsy of her calciphylaxis areas due to increased risk of infection. She was evaluated on [4-1] by the General Surgery team who recommended parathyroidectomy. The patient underwent this procedure on [2162-4-12]. The details of this procedure can be seen in the operative note. The patient was also evaluated by the Plastic Surgery team who followed the patient's calciphylaxis as well as a sacral decubitus ulcer. No procedures were done by this service during the [Hospital 228] hospital stay. Cardiology: The patient was consulted by the Cardiology Service for risk assessment prior to her parathyroidectomy. The patient was continued on her Lopid and her enteric coated aspirin 325 mg po q day and was started on beta blocker and ace inhibitor as per cardiology recommendations. The patient had a stress test done as part of her preoperative workup, which was negative for a reversible perfusion defect. The patient seemed to tolerate surgery well, however, on postoperative day number three the patient experienced shortness of breath and chest pain. The patient then developed ventricular arrhythmias and cardiogenic shock. A code was called and the Cardiology Service was called to assist with management of the patient. The patient had a prolonged arrest with incessant ventricular fibrillation polymorphic ventricular tachycardia and runs of monomorphic ventricular tachycardia. Despite high dose pressors, intravenous Amiodarone and Lidocaine the patient expired with asystole pulseless electrical activity and severe acidosis. The family agreed to partial autopsy after the patient's demise with examination of the heart. The pathology report can be reviewed separately. The patient was pronounced dead at 6:30 a.m. on [2162-4-15]. DR.[First Name (STitle) ],[First Name3 (LF) ] 11-436 Dictated By:[Last Name (NamePattern1) 7896] MEDQUIST36 D: [2162-6-8] 15:16 T: [2162-6-8] 15:32 JOB#: [Job Number 22829] Name: [Known lastname 3855], [Known firstname ] Unit No: [Numeric Identifier 3856] Admission Date: [2162-2-4] Discharge Date: Date of Birth: [2107-3-22] Sex: F Service: Internal M Date of discharge to be added with the next addendum. [First Name8 (NamePattern2) 126] [Name8 (MD) ], M.D. [MD Number(1) 2435] Dictated By:[Last Name (NamePattern1) 1875] MEDQUIST36 D: [2162-4-1] 19:46 T: [2162-4-5] 10:04 JOB#: [Job Number 3857]	[ "424.0", "567.9", "585", "008.45", "250.41", "427.0", "410.71", "996.56", "588.8" ]	icd9cm	[ [ [] ] ]	[ "86.05", "38.93", "38.95", "54.92", "96.04", "54.91", "88.72", "06.89" ]	icd9pcs	[ [ [] ] ]													3053, 3659	22876, 25665																					3682, 5321											128, 165														194, 1776													1798, 2845	2862, 3027
18,473	107,345	47591	Discharge summary	report	Admission Date: [2193-1-17] Discharge Date: [2193-1-27] Date of Birth: [2134-12-30] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: The patient is a 58 year old male with new diagnosis of alcoholic cirrhosis who was recently admitted to [Hospital1 18] for significant GI bleeding. He was discharged five days prior to presentation, and reports that he had no pain at the time of discharge. Over the next few days, he developed right upper quadrant abdominal pain. Two days prior to discharge saw his PCP, [Name10 (NameIs) 1023] ordered a RUQ US that was performed on the day of admission. That imaging test showed a probable portal vein thrombosis and he was sent to the [Hospital1 18] ED for further management. . In the ED, his VS were T 97.8, BP 121/73, HR 70, RR 16, SpO2 100% on RA. The patient appeared jaundiced (present at discharge) but had a quite distended abdomen, which he said was worse than baseline. After discussion with Hepatology the patient was admitted for further work up. Given his recent GIB, Heparin was held pending cross sectional imaging and discussion with attending in the AM. . On arrival to the floor, the patient reported mild RUQ discomfort but denied pain, confusion, tremor, or any other acute changes. . REVIEW OF SYSTEMS: Positive per HPI for RUQ discomfort, abdominal distention, and ~10 lb weight gain. Also endorsed loose stools getting worse since discharge. Finally, endorsed darkened urine. Denies fevers, chills, night sweats, rash, pruritus, confusion, somnolence, slurred speech, chest pain, dyspnea, headache, or visual changes. Past Medical History: # Alcoholic cirrhosis -- newly diagnosed at last admission # GI Bleeding -- known esophageal varices # Gastritis # Hypertension Social History: The patient is a project manager for an electronics contractor. He was working up until his recent hospitalization. No history of tobacco use. Up until his last hospitalization, he was drinking 3-4 beers/day. He denies any alcohol over the last two weeks. Denies any illicit drug use. Family History: Coronary artery disease, diabetes mellitus. His mother had emphysema. Physical Exam: Physical Exam On Admission: VS: T 96.3, BP 122/76, HR 94, RR 18, O2 97% on RA Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting in bed. HEENT: NCAT. PERRL, EOMI. Markedly icteric sclera. MMM, OP benign. Neck: Supple. JVP elevated to ~8 cm. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. Holosystolic murmur [1-6] heard best at the apex with radiation to the axilla. Chest: Respiration unlabored, no accessory muscle use. Decreased breath sounds and coarse crackles at bilateral bases, right greater than left. No wheezes or rhonchi. Abd: BS present. Tensely distended with ascites. Unable to assess for organomegaly due to distention. Ext: WWP, no cyanosis or clubbing. Trace LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Skin: Marked jaundice. No spiders, palmar erythema, or other stigmata of liver disease. Neuro: CN II-XII grossly intact. Moving all four limbs. No asterixis. . Pertinent Results: Labs on Admission: [2193-1-17] 08:52PM BLOOD WBC-7.0# RBC-3.51* Hgb-13.4* Hct-39.0* MCV-111* MCH-38.2* MCHC-34.3 RDW-18.6* Plt Ct-106# [2193-1-17] 08:52PM BLOOD Neuts-72 Bands-0 Lymphs-9* Monos-17* Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [2193-1-17] 08:52PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-2+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL Burr-2+ [2193-1-17] 08:52PM BLOOD PT-35.8* PTT-63.2* INR(PT)-3.7* [2193-1-17] 08:52PM BLOOD Glucose-136* UreaN-19 Creat-1.2 Na-132* K-4.2 Cl-97 HCO3-22 AnGap-17 [2193-1-17] 08:52PM BLOOD ALT-80* AST-153* LD(LDH)-341* AlkPhos-201* TotBili-34.6* DirBili-25.5* IndBili-9.1 [2193-1-17] 08:52PM BLOOD Lipase-162* . Parcentesis: [2193-1-18] 04:25PM PERITONEAL WBC-105* RBC-192* Polys-3* Lymphs-13* Monos-0 Meso-5* Macro-79* [2193-1-18] 04:25PM PERITONEAL TotProt-0.3 Albumin-LESS THAN . Urinalysis: [2193-1-18] 09:51PM URINE Color-AMBER Appear-Hazy Sp [Last Name (un) ]-1.022 [2193-1-18] 09:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-NEG [2193-1-18] 09:51PM URINE Hours-RANDOM UreaN-543 Creat-203 Na-LESS THAN K-72 Cl-15 . Imaging / Studies: # CT ABD & PELVIS WITH CONTRAST ([2193-1-18] at 1:14 AM): The lungs are clear. There are coronary artery calcifications and calcifications are noted in the thoracic aorta without any aneurysmal dilatation. There is a very large esophageal varix seen just superior to the gastroesophageal junction. In addition, there are numerous tortuous periesophageal varices as well. These varices are fed by a dilated coronary vein the appears to be decompressing the patient's portal hypertension. The cirrhotic liver is shrunken and nodular suggestive of end stage liver disease. The portal vein and all the major portal branches are patent. There is no focal lesion seen within the parenchyma. The gallbladder is partially collapsed and unremarkable. The spleen, adrenals and kidneys and pancreas are unremarkable. There is ascites seen surrounding the liver and the spleen and tracking inferiorly along the right paracolic gutter. There is a small spleno-renal shunt. There are scattered mesenteric lymph nodes; however, none meet CT criteria for lymphadenopathy. Note is made of edematous wall of the ascending colon, likely the result either from underlying hypoalbuminemia or the portal hypertension. Otherwise, remaining loops of small and large bowel appear essentially unremarkable. BONES: There is an old compression fracture seen at T12. Otherwise, there are no other additional evidence of acute fracture. There are no lytic or sclerotic lesions suggestive of metastatic disease. IMPRESSION: 1. Nodular shrunken liver suggestive of cirrhosis. 2. Ascites seen surrounding the liver and the spleen. 3. Large coronary vein with gastric varices and very large esophageal and perasophageal varices. 4. The portal vein is well opacified and there is no evidence of any filling defect (clot) within the portal vein or the major branches, including the SMV and the splenic vein. 5. Edematous ascending colon bowel wall likely secondary to low albumin and portal hypertension. . # CHEST (PA & LAT) ([2193-1-18] at 2:49 PM): An NG tube lies with its tip in the duodenum. The trachea is central and the cardiomediastinal contour is normal. There is volume loss evident in the right lung base with an airspace opacity adjacent to the right heart border, better appreciated on the lateral view consistent with right lower lobe consolidation or atelectasis. While this could reflect atelectasis given the volume loss, in the appropriate clinical setting pneumonia is also a possiblity. Small bilateral pleural effusions. Multiple old rib fractures. IMPRESSION: Right lower lobe airspace opacity may reflect atelectasis or pneumonia. . Brief Hospital Course: The patient is an 58 year old male who was recently discharged on [2193-1-12] after an admission for significant GI bleeding, with newly diagnosed with alcoholic cirrhosis, esophageal varices, and severe portal hypertensive gastropathy. He presented several days after discharge with RUQ pain, decompensated cirrhosis, and question of portal vein thrombosis on RUQ ultrasound which was later ruled out with CTA abdomen. . # Acute on Chronic Liver Failure: He was recently diagnosed with alcoholic cirrhosis on his prior admission from [2193-1-10] to [2193-1-12] for GI bleeding and discharged with outpatient followup after being stabilized. His transaminases, bilirubin, and coags this admission had worsened significantly compared to those at his prior admission. He had MELD score 36 and DF 145. Portal vein thrombosis was an initial concern given the reported results of his RUQ ultrasound, but was ruled out by CTA. Other possible etiologies include infection, recent alcohol use, or medication effects. There are no obvious medication changes that would explain his decompensation, but he did receive Ceftriaxone during his prior admission and was started on Nadolol. Paracentesis showed no evidence of SBP, and UA was unremarkable. His CXR showed a possible infiltrate in the RLL, but he has not demonstrated any other signs or symptoms of pneumonia. He was started on Prednisone 40 mg PO daily given the relatively low likelihood of pneumonia. Given his significant illness, however, he was started on Ceftriaxone 1000 mg IV daily and Azithromycin 500 mg PO daily for a 7 day course. . His mental status deteriorated on [2193-1-24] and he became no longer responsive to noxious stimuli and was noted to no longer have a gag reflex. His antibiotics were broadened to vancomycin, zosyn, and flagyl and he was transferred to the MICU. In the MICU, he was continued on the broad spectrum antibiotics though his culture data was negative. He was also continued on IV steroids for alcoholic hepatitis though his liver failure persisted and had a MELD of 48 on [1-26]. Was showing signs of end organ failure with worsened liver function, renal function (near anuric) and unresponsiveness. Goals of care discussions where held with his wife and he was transitioned to DNR/DNI on [1-26], however was not made comfort measures only. Palliative care consult was declined. His blood pressures proved labile and he was treated with fluid boluses with initial response since the family had decided not to escalate care. By the end of the day, patient was no longer responding to fluid boluses and dropped his pressures. He passed away on [2193-1-27] at 12:01AM with family at his bedside. . # [Last Name (un) ]: Cr increased from 1.2 on admission to 1.9 two days later. He appeared to have mild intravascular volume depletion on exam, with dry MMs and a new aortic outflow tract murmur. His urine electrolytes were consistent with a prerenal picure with urine Na <10. He was volume repleted with Albumin (25%) 75 g daily for two days. Ultimately, developed worsening renal failure with creatinine of 2.1 prior to expiration- attributed to hepatorenal syndrome. . # GI bleeding History: His Hct was stable at 39.0 on admission from Hct 32.0 on his recent discharge on [2193-1-12]. There were no signs of active bleeding. His EGD showed no evidence of active bleeding, but did show significant esophageal varices and gastropathy. He was continued on Omeprazole 40 mg PO daily and Nadolol 20 mg PO daily. His Type and Screen was kept active and he was montitored closely for any bleeding- he did not have any active bleeding during this hospitalization. . # Contacts: Wife -- [First Name9 (NamePattern2) 100569] [Known lastname ] (Phone: [Telephone/Fax (1) 100570]) Medications on Admission: Nadolol 20 mg PO DAILY Omeprazole 40 mg PO DAILY Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Alcoholic hepatitis Discharge Condition: Expired. Discharge Instructions: None. Followup Instructions: None. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2193-1-27]	[ "486", "530.3", "571.2", "401.9", "584.5", "553.3", "572.8", "V49.86", "456.1", "537.89", "303.90", "995.91", "276.0", "038.9", "287.5", "572.3", "572.2", "570", "571.1", "276.3", "530.10", "789.59" ]	icd9cm	[ [ [] ] ]	[ "96.08", "54.91", "45.13", "96.6" ]	icd9pcs	[ [ [] ] ]	11239, 11248	7252, 11074	322, 336	11311, 11321	3390, 3395	11375, 11547	2307, 2378		11209, 11216		11269, 11290		11100, 11186			11345, 11352								2393, 2407																		1511, 1833				273, 284														364, 1492							3409, 7229						1855, 1985	2001, 2291
16,913	141,587	50630	Discharge summary	report	Admission Date: [2175-7-6] Discharge Date: [2175-7-11] Date of Birth: [2122-10-22] Sex: M Service: CA/TH [Doctor First Name 147] CHIEF COMPLAINT: The patient presents with significant coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient is a 52 -year-old male with a history of angina and shortness of breath. The patient has not seen his medical provider in approximately twenty years or so. The patient eventually presented with the above mentioned complaint and underwent extensive cardiac work up, including an echocardiogram and exercise stress thallium test, showing wall perfusion deficits. Cardiac catheterization showed aneurysmal left anterior descending, a right coronary artery and distal three vessel disease. Ejection fraction was measured at approximately 25%. An intra-aortic balloon pump was placed for the patient's symptomatic presentation and an emergent Cardiothoracic consultation was obtained. PAST MEDICAL HISTORY: 1. Hyperlipidemia. 2. Heavy tobacco use. 3. Adult onset diabetes. 4. Obesity. 5. Left chest wall mass. ADMITTING MEDICATIONS: Include aspirin 325 mg q day, Lipitor 30 mg q day, Paxil, Atenolol 25 mg q day, Zestril 25 mg q day, Keflex, Tylenol, and "diabetic medications." ALLERGIES: None. REVIEW OF SYSTEMS: Includes no clear history of transient ischemic attack or stroke; however, there was some left sided numbness reported. PHYSICAL EXAMINATION: The patient was a morbidly obese male, appearing anxious and in distress. The patient's overall hygiene was poor. Lungs were clear to auscultation bilaterally without evidence of wheezes or rhonchi. Heart rate was regular rate and rhythm without murmurs, rubs, or gallops appreciated. The chest wall showed a moderately sized ulcerated lesion overlying the left mid clavicular line. Extremities appeared to be mildly edematous, but were warm and well profused. Pulses were palpable throughout without indication of carotid bruits. The patient's neurologic examination was nonfocal. HOSPITAL COURSE: The patient was taken to the Operating Room on [2175-7-6] and underwent a three vessel coronary artery bypass graft; with a saphenous vein graft to the CMI, saphenous vein graft to the right posterior descending artery (with a proximal anastomosis from the diagonal), and a saphenous vein graft to the diagonal. The left chest wall ulcer was also resected and the wound base was left open. The patient tolerated the procedure well and was transferred to Cardiothoracic Intensive Care Unit in stable condition. Over the following hours postoperatively the patient was noted to have continuously high sanguinous output from his chest tubes. Despite question of coagulopathy, the patient continued to dump large amounts of blood and required transfusions with blood products. The decision was made to take the patient back to the Operating Room and a left sided bleeding intercostal artery was identified and ligated. Following re-exploration, the patient did quite well and was transferred back to the Cardiothoracic Intensive Care Unit in a stable condition. Over the following two days, the patient was weaned off the intra-aortic balloon pump and was then weaned off the ventilator support. Chest tubes were removed. The patient was afebrile with stable vital signs, was alert and oriented times three, moving all extremities and following all commands. The patient was diuresing well and appeared to have no respiratory complaints. The patient was transferred to the floor on [2175-7-9] and continued to do quite well. The patient worked with Physical Therapy and ambulated on the floor. The patient had removal of both Foley catheter and central line and began to void on his own and take a regular diet. The patient reported feeling quite well and was having no difficulties with breathing or with recurrent chest pain. Ionized calcium at that time was 1.85 and a repeat calcium was 1.8. It was unclear as to why the patient was hypercalcemic at this time. The patient denied excessive intake of milk alkalies or calcium products and no history of parathyroid disease. The patient was completely asymptomatic from his hypercalcemia and was denying any symptoms of nausea or vomiting, abdominal distress, constipation, diarrhea, or extensive bone / joint pains. It was felt that Lasix induced diuresis would be a good treatment for this. The patient was given IV Lasix in addition to his oral Lasix to achieve his means. Repeat calcium on [2175-7-11] was 1.81. As the patient was entirely asymptomatic from his hypercalcemia, it was felt that this would be reasonable to work up as an outpatient with his primary care provider. The patient also was noted to have a low hematocrit of 21.9 prior to discharge; however, the patient again was asymptomatic with only mild complaints of fatigue after walking on the floors. It was felt that this does not substantiate any particular need for transfusions; however, the patient was started upon Niferex iron supplementation for a total of two weeks in order to augment his recuperation in his red cell mass. On [2175-7-11], the patient was afebrile with stable vital signs. The patient was in no apparent distress and had no complaints. Chest was clear to auscultation bilaterally and heart was regular rate and rhythm. The left chest wall lesion showed viable tissue margins, without signs of infection or exudates. The patient's incisions were clean, dry, and intact and extremities were warm and well profused. It was felt at this point that the patient was stable from a medical and surgical standpoint to be discharged to a rehabilitation center. DISCHARGE CONDITION: Stable. DISPOSITION: Home. DISCHARGE MEDICATIONS: To include Lopressor 50 mg po bid, Lasix 20 mg po bid, KCL 20 mEq po bid, Colace 100 mg po bid, Zantac 150 mg po bid, aspirin 81 mg po q day, sliding scale insulin, vancomycin 1.0 gm IV q twelve hours, ciprofloxacin 500 mg po bid, amiodarone 200 mg po bid, Niferex 250 mg po bid times two weeks, Percocet one to two tablets po q four to six hours prn. FOLLOW UP: The patient is to continue same medications as outlined above. Upon follow up with Cardiothoracic Surgery (within two to three weeks) the patient will be informed of the duration of treatment with the Lasix, KCL, and vancomycin. If side effects develop from any of these medications, the Cardiothoracic Surgery office should be called and alterations can be made. The patient is to follow up with his primary care provider within one week for the following: 1) work up for hypercalcemia (asymptomatic) noted during admission, 2) general medical management. DISCHARGE INSTRUCTIONS: The patient is to continue getting wet-to-dry dressing changes to the left chest wall [Hospital1 ]. The status of this wound can then be readdressed when the patient follows up with the Cardiothoracic service within two weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 13463] MEDQUIST36 D: [2175-7-11] 11:46 T: [2175-7-11] 14:26 JOB#: [Job Number ]	[ "173.5", "250.00", "272.4", "998.11", "414.01", "411.1", "V15.82", "707.8", "285.1" ]	icd9cm	[ [ [] ] ]	[ "86.3", "39.61", "42.23", "88.57", "36.15", "36.12", "88.53", "88.72", "37.22" ]	icd9pcs	[ [ [] ] ]				5731, 5761					5785, 6138					2067, 5709		6736, 7243															6150, 6711				1459, 2049							1315, 1436				184, 248														277, 974													996, 1295
30,589	102,263	28811	Discharge summary	report	Admission Date: [2116-5-6] Discharge Date: [2116-5-12] Date of Birth: [2043-8-5] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2116-5-8] Redo Sternotomy, Redo Coronary Artery Bypass Grafting with saphenous vein grafts to left anterior descending, obtuse marginal, and right coronary arteries. History of Present Illness: Mr. [Known lastname ] is a 72 year old male s/p CABG in [2114], graft failure [2115-4-11] undergoing cypher(DES) stenting of LAD and LCx, and three prior Vision (BMS) placed in mid and proximal LAD and one to the proximal circumflex arteries. He recently presented to [Hospital6 ] with precordial chest "heaviness" [9-20], on [2116-5-5]. He concomitantly had shortness of breath with chest pain but denied nausea, vomiting, diaphoresis, and presyncope. No radiation of pain. He was noted to have new 2mm ST depressions v4-v6, TWI v3-v6. He received IV morphine, NTG x3, and was started on weight based enoxaparin regimen. He was already on Plavix. Pain was controlled to point where he was chest pain free in ED. He ruled in for a NSTEMI. Initial neg trop 0.04, that rose to 1.26, then 1.34. CK peak at OSH was 94. He was stablized on medical therapy and was transferred to [Hospital1 18] after diagnosis of NSTEMI so that he could be managed by his primary cardiologist Dr. [First Name (STitle) ]. On arrival to [Hospital1 18], patient was chest pain free. Pt had ECG w/ new 1-2mm ST elevation in V1-V2, and 2mm ST depression v4-v6, TWI v3-v6. 1mm ST depression and TWI in I & avl are old. Pt was started on Heparin and Integrillin on arrival to [Hospital1 18]. Past Medical History: Coronary Artery Disease, History of CABG [2114] (LIMA to LAD, SVG to RCA, sequential SVG to D1 and OM1) Recent NSTEMI [2116-4-11] Ischemic Cardiomyopathy/Chronic Systolic Heart Failure Hypertension Elevated Cholesterol Type II Diabetes Mellitus History of renal cancer status post left nephrectomy in [2105]. History of bilateral cataracts with repair. Social History: Patient is originally from [Country 11150], where he worked in agriculture. He denies ever smoking, drinking etoh or using illicit drugs. He came to the US in [2094], but returns frequently to [Country 11150]. Last trip to [2116-3-13]. Pt lives with son and wife in [State 350]. Family History: Family history is significant for a brother with a CABG at the age of 65. Parents died of old age. Physical Exam: PREOP EXAM: VS - T 96.7, BP 109/49, HR 63, RR 16, 97% RA. Gen: Indian male, No chest pain, resting comfortably. HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, good dental hygeine Neck: Supple with JVP of 12 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Crackles at the bases bilaterally. poor air movement. No rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No edema. Nontender, 1+ weak DP/PT bilat. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Discharge VS T98.4 HR 104ST BP 109/57 RR 18 O2sat 96% 2LNP Gen NAD Neuro Alert, orientedx3, non focal exam Pulm CTA bilat CV RRR-tachy, sternum stable, incision CDI Abdm soft NT/+BS Ext warm well perfused. 1+ pedal edema bilat Pertinent Results: [2116-5-7] Cardiac Cath: 1. Limited coronary angiography of this right dominant system demonstrated severe three (3) vessel coronary artery disease. The right coronary artery was diffusely diseased with pressure damping upon engaging. The RCA had a 70% proximal lesion. The left main was diffusely diseased with a 70% distal lesion. The left circumflex demonstrated 70% in-stent restenosis of the proximal stent. The left anterior descending artery was diffusely diseased with a tight 95% proximal lesion along with serial 90% in-stent restenotic lesions in the proximally placed stent. 2. Arterial conduit angiography was deferred - LIMA-LAD known atretic. Venous conduit angiography was also deferred since both grafts known to be occluded. 3. LV ventriculography was deferred. 4. Limited resting hemodynamics demonstrated moderate central aortic (160/73mm Hg) hypertension. [2116-5-7] Carotid Ultrasound: Less than 40% internal carotid artery stenosis bilaterally. Findings suggesting distal left vertebral artery occlusion. [2116-5-8] Intraop TEE: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is severely depressed (LVEF= 20 - 25 %). There moderate global RV hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are moderately thickened. Mild to moderate ([2-12]+) mitral regurgitation is seen. There is no pericardial effusion. Post- CPB: The patient is on an infusion of Epinephrine. RV systolic fxn is normal. LV systolic fxn is moderately globally depressed. MR is 1+. No AI. Aorta intact. [2116-5-6] 06:10PM BLOOD WBC-6.8 RBC-4.27* Hgb-13.1* Hct-38.6* MCV-90 MCH-30.7 MCHC-34.0 RDW-12.3 Plt Ct-126* [2116-5-6] 06:10PM BLOOD PT-15.3* PTT-45.6* INR(PT)-1.3* [2116-5-6] 06:10PM BLOOD Glucose-180* UreaN-19 Creat-1.3* Na-140 K-4.8 Cl-105 HCO3-27 AnGap-13 [2116-5-6] 06:10PM BLOOD ALT-19 AST-21 CK(CPK)-66 AlkPhos-58 [2116-5-6] 06:10PM BLOOD CK-MB-NotDone cTropnT-0.09* [2116-5-7] 12:30AM BLOOD CK-MB-NotDone cTropnT-0.08* [2116-5-7] 04:00AM BLOOD CK-MB-NotDone cTropnT-0.06* [2116-5-6] 06:10PM BLOOD Albumin-3.4 Calcium-8.7 Phos-2.5* Mg-2.1 [2116-5-7] 11:50AM BLOOD %HbA1c-7.5* [2116-5-12] 09:19AM BLOOD Hct-25.5* [2116-5-12] 04:33AM BLOOD Plt Ct-109* [2116-5-11] 03:36AM BLOOD PT-17.2* PTT-35.0 INR(PT)-1.6* [2116-5-12] 04:33AM BLOOD Glucose-185* UreaN-29* Creat-1.5* Na-134 K-3.8 Cl-100 HCO3-29 AnGap-9 RADIOLOGY Preliminary Report CHEST (PA & LAT) [2116-5-12] 2:02 PM CHEST (PA & LAT) Reason: ? effusion [Hospital 93] MEDICAL CONDITION: 72 year old man with s/p cabg REASON FOR THIS EXAMINATION: ? effusion HISTORY: Status post CABG. FINDINGS: In comparison with study of [5-11], the chest tubes have been removed. No evidence of acute pneumothorax. Extensive opacification at the left base is consistent with pleural fluid and underlying atelectasis, though the possibility of supervening pneumonia cannot be excluded. DR. [First Name8 (NamePattern2) 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] Brief Hospital Course: Pt is a 72 y/o M w/ DM, HTN, s/p CABGx4V [2114], graft failure [4-17],w/ multiple stents, most recent cath shows occluded SVGs and LIMA-LAD arterial conduit, who is transferred to [Hospital1 18] from OSH w/ NSTEMI, Cardiac Cath: [5-7] LMCA: Distal 70% lesion LAD: Origin 95% lesion w/ serial 90% lesion ISRS in the previous DES. The origin D1 has mild restenosis. LCX: Non-Dominant vessel w/ 70% origin ISRS in the previous DES. The OM1 origin is widely patent. RCA: Dominant vessel with proximal 70% lesion at previous mild lesion. There are r-l collaterals to the LAD and distal OM. . #Pump: Patients last echo [10-18] showed EF of 35-40%, with mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the inferolateral and inferoseptal walls and apex. Cardiac Surgery Pt brought to operating room for redo CABG on [5-8]. Please see OR note for details, in summary patient had redo CABG x3 with SVG>LCX, SVG>LAD, SVG>PDA, his bypass time was 109 minutes with a crossclamp of 74 minutes. He did well in the immediate postop period, was kept sedated throughout the night and was extubated on POD #1. Additionally his swan was removed. His mediastinal tubes were taken out POD #2. Cordis was replaced with a triple lumen catheter due to difficulty with peripheral access. Pt was transferred to the floor on POD #3. Once on the floor he had an uneventful post operative course, his activity level was advanced and medications adjusted. On POD4 it was decided he was ready for discharge to rehabilitation at Palm [Hospital 731] rehabilitation in [Location (un) 15749], MA Medications on Admission: -Aspirin 325 mg once daily -Imdur 30 once daily -Plavix 75 once daily -Zocor 40 once daily -Diovan 80 mg daily -Toprol 150 mg daily -Feosol 65 mg daily -insulin per protocol -Colace 100 mg daily -senna 2 mg daily -sublingual nitroglycerin 0.03 mg p.r.n. 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days: then 20mg QD. 8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 10 days: then 20mEq QD. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily): 75mg total. 16. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lantus 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 18. Humalog 100 unit/mL Solution Sig: Ten (10) units Subcutaneous Q breakfast/lunch/dinner. 19. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. Discharge Disposition: Extended Care Facility: Palm [Hospital 731] Nursing Home Discharge Diagnosis: Coronary Artery Disease, History of CABG [2114] - s/p Redo CABGx3(SVG-LAD,SVG-OM,SVG-RCA)[5-8] Ischemic Cardiomyopathy/Chronic Systolic Heart Failure Recent NSTEMI [2116-4-11] Hypertension Elevated Cholesterol Type II Diabetes Mellitus History of Renal Cancer, s/p Left Nephrectomy Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection, redness or drainage from wound. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [Last Name (STitle) ] in [5-16] weeks, call for appt Dr. [First Name (STitle) ] in [3-15] weeks, call for appt Dr. [Known lastname ] in [3-15] weeks, call for appt Completed by:[2116-5-12]	[ "414.04", "428.22", "996.72", "414.01", "458.29", "401.9", "410.71", "285.9", "272.0", "414.02", "428.0", "250.00" ]	icd9cm	[ [ [] ] ]	[ "37.22", "39.61", "38.93", "99.04", "88.56", "99.20", "36.13" ]	icd9pcs	[ [ [] ] ]	10855, 10918	6896, 8528	286, 459	11256, 11263	3605, 6334	11631, 11854	2512, 2612		8832, 10832	6371, 6401	10939, 11235		8554, 8809			11287, 11608								2627, 3586																						236, 248	6430, 6873													487, 1791													1813, 2180	2196, 2496
75,890	157,557	1555	Discharge summary	report	Admission Date: [2143-11-12] Discharge Date: [2143-11-16] Date of Birth: [2090-8-5] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base Attending:[First Name3 (LF) 7651] Chief Complaint: Hypertensive Emergency Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 53 yo W with no significant PMH who presented to her PCP yesterday with 2 week hx of DOE. Pt was concerned she had pneumonia but denied fever, chill, productive cough or URI symptoms. VS at PCP's office were BP 180/104, HR 104, 97% RA. Pt was sent home with metoprolol 25mg [Hospital1 ] and plan for stress ECHO the following day. Upon arrival to stress lab, pt's BP was elevated to systolic 230. She was sent directly to the ED for further evaluation. There she complained of HA and nausea. She denied visual changes, chest pain, palpitations, back pain, abdominal. She did report diaphoresis. Initial VS's were: T98.9, HR110, 239/139, RR16 97 . Patient was started on nitro gtt with no improvement in BP despite max dose of nitro. She was then switched to labetalol gtt with improvement in BP to 159/97. Pt developed progressive respiratory distress with exam notable for crackles [1-9] way up posteriorly. Patient received lasix 40mg IV x1 and was started on BIPAP, which was d/c'd after patient vomited into the mask. She was then placed on NRB. She also received zofran, ativan. Initial labs notable for BUN/Cr 27/1.2, proBNP of 10,933, CK 104, MB 4, Tn-T 0.02. She was transferred to the CCU for further management. 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. She 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, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: No prior history of HTN, last recorded BP was several months ago and normal per pt Bilateral shoulder pain Headaches Social History: Patient is married. Pt denies tobacco or alcohol abuse. Family History: No family history of early MI, otherwise non-contributory. Physical Exam: VS: T=97.3 BP= 138/84 HR= 69 RR= 14 O2 sat= 96% 2L GENERAL: WDWN 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 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. III/VI systolic murmur at LUSB, nonradiating. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at bilateral bases with decreased BS. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. No radial femoral delay. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. 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: [2143-11-12] 12:50PM CK(CPK)-104 [2143-11-12] 12:50PM cTropnT-0.02* [2143-11-12] 12:50PM CK-MB-4 proBNP-[Numeric Identifier 9053]* [2143-11-12] 12:50PM TSH-2.2 [2143-11-12] 12:50PM T4-10.5 [2143-11-11] 12:15PM WBC-8.1 RBC-4.43 HGB-13.3 HCT-38.3 MCV-86 MCH-30.1 MCHC-34.8 RDW-14.7 [2143-11-12] 12:50PM GLUCOSE-106* UREA N-27* CREAT-1.2* SODIUM-140 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-29 ANION GAP-14 [2143-11-12] 05:01PM URINE HOURS-RANDOM CREAT-60 TOT PROT-18 PROT/CREA-0.3* Renin-pending Aldosterone-pending Plasma metanephrines-pending Imaging: Prelim MRI/MRA abdomen: No evidence of pheochromocytoma/ paraganglioma or renal artery stenosis. CT Head: 1. Patent major intracranial arteries, without flow limiting stenosis, occlusion, or aneurysm. 2. White matter hypodense areas can be better evaluated with MR [Name13 (STitle) 430] without and with IV contrast as these are less likely to relate to chronic small vessel occlusive disease given the patient's age. 3. Prominent plexus of veins in the region of the left pterygoid muscles, with one of the tributaries having a varicose appearance with a maximum dimension of 6mm but patent. Consult with Interventional neuroradiologist would be helpful to assess the significance of this findings and if any further work up is necessary. Brief Hospital Course: 53 yo W with no significant PMH presents with hypertensive emergency and acute pulmonary edema CV/HTN: - Pt initially had evidence of cardiomegaly and pulmonary edema on physical exam and cxr as well as LVH on EKG. Cr was elevated at 1.1-1.3. TTE showed moderate symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function, mild mitral regurgitation, elevated left ventricular filling pressures. Pt's BP was initially controlled on labetolol drip and switched to PO labetolol. Control of BP with PO meds required labetolol 800mg TID and lisinopril 10mg daily. Workup for causes of secondary hypertension, including MRI/MRA abdomen (preliminarily negative for RAS, Pheo, other tumors), plasma metanephrines and renin/[Male First Name (un) 2083] levels was negative or pending at time of discharge. Urine studies showed Urine protein of 18, CR of 60 for an elevated Up/cr ratio of .3. Neuro: - Pt complained of vertigo, nausea and vomiting shortly after admission (immediately after begining CPAP), associated with any movement. Physical exam was negative for any cerebellar, vestibular or proprioceptive signs. CT head showed white matter hypodensities and prominent venous plexus in the pterygoid muscle, and follow up MRI showed no infarct, moderate small vessel disease, and no signs of hypertensive encephalopathy; MRA normal. Neuro consult found no neurologic cause for vertigo. Medications on Admission: ASA 81mg daily Ibuprofen PRN Centrum silver Calcium Discharge Disposition: Home Discharge Diagnosis: Hypertensive Emergency Vertigo (etiology unclear) [Name2 (NI) 2325] ventricular hypertrophy Discharge Condition: stable Discharge Instructions: [Doctor Last Name ] had very high blood pressure with vomiting and a headache. The high blood pressure is unclear in etiology. We treated you with labetolol three times a day to lower the blood pressure. You should have a blood pressure cuff at home to monitor your pressure. Please check it every day at different times of the day and keep a log for Dr. [Last Name (STitle) 6481]. Please take your medicines exactly as directed. You also have vertigo. New medicines: 1. Labetolol: a beta blocker that lowers your blood pressure and heart rate. 2. Aspirin: as a mild blood thinner to protect your heart. 3. Ibuprofen: a non steroidal medicine to treat your headache. . Please call Dr. [Last Name (STitle) 6481] or come to the emergency room if you have develop a severe headache, nausea or vomiting. Please check your blood pressure at that time also. . Please also call Dr. [Last Name (STitle) 6481] for any other symptom such as worsening dizziness, trouble walking, nauseea, Followup Instructions: See primary care physician for follow up of renin/aldosterone, plasma metanephrine levels. Primary Care: Provider: [Name10 (NameIs) 9054] [Name11 (NameIs) 6481], MD Phone: [Telephone/Fax (1) 4775] Date/time: Wednesday [11-20] at 1:30pm. . Cardiology: Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Phone: [Telephone/Fax (1) 62] Friday [11-22] at 3:20pm. Completed by:[2143-11-18]	[ "402.91", "780.4", "276.8", "428.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6259, 6265	4723, 6156	316, 322	6405, 6414	3351, 4049	7457, 7935	2331, 2391				6286, 6384		6182, 6236			6438, 7434								2406, 3332																						254, 278														350, 2101		4058, 4700											2123, 2242	2258, 2315
19,552	185,868	6272	Discharge summary	report	Admission Date: [2122-6-11] Discharge Date: [2122-7-23] Date of Birth: [2060-9-12] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[First Name3 (LF) 783] Chief Complaint: [Hospital ] transfer from rehab facility Major Surgical or Invasive Procedure: triple lumen VIP hemodialysis catheter placed HD on [6-11] Multiple PICC line placements History of Present Illness: Pt is a 61 y/o male w/ a paravertebral abscess, vertebral osteomyelitis, T3-T4 epidural abscess, and a significant PMH of CAD (s/p PIC in '[11]), HT, DM II, and morbid obesity who comes into the ER w/ a 4d h/o lethargy/AMS/decreased urine output. He was dx w/ a paravertebral abscess and MRSA osteomyelitis 6wks ago ([4-30]). Surgery was deemed to be too high risk because of his weight and the proximity of the abscess to the spine so he was treated w/ IV vancomycin and transfered to rehab. In rehab, he lost IV access ([6-2]) and refused line placement. Resultingly, he was started on gentamycin po tid (no levels checked). . Since [6-6], the pt was noted to have lethargy, tea colored urine w/ decreased urine output, altered mental status, N/V, and diarrhea. Labs were sent and his Cr was 5.3 (previous 1.1). At this time he noted decreased PO intake for [12-14] wks but denied fever/HA/paresthesia. Pt was admitted to the MICU. Past Medical History: 1. MRSA Bacteremia 2. MRSA osteo of vertebrae and para-vertebral abscess, not drained because too close to the spine, no [Doctor First Name ] due to high risk 3. HTN 4. Morbid Obesity (~500lbs per pt report -> bedbound X3y) 5. CAD s/p MI stents 6. DMII 7. Depression 8. Anxiety Social History: He reports that he quit smoking yrs ago. He denies alcohol/drug use. He lives with wife and son and has been bedbound for 3yrs. Until he got the MRSA infection, he was able to transfer from bed to WC without assistance. At this point, he is unable to transfer without max assist. Family History: Noncontributory Physical Exam: VS: 98.3\|90/70\|86\|18\|100% 4L . Gen: Obese, disheveled, AA&Ox3, appropriate HEENT: mmm, op clear, eomi, PERRLA CV: difficult exam, normal s1s2, no M/R/G. Pulm: CTA B anteriorly Abd: Very obese, dressing over scrotum, foley in place. Ext: 2+ pitting edema L>R, L leg externally rotated immobile. PT pulses subtle, but intact bilaterally. Venous stasis discoloration noted over bilateral tibiae. Neuro: Appropriate, fully oriented. RLE dorsiflexion [1-17], plantarflexion [1-17]. Hip and knee flexion [12-17] on right side. LLE dorsiflexion [2-14], plantarflexion [1-17]. Sensation intact to light touch and pinprick BLE. Pertinent Results: [2122-6-10] 06:15PM WBC-5.8 RBC-3.37* HGB-10.2* HCT-30.4* MCV-90 MCH-30.3 MCHC-33.6 RDW-15.0 [2122-6-10] 06:15PM CK-MB-3 [2122-6-10] 06:15PM cTropnT-0.07* [2122-6-10] 06:15PM CK(CPK)-181* [2122-6-10] 06:15PM GLUCOSE-100 UREA N-88* CREAT-5.0* SODIUM-131* POTASSIUM-5.8* CHLORIDE-90* TOTAL CO2-25 ANION GAP-22* [2122-6-10] 10:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG [2122-6-10] 10:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2122-7-12] 03:24AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [2122-7-17] 05:30AM BLOOD WBC-7.3 RBC-3.25* Hgb-9.7* Hct-31.3* MCV-96 MCH-29.8 MCHC-31.0 RDW-16.0* Plt Ct-344 [2122-7-17] 05:30AM BLOOD Glucose-139* UreaN-11 Creat-1.3* Na-144 K-3.8 Cl-100 HCO3-36* AnGap-12 [2122-7-8] 05:44AM BLOOD ALT-14 AST-20 LD(LDH)-241 AlkPhos-116 TotBili-0.2 [2122-7-17] 05:30AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.8 [2122-7-23] 05:47AM BLOOD WBC-6.8 RBC-3.35* Hgb-10.1* Hct-32.2* MCV-96 MCH-30.1 MCHC-31.3 RDW-16.2* Plt Ct-323 [2122-7-23] 05:47AM BLOOD Glucose-140* UreaN-12 Creat-1.1 Na-143 K-4.2 Cl-100 HCO3-37* AnGap-10 [2122-7-8] 05:44AM BLOOD ALT-14 AST-20 LD(LDH)-241 AlkPhos-116 TotBili-0.2 [2122-7-23] 05:47AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.9 [2122-7-23] 03:00AM BLOOD Vanco-20.8* Brief Hospital Course: Pt was seen in the ER w/ ARF, hyperkalemia, N/V/D, and AMS changes. He was intermittantly hypotensive and required NS bolus but remained afebrile. While awaiting nephrology evaluation, he experienced an episode of shaking limbs and unresponsiveness. He had shaking movements of his arms for several seconds and was then unarousable to sternal rub for [4-21] minutes. After being aroused, he remained lethargic and confused for several minutes. He was admitted to General Medicine. . 1. ARF: Following the seizure-like episode, he had a R subclavian VIP HD line placed and received 1g of vancomycin. He went to HD at 3:30pm and tolerated the process well. He maintained his BP in the 110/80 range w/ a HR of 70 and had 0.5L removed during the procedure. Neurology was consulted for the seizure activity and the patient was loaded on dilantin, with no side effects and no further episodes. The patient was transferred to the MICU with hypotension and bradycardia that responded gradually to fluid rescusitation. The patient was stabilized and transferred to the general medicine floor. His creatinine continued to improve with fluids. A repeat UA showed muddy casts in the spun urine consistent with ATN. His renal function continued to improve up to discharge. It is felt that his ARF was due to a combination of prerenal azotemia and ATN, possibly secondary to supratherapeutic levels of gentamycin. At time of discharge, his Cr had stabilized at about 1.1-1.2, and his urine output was good. He has chronic floey at this point due to difficulty voiding. . 2. NSTEMI: Following the HD, the patient had an episode of hypotension and bradycardia, requiring transfer to the MICU for further observation and care. The patient was rescusitated with fluid boluses, but he developed angina. A troponin and EKG were performed, revealing NSTEMI. The patient was started on ASA, Plavix, and a heparin gtt. Unfortunately, the heparin had to be discontinued as the patient developed bleeding complications from a peri-scrotal tear that has been a chronic problem for years. The patient had no further anginal symptoms throughout his stay, and was discharged on ASA and plavix (does not tolerate B.block). . 3. MRSA osteomyelitis and MRSA epidural abscess: Cultures were negative on admission for MRSA bacteremia. The patient was started on IV Vancomycin on admission, renally dosed. Levels were closely followed by ID throughout the hospitalization. The patient had an Open MRI in [Month (only) ], prior to his arrival. His vancomycin is to be continued for 8-10 weeks after starting. He was dosed Q48h, then based on a trough of 15-20, and now that his renal function has improved and stabilized, he has been on Vanco 1g IV q12 hours (want trough 15-20). He remained afebrile toward the later half of this admission, with normal WBC counts, and markedly reduced back pain. Repeat ESR and CRP were done prior to discharge to be used as baseline for ID follow up. 4. Yeast UTI: Treated for seven days with fluconazole, with resolution. 5. Sleep apnea: pt was complaining of shortness of breath and difficulty sleeping. Pulmonology saw the patient, and diagnosed OSA. They recommended a trial of BiPAP, which the patient tried several times, but was unable to tolerate the mask. He feels as though he wants to try it again in the future, maybe with a different machine. He was not complaining of difficulty breathing upon discharge. He was using 6. Mental status changes: Pt developed some confusion / agitation during the hospitalization. It was felt to be a combination of toxic (oxycodone among others) or metabolic deliurium. EEG / Blood cultures were obtained and were negative. He had no new localizing signs. Psychiatry was consulted and decreased dose of oxycontin, recommended haldol, and continuing anxiety meds. Haldol was given [Hospital1 ] for one week, and he was at baseline, so decreased it to PRN. He was completely back to baseline mental status at time of discharge, and stablized on medical regimen of SSRI / klonopin / Haldol prn. 7. Anxiety: This was a recurring problem for Mr. [Known lastname 24365], who would recurrently have difficulty sleeping overnight due to nerves. He takes klonopin at home, and by the end of his stay, he was on a stable regimen that worked for him (0.5mg tid 6a 1p 6p), and his SSRI. He was very comfortable on this regimen at the time of discharge. 8. Calf pain: He developed bilateral calf pain during the first week of [Month (only) ], and altough low suspicion for DVT, a D.Dimer was sent and was elevated, so bilateral dopplers were performed, and were negative for DVT. He was not able to fit onto a CT scan table. His pain then progressed to "jumpy" and he was started on Neurontin 300mg PO TID, which worked well to control this pain. 9. RUE swelling: His right upper extremity showed some non-pitting edema, and a doppler was performed, which showed no DVT presenet. Most likely explanation was decreased venous / lymph drainage after mult PICC line placements / manipulations. Medications on Admission: Gent 40 tid Actos 30 qd Klonopin Lopressor 50 tid Lasix 40 tid Effexor 150 qd Naprosyn 500 [Hospital1 ] (d/c'ed [6-9]) Protonix 40 qd Morphine 40 qd Insulin 70/30 30u q am 20 u q pm Xanax 0.5bid ECASA 325 qd Lisinopril 15qd Plavix 75qd Captopril 6.25qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for secretions. 10. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO QAM (once a day (in the morning)). 11. Oxycodone 5 mg Tablet Sig: 2-4 Tablets PO Q4H (every 4 hours) as needed for back pain. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1) Packet PO qd () as needed for constipation. 14. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO QAM AND QHS (). 15. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): GIve at 6am, 1pm, 6pm. 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 20. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for agitation: Give as needed for agitation. 21. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Heparin Sodium (Porcine) 10,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 23. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 24. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 25. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 26. Prochlorperazine 10 mg IV Q6H:PRN 27. Vancomycin HCl 1000 mg IV Q 12H Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Non ST elevation MI Acute Tubular Necrosis MRSA Osteomyelitis and Epidural Abscess Acute Renal Failure Delerium Diabetes Neuropathic Pain Lower Extremity Paresis Discharge Condition: Stable, afebrile, no pain, no difficulty breating, tolerating physical therapy, tolerating diet. Discharge Instructions: Please take all medications as perscribed. Please keep all follow up appointments. Please report to the emergency room with any chest pain, nausea, vomiting, lower extremity swelling, fevers, chills, altered mentual status. Please have Chem 7 checked at least weekly, continue prophylactic sub cutaneous heparin. Will need to have labs / CBC, Chem 7, ESR, CRP done before [8-18] appointment with Dr. [First Name (STitle) 2505]. Followup Instructions: Infectious Disease-Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2505]- [Telephone/Fax (1) 457]- [8-18] at 9AM Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 24366] [Hospital3 ]- [Telephone/Fax (1) 250]- [2122-8-10] at 1:30PM [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "410.71", "324.1", "401.9", "780.57", "788.20", "478.29", "584.5", "311", "349.82", "300.00", "250.00", "730.08", "518.82", "112.2", "278.01", "428.30", "458.9" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.04", "38.95", "00.17", "38.93" ]	icd9pcs	[ [ [] ] ]	12011, 12090	4100, 9200	313, 407	12296, 12394	2710, 4077	12880, 13303	2015, 2032		9511, 11988		12111, 12275		9226, 9488			12418, 12857								2047, 2691																						229, 275														435, 1396													1418, 1701	1717, 1999
47,271	160,335	35701	Discharge summary	report	Admission Date: [2122-4-24] Discharge Date: [2122-5-5] Date of Birth: [2057-1-21] Sex: F Service: NEUROLOGY Allergies: Erythromycin Base Attending:[Doctor Last Name 15044] Chief Complaint: Generalized weakness. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [Known lastname 8163] is a 65 year-old woman with a history of myasthenia [Last Name (un) 2902], stroke ([2121]), lung cancer s/p chemoradiation, hypertension, hypercholesterolemia, atrial fibrillation who presents from her NH with a history of worsening NIF and weakness. She was originally admitted on [3-25] for endovascular repair of enlarging aortic aneurysm. She was extubated on POD 1 and on [3-27] a medical consult was called for evalution of hyponatremia; this was felt to be secondary to SIADH. Over the subsequent days, she was noted to have generalized weakness and fatigueability. Neurology was consulted on [3-30] and per their note, she complained of limb weakness, facial weakness marked by difficulty maintaining her eyes open. VC was 0.95L with NIF of -40 on this date. Her overall post-operative course was complicated by a myasthenia flare requiring MICU stay with intubation x2, plasmapheresis x5 treatments, mestinon and steroids. She was discharged to rehab on [2122-4-16] after experiencing improvement on the floor. She represented to the emergency room with declining NIF, weakness and fevers to 100.5 degrees. Per rehab, she had been feeling well and improving her strength but for the past four to five days had had worsening weakness. Serial NIFs prior to transfer were 36 and 24 on the day of transfer. Although she appeared short of breath she was not complaining of dyspnea. In the emergency room her initial vitals were T: 98.9 HR: 80 BP: 113/65 RR: 20 O2: 99% on RA. She received levofloxacin 750 mg IV x 1, methylprednisolone 125 mg IV x 1. She was evaluated by the neurology consult service who recommended Q2H NIFs and vital capacity checks. On arrival to the ER her NIF was -30 and her vital capacity was 1.4. She was initially admitted to the MICU for serial NIFs. Medications which can exacerbate myasthenia [Last Name (un) 2902] were held including beta blockers and calcium [Last Name (un) 21766] blockers. She was stable overnight and transferred to the floor in the afternoon of [2122-4-25]. NIF on transfer was -45 with a vital capacity of 1 L. On review of systems she currently denies fevers, chills. She does have mild cough but is unable to bring up sputum. She denies shortness of breath and chest pain. No nausea, vomiting, abdominal pain, dysuria, hematuria, leg pain or swelling. All other review of systems negative in detail. Past Medical History: 1. Myasthenia [Last Name (un) 2902]: - [2121]: diagnosed; closely followed by primary neurologist in [Location (un) 38] - mild crisis in the past marked by visual changes (diplopia) and generalized weakness - has been on mestinon 60mg TID for her maintenance and recently prednisone 60mg qd since discharge on [2122-4-16] - at baseline, uses wheelchair for any extended travel and walks around the home with a walker most of the time - not really able to perform activities of daily living without substantial support by her husband who is also her primary caretaker 2. Stroke, [2121] - felt to be [2-9] hypertension - residual weakness in BLLE 3. History of lung CA in [2116], s/p chemoradiation, treated by Dr. [First Name8 (NamePattern2) ] [Name (STitle) 4223] in [Name (NI) 392], pt believes it was small cell lung cancer. 4. Atrial fibrillation 5. Hypertension 6. Hypercholesterolemia 7. OSA 8. GERD 9. Chronic low back pain 10. Spine surgery, [2120] 11. Bilateral knee arthroscopy 12. Degenerative arthritis 13. Cholecystectomy Social History: Lives with husband. She is a former heavy smoker up to a pack and a half of cigarettes per day and continues to actively smoke, although she says now only a few cigarettes per day. Family History: Denies any known neurological familial history. Physical Exam: On admission: General: Awake, alert, taking shallow breaths, no distress HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. JVP not elevated Pulmonary: Lungs clear to auscultation bilaterally without wheezes, rales or ronchi, reduced inspiratory air entry noted bilaterally Cardiac: Regular rate and rhythm, normal s1 and s2, no murmurs, rubs, or gallops Abdomen: soft, non-tender, non-distended, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No clubbing, cyanosis or edema, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Pertinent Results: Labs on admission: [2122-4-24] 09:05PM BLOOD WBC-7.7 RBC-3.19* Hgb-10.1* Hct-30.3* MCV-95 MCH-31.7 MCHC-33.3 RDW-14.9 Plt Ct-190 [2122-4-24] 09:05PM BLOOD Neuts-75.5* Lymphs-16.9* Monos-6.0 Eos-1.4 Baso-0.3 [2122-4-24] 09:05PM BLOOD PT-17.3* PTT-24.3 INR(PT)-1.6* [2122-4-24] 09:05PM BLOOD Glucose-152* UreaN-41* Creat-1.1 Na-126* K-6.5* Cl-88* HCO3-28 AnGap-17 [2122-4-25] 02:42AM BLOOD ALT-14 AST-14 LD(LDH)-164 AlkPhos-19* TotBili-0.1 [2122-4-24] 10:25PM BLOOD Calcium-9.8 Phos-3.8 Mg-1.9 [2122-4-24] 09:14PM BLOOD Lactate-1.8 Chest x-ray [2122-4-24]: Stable chest radiograph with no acute cardiopulmonary process. ECHO [2122-4-25]: Mildly dilated right ventricle with normal systolic function. Mild symmetric left ventricular hypertrophy with preserved global and regional systolic function. Mild mitral regurgitation. Moderate tricuspid regurgitation. Mild pulmonary hypertension. [4-28] CT Head: IMPRESSION: 1. Post-surgical changes following prior right frontal burr hole. 2. Chronic small vessel ischemic disease. 3. No intracranial hemorrhage or acute infarct. If there is a high clinical suspicion for an acute infarct, an MR is suggested. [5-3] CT Pelvis: IMPRESSION: 1. Large bilateral low-attenuation inguinal collections. Differential diagnosis includes a seroma, or chronic hematoma 2. Non- opacification of right SFA given recent right femoral endarterectomy. 3. Infrarenal abdominal aortic aneurysm with patent aortobiiliac graft without evidence of endoleak. Brief Hospital Course: Mrs [Known lastname 8163] was intially admitted to the [Last Name (un) 5355]. Due to decreasing NIF and VC she was transferred to the MICU: This is a 65 year old female with history of myasthenia [Last Name (un) 2902], recent prolonged hospital course after MG flare s/p elective AAA repair who is transferred to the MICU for increasing weakness and worsening NIF/Vital Capacity measurements. #. Myasthenia Flare: For the past week the patient has had increasing weakness and worsening NIF/vital capacity. Since transfer to the floor during last hospitalization she has been stable. Her metoprolol was restarted for atrial fibrillation. On the night of [4-26], the ICU team was called to reassess for worsening NIF and vital capacity (-32 and 750 cc). Of note she had recently received Ambien for insomnia. On exam she did not endorse worsening dyspnea but reported feeling weak persistently since transfer to rehab. She was unable to receive NIFs more frequently than [Hospital1 ] on the floor and so the ICU team was asked to transfer patient to the MICU. Her ABG was notable for a compensated chronic respiratory acidosis. Infectious workup initiated on admission has been unrevealing. CXR was negative for acute cardiopulmonary process. Echocardiogram during this admission was unremarkable. She was followed in the ICU for two days with improving NIF from -33 to -34 to -40 on [4-28]. Sedating medications including Ambien were held. She was continued on Prednisone, with addition of standing vitamin D and calcium, insulin sliding scale while on prednisone. She was also continued on Pyridostigmine, Mycophenolate, and Bactrim prophylaxis. She was followed by Neurology as well. It remains unclear whether this is a worsening of her Myasthenia or rather a prolonged recovery from her previous flare complicated by reduced endurance and deconditioning from prolonged hospital course. In the MICU other causes of weakness were evaluated and the CT head showed no evidence of new infarction. Pt also had a chest floroscopy study to evaluate for phrenic nerve injury given her recent AAA repair. The floro study was negative - pt had good diaphragmatic movement bilaterally. Pt's weakness was attributed to the [Month/Year (2) 15099] and deconditioning. Pt remained stable while on the medical floor, and her NIF remained -40 to -50, with a VC 0.9 to 1.5L. On transfer to the neuro floor plasmaphresis was being considered. Also her prednisone was decreased to 40mg [5-1]. After discussion with transfusion medicine, we decided not to pursue plasmaphoresis for multiple reasons: no fatigability or physical signs of active [Month/Year (2) 15099], risks associated with putting phoresis catheter in her right atrium with new onset a. fib, and it would pull off her coumadin and make anticoagulation more difficulty. We intiated CPAP at night to improve her respiratory mechanics and treat OSA in hopes it would help her fatigue as well. She was gotten up to chair and started working with physical therapy. -Follow NIF and VC [Month/Year (2) 41412] daily - Avoid sedating medications as these have been coorelated with poor NIF/VC this admission - Continue cellcept 500mg [Hospital1 ], prednisone 40mg daily, and pyridostigmine 60mg q8h. - Follow up with Dr. [Last Name (STitle) 1206] in neurology clinic. #. Atrial fibrillation: Patient with episodes of rapid atrial fibrillation in the setting of holding metoprolol (held due to potential to worsen her Myasthenia). This was cautiously continued but with low threshold to discontinue if worsening respiratory status. She was also continued on Digoxin and Coumadin. Whle on the medical floor patient remained rate controlled. The neurology consultants felt that it is very unlikey that the BB was contributing to her MG flare. Her BB was not changed, and afib remained stable. On the neurology floor her INR was 1.3 the day prior to and the day of discharge so lovenox subcutaneous was started while INR is subtherapeutic. Coumadine was increased from 5mg 5x/week and 2.5mg 2x/week to 5mg daily. She needs to be anticoagulated for A fib and DVT. She has a history of stroke. - Follow daily INR and adjust coumadin as needed - Continue lovenox while INR is subtherapeutic #. SIADH: Pt devleoped SIADH last admission in the setting of the surgery. The exact cause was unknown, but it resolved once she was transferred from the unit to the floor and retained a normal Na for the rest of her inpatient stay. During this admission she developed hyponatremia again while on the floor. Her Uosm and Sosm continue to be c/w SIADH, along with her urine NA level. Pt began to improve on a 1.5L fluid restriction, and may need a 1L fluid restriction for full improvement. On the neurology floor her Na remained low and SIADH diagnosis was reevaluated. Her urine and serum osmolarity are consistent with this diagnosis. Only her SSRI can be associated with SIADH and she has been on this since [First Name9 (NamePattern2) 41412] [January 2122]. She has a history of small cell lung cancer (per pt) which can be attributed with SCLC but no neoplasm was seen on CT chest done [4-7]. We attributed her SIADH to her moderate to severe COPD which she has on chest CT. - Continue fluid restriction of 1.5L. [Month (only) 116] need more strict fluid restriction. - Follow Na #. Right common femoral DVT: She was diagnosed with new right common femoral DVT during last admission. She was maintained on coumadin after that discharge and this was continued here (see A. fib section). #. Stauts-post AAA repair: She had a successful repair on [3-25]. Post-operative course as outlined above with Myasthenia crisis. During plasmapheresis treatment during the prior admission, the patient had developed bleeding from wound. This was treated with Kelfex which she took for one week after discharge. On the neurology floor she complained of hip pain and CT pelvis was done to evaluate for hematomas at catheter sites or avascular necrosis given pt's treatment with prednisone. CT found no AVN but there were bilateral hematomas or seromas. [Month/Year (2) ] surgery consulted and did not recommend any further intervention. Medications on Admission: Ambien 10mg qhs Apresoline 25mg po q6H Aspirin 81mg daily Bactrim DS 1tab qmwf Celexa 20mg po daily Cellcept 500mg po bid Cephulac 20ml po qid Colace 100mg po bid Digoxin 0.25mg po daily Duoneb INH QID Duragesic Patch 12mcg TD q72hrs (New since D/C) Elavil 25mg po qhs Iron 324mg po daily Flovent 2puffs INH [Hospital1 ] Folate 1mg po daily Habitrol 7mg top daily Hydrochlorothiazide 50mg po qd Metoprolol 25mg po bid Mestinon 60mg po q8 Multivitamin daily Prednisone 60mg po daily Prilosec 20mg po daily Prinivil 40mg po daily Provigil 200mg po daily Senna 2tabs qd Tums 500mg po QID prn Tylenol prn Vicodin prn Vitamin D po daily Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: Five (5) ml PO Q8H (every 8 hours). 11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 20. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous [Hospital1 ] (2 times a day). 21. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO BID (2 times a day) for 2 doses: 1st of 2 doses given at [Hospital ] hospital [5-5] to repleate phos of 2.6. 22. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Follow INR and hold for INR over 3.0. . 23. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain. 24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 25. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 26. Insulin Lispro 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous ASDIR (AS DIRECTED): Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 71-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 0 Units 161-200 mg/dL 4 Units 4 Units 4 Units 2 Units 201-240 mg/dL 6 Units 6 Units 6 Units 4 Units 241-280 mg/dL 8 Units 8 Units 8 Units 6 Units 281-320 mg/dL 10 Units 10 Units 10 Units 8 Units 321-360 mg/dL 12 Units 12 Units 12 Units 10 Units 361-400 mg/dL 14 Units 14 Units 14 Units 12 Units . Discharge Disposition: Extended Care Facility: [Hospital 81219] [Hospital 7755] Hospital Discharge Diagnosis: MYASTENIA FLARE SIADH Atrial fibrillation Hypertension Right common femoral DVT Anemia Discharge Condition: Stable. Discharge Instructions: You were admitted with an exacerbation of your myasthenia [Last Name (un) 2902]. You were watched in the ICU for monitoring and were seen by Neurology. You were found to have low sodium which may have been contributing to your symptoms. You should avoid excessive drinking (over 2.5 liters per day) as this could cause a low sodium level. You were transferred to the neurology service. Medication changes: stop hydralizine, HCTZ, duragesic, provigil. Change ace. . Please take all medications as perscribed. If you have concerns about the medications, please call your PCP before changing the doses. . Please call your PCP or return to the emergency room if you experience any worsening in your symptoms or have other concerns. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2122-5-28] 11:30 Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2122-8-3] 2:45 Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2122-8-3] 3:30 Follow up with your primary care provider after hospital discharge Given your low sodium and SIADH you should follow up with Dr. [First Name4 (NamePattern1) 4223] [Last Name (NamePattern1) 15528] your prior lung cancer after discharge from rehab. Completed by:[2122-5-5]	[ "305.1", "530.81", "V12.51", "327.23", "276.2", "276.7", "428.0", "496", "427.31", "401.9", "V10.11", "358.01", "285.9", "728.89", "272.0", "438.89", "253.6" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	16247, 16323	6356, 12608	301, 308	16454, 16464	4806, 4811	17252, 17941	4082, 4131		13294, 16224		16344, 16433		12634, 13271			16488, 16883								4146, 4146																			16903, 17229			240, 263														336, 2767		5751, 6333					4825, 5742						2789, 3868	3884, 4066
7,629	164,929	20355	Discharge summary	report	Admission Date: [2117-10-25] Discharge Date: [2117-11-25] Service: MEDICINE Allergies: Amoxicillin / Tegretol / Dilantin Attending:[First Name3 (LF) 3556] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: Endotracheal Intubation x 2 Tracheostomy Peg tube placement History of Present Illness: 82 yo M with with tracheomalacia secondary to T-tube placement in the setting of stroke, now with chronic tracheostomy since [3-27] presented to OSH on [2117-10-22] with resp failure, cough and fever. Pt initially intubated on [2115] after a stroke. He had difficulty weaning from the vent and underwent a tracheostomy. Pt was then weaned from the vent and a T-tube was placed for tracheomalacia. Pt followed here by IP. Pt continued to do well over 2.5 years and T-tube removed, pt allowed to decannulate. Pt then presented to [Hospital6 ] ED on [2117-10-22] with a 2 day hx of SOB, cough and fever. Pt was seen in outpatient clinic with complaint of difficultly clearing secretions and was treated with abx and pulm toilet without improvement. There was also a question of aspiration per pts wife as he has had choking episodes while eating. Pt was admitted to OSH MICU and intubated for resp failure. CXR noted R-sided atelectasis which resolved after intubation. Pt was started on Vanc and Levo for suspected aspiration PNA. Pt was able to breathe spontaneously for a few hours on am of [10-24] but failed extubation due to increased secreations and poor gag. Pt then self extubated on [10-24] and required reintubation. Pt was afebrile during this admission, he had one episode of transient hypotension, cosyntropin test negative. Resolved with IVF. . Pt transfered to [Hospital1 18] because he gets his pulmonary care here. On arrival, pt intubated but responding to questions. Denies pain and currently comfortable breathing. Past Medical History: 1) Tracheomalacia, status post stent x 2 with failure secondary to stent migration. Status post trach revision [3-27]. Status post T-tube removal on [2115-6-26]. 2) Status post stroke in [2109] with TIA; right upper extremity weakness resulting. 3) Hypertension. 4) Seizure disorder. 5) History of MRSA. 6) Hemorrhoids. 7) Arthritis. 8) Depression. 9) History of CHF. 10) CRI Social History: Married and lives at home with wife with nursing care. Remote hx of smoking, duration unknown. Rare Etoh. Family History: NC Physical Exam: VS T: 98.1 P:77 BP: 138/68 RR:15-17 O2Sat: 94% Vent: AC 600x12, FiO2 0.40, PEEP 5. GENERAL: Intubated, light sedation, responding to commands, agitation. HEENT: Pupile equal, EOMI, no icterus, non-injected. NECK: Supple, no JVD appreciated. CARDIOVASCULAR: RRR no murmur appreciated. LUNGS: Ant and lat fields with coarse breath sounds. ABDOMEN: Obese, NDNT, NABS, soft. EXTREMITIES: No edema, warm and well perfused. NEURO: R UE with weakness, LUE strong, able to move toes bilaterally. Alert, unable to assess orientation. Pertinent Results: [2117-10-25] 10:29PM TYPE-ART PO2-80* PCO2-40 PH-7.42 TOTAL CO2-27 BASE XS-0 [2117-10-25] 10:29PM LACTATE-1.0 [2117-10-25] 06:38PM GLUCOSE-112* UREA N-26* CREAT-1.5* SODIUM-145 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-25 ANION GAP-15 [2117-10-25] 06:38PM CK(CPK)-134 [2117-10-25] 06:38PM CK-MB-3 cTropnT-0.03* [2117-10-25] 06:38PM CALCIUM-8.1* PHOSPHATE-2.2* MAGNESIUM-2.1 [2117-10-25] 06:38PM PHENOBARB-23.6 [2117-10-25] 06:38PM WBC-7.0 RBC-4.56* HGB-14.3 HCT-42.1 MCV-92 MCH-31.3 MCHC-34.0 RDW-14.8 [2117-10-25] 06:38PM NEUTS-74.4* LYMPHS-19.5 MONOS-4.9 EOS-1.0 BASOS-0.2 [2117-10-25] 06:38PM PLT COUNT-121* [2117-10-25] 06:38PM PT-12.3 PTT-32.6 INR(PT)-1.1 . CHEST (PORTABLE AP) [2117-11-23] 7:14 AM Reason: interval change IMPRESSION: AP chest compared to [11-19] through 29: Endotracheal tube ends in the tracheobronchial stent, tip between 3 and 4 cm from the carina. Lungs are low in volume and mild left lower lobe atelectasis is stable. Mild pulmonary edema unchanged. Heart size normal. No appreciable pleural effusion. Nasogastric passes below the diaphragm and out of view. Right jugular line can be traced as far as the upper right atrium but the tip is indistinct. No pneumothorax. . Cardiology Report ECG Study Date of [2117-11-20] 9:05:06 AM Sinus rhythm. Leftward axis. Compared to the previous tracing of [2117-11-10] no change. . Brief Hospital Course: 1) Resp failure: possible etiologies included aspiration vs bacterial PNA vs bronchitis. Likely combination of increased secretions with tracheomalacia making pt unable to clear secretions requiring intubation. Initial extubation was not tolerated by the patient with increased respiratory distress, requiring reintubation and eventual tracheostomy with prolonged weaning course likely. - Continued Vanc and Levoquin on admission given hx of MRSA PNA, and was switched to and completed a 10 day course of Aztreonam and Vanco. The patient spiked a temp to 101 several days after completing this course and given that there was a witnessed aspiration when he self d'c'd his NGT, he was restarted on Vanc and Aztreonam for a 7 day course. All cultures were negative. - was extubated and reintubated on [11-4] given acute resp distress/stridor (fiberoptic intubation by IP). He was extubated again on [11-17] and reintubated on [11-19] for tachypnea and inability to clear secretions. It was d/w IP and family and patient underwent tracheostomy [11-23]. . 2) Tracheomalacia: Pt followed by IP service. Underwent rigid bronchoscopy on [10-27], which showed granulation tissue on the L lateral wall of the trachea causing tracheal stenosis and moderate to severe tracheobronchomalacia. The area of tracheal stenosis was balloon dilated and the granulation tissue was excised. He was transiently given Heliox for tenuous respiratory status right after bronchoscopy. He was started on dexamethasone post-bronchoscopy for empiric treatment of tracheolaryngeal edema and continued on high dose guafenesin. . 3) HTN: Continued metoprolol once more clinically stable. Pt has been HD stable since admission. Initially underwent aggressive diuresis for management of his resp distress, but with reintubation on [11-19], patient's CVP's were 0-2 and MAP's were less than 60, requiring 2 days of levophed gtt. Lasix was stopped and aggressive fluid repletion with a goal of CVP 8-10 and MAP's>60 was started with good response and levophed was able to be weaned [11-20]. . 4) CRI: Baseline 1.2-1.5. After repleting fluids, patient remained in the lower range of his baseline for the rest of his admission. . 5) Hx CVA: continued aspirin. . 6) Sz Disorder: Maintained on phenobarbital throughout admission, dosing by level secondary to renal insufficiency. Medications on Admission: Lopressor 12.5 [Hospital1 ] Zantac 150 [Hospital1 ] Lasix 40 daily Potassium 10 qd phenobarb 200 qd baclofen 2.5 [Hospital1 ] aspinrin flomax 0.4 qd tums Duoneb Discharge Medications: Lopressor 12.5 [Hospital1 ] Zantac 150 [Hospital1 ] Lasix 40 daily Potassium 10 qd phenobarb 240 qd baclofen 2.5 [Hospital1 ] aspirin flomax 0.4 qd Discharge Disposition: Extended Care Facility: [Location (un) 32674] - [Location (un) ] Discharge Diagnosis: respiratory distress secondary to aspiration pneumonia and tracheomalacia tracheostomy placement gastrostomy placement bacteremia acute renal failure shock diabetes Discharge Condition: Stable Discharge Instructions: Please return to the hospital for shortness of breath, fevers, chest pain, fainting. Followup Instructions: Please follow up with your pulmonologist within 3 weeks of discharge from the hospital. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560]	[ "285.29", "519.19", "428.0", "999.9", "799.02", "728.87", "518.84", "276.52", "934.1", "790.7", "507.0", "780.39", "403.90", "458.8", "490", "584.9", "585.9", "560.1", "438.89", "996.59", "263.9" ]	icd9cm	[ [ [] ] ]	[ "33.23", "38.91", "31.1", "96.56", "31.93", "43.11", "96.6", "96.72", "31.99", "96.05", "00.17", "96.04", "33.24", "38.93", "32.01", "96.71" ]	icd9pcs	[ [ [] ] ]	7271, 7346	4493, 6862	264, 325	7555, 7563	3036, 4470	7696, 7916	2471, 2475		7086, 7248		7367, 7534		6888, 7063			7587, 7673								2490, 3017																						204, 226														353, 1920													1942, 2332	2348, 2455
55,923	140,131	33400	Discharge summary	report	Admission Date: [2172-6-26] Discharge Date: [2172-6-26] Date of Birth: [2109-12-14] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Percocet / Vicodin / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1505] Chief Complaint: abdominal pain, likely perforated viscus Major Surgical or Invasive Procedure: [2172-6-26] Exploratory laparotomy. 2. Suture repair of bleeding mesenteric blood vessels. 3. Subtotal gastrectomy. 4. Evacuation of intraperitoneal clot. 5. Endoscopy History of Present Illness: 62-year-old woman who was transferred from an outside facility early this morning with abdominal pain and blood loss anemia, nausea, vomiting. She evidently suffered a PEA arrest and was resuscitated with 10 minutes of cardiopulmonary resuscitation, intravenous fluid and blood replacement, as well as vasopressor. In the MICU this morning, she had respiratory decompensation and a PEA arrest requiring 3mg epinephrine and 10 minutes of chest compressions. She has since regained a pulse and a blood pressure, although she is very tenuous and is now on multiple vasopressors (levo/neo/vasopressin). Prior to her intubation, she was tachypneic and complaining of diffuse abdominal pain. Past Medical History: alcohol abuse, history of withdrawal seizures - barrett's esophagus - recurrent cholangitis s/p PTC drain placement - Atrial fibrillation, not on coumadin - iron deficiency anemia - PUD - history of GI bleed - history of pericardial and pleural effusions - L breast cancer PSH: - s/p open gastric bypass surgery - s/p open cholecystectomy - s/p c-section - s/p L thoracotomy for empyema - s/p L mastectomy Social History: married, otherwise unknown Physical Exam: HR 130s, BP ~100 systolic, now on levophed/neo/vasopressin intubated, sedated, moving all 4 extremities tachycardic bilateral breath sounds present abdomen obese, soft, diffusely tender to palpation; vertical midline incision present; [Doctor Last Name ] incision present unable to perform rectal exam given acute decompensation Pertinent Results: [2172-6-26] 02:51PM BLOOD WBC-1.6# RBC-2.81 Hgb-8.3* Hct-24.2* MCV-86 MCH-29.6 MCHC-34.4 RDW-14.8 Plt Ct-177# [2172-6-26] 02:51PM BLOOD Neuts-39* Bands-11* Lymphs-37 Monos-7 Eos-2 Baso-1 Atyps-0 Metas-2* Myelos-1* [2172-6-26] 02:51PM BLOOD Plt Smr-NORMAL Plt Ct-177# [2172-6-26] 02:10PM BLOOD Fibrino-99* [2172-6-26] 02:51PM BLOOD Glucose-312* UreaN-23* Creat-0.9 Na-153* K-3.3 Cl-107 HCO3-23 AnGap-26* [2172-6-26] 02:51PM BLOOD ALT-21 AST-53* LD(LDH)-196 CK(CPK)-187 AlkPhos-40 Amylase-30 TotBili-2.7* [2172-6-26] 02:51PM BLOOD Lipase-18 [2172-6-26] 02:51PM BLOOD CK-MB-10 MB Indx-5.3 cTropnT-0.21* [2172-6-26] 02:51PM BLOOD Albumin-2.0* Calcium-11.5* Phos-6.1* Mg-1.4* Iron-67 [2172-6-26] 02:51PM BLOOD calTIBC-146* Ferritn-146 TRF-112* [2172-6-26] 05:06AM BLOOD Digoxin-0.8* [2172-6-26] 03:10PM BLOOD Type-ART pO2-97 pCO2-49* pH-7.28* calTCO2-24 Base XS--3 [2172-6-26] 02:16PM BLOOD Type-ART pO2-202* pCO2-41 pH-7.31* calTCO2-22 Base XS--5 Intubat-INTUBATED [2172-6-26] 03:10PM BLOOD Lactate-16.7* [2172-6-26] 02:16PM BLOOD Glucose-268* Lactate-16.4* Na-145 K-3.7 Cl-109 calHCO3-22 Brief Hospital Course: She has acutely decompensated and coded since her transfer from [Hospital1 ] to the [Hospital1 18] MICU at approximately 5am; she has been intubated and has barely survived with most recent ABG 6.91/54/67 with base excess -24. Plan: - to OR emergently for exploration - unable to speak with family despite numerous attempts, statement of medical necessity for OR in chart - aggressive IVF resuscitation with colloid - has received 3U PRBC and 4L IVF resuscitation and will need more - broad spectrum antibiotics - is receiving Vancomycin/Zosyn - central access placed emergently in MICU prior to OR - will need to be changed the patient was seen and discussed with Dr. [Last Name (STitle) ], who agrees with the plan and will take her to OR emergently. FINDINGS: 1. Gastric perforation. 2. Approximately 2 liters of clots in the lesser sac. 3. Bleeding from the superior mesenteric vein and branches, which appeared to be dilated consistent with varices. 4. Fatty liver consistent with steatohepatitis. 5. Gastrocardiac fistula from the gastric fundus to the left ventricle. Massive fluid resuscitation with approx. 40 units of PRBCs, 25 units cryo/platelets/FFP, as well as three doses of Factor VII. Pt transferred to the CVICU on high -dose levophed, epinephrine, milrinone, and vasopressin drips. Pt. continued to hemorrhage and family was notified of her imminent death. Social work consult done with family. Pt. expired at 7:26 pm. Medications on Admission: Meds on transfer: - Ceftriaxone - Flagyl - Digoxin 0.125 mg daily - ativan PRN - protonix - zofran previously, on celexa, seroquel, lasix, prilosec, gabapentin, calcium, folic acid, lopressor, heparin, thiamine Discharge Disposition: Expired Discharge Diagnosis: expired s/p gastic-ventricular fistula / massive hemorrhage/ PEA arrest Discharge Condition: expired Completed by:[2172-6-29]	[ "571.8", "537.89", "285.1", "038.9", "427.31", "553.3", "V10.3", "423.9", "530.85", "518.82", "V45.71", "456.8", "537.4", "427.5", "V45.86" ]	icd9cm	[ [ [] ] ]	[ "39.32", "39.61", "45.13", "34.84", "43.89", "37.49" ]	icd9pcs	[ [ [] ] ]	5005, 5014	3280, 4743	371, 545	5129, 5167	2109, 3257						5035, 5108		4769, 4769											1755, 2090																						291, 333														573, 1264													1286, 1695	1711, 1740		4787, 4982
49,018	147,997	23212	Discharge summary	report	Admission Date: [2168-7-7] Discharge Date: [2168-7-19] Date of Birth: [2109-5-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: NG tube place and replaced multiple times diagnostic and therapeutic paracentesis x 3 ET intubation x 2 History of Present Illness: Patient is a 59 year old male with a history of intermittent GERD who presents with dyspnea for many weeks. Patient notes progressive DOE without any other associated symptoms. Denies chest pain/pressure, no syncope. (-) f/c, (-) cough. (-) abdominal pain, nausea, or vomiting. He denies melena/BRBPR. He does note increasing jaundice over the past week, first recognized by his sister. [Name (NI) ] has a significant history of alcohol dependence. He endorses at least 4-5 beers daily since high school. He sometimes consumes more than that when he goes to Elks dinner. His last drink was this morning, he had a gin and tonic. He also endorses a 50 pound weight gain since [Month (only) 547], with an enlarging abdomen. His worsening DOE brought him to the ED earlier today. . In ED initial VS were T 97.8, HR 96, BP 126/95, RR 18 98%. a and o x 3. Received ciprofloxacin 500 mg x 1 for (+) u/a. also received thiamine, folate, potassium, magnesium, lorazepam. guaiac (+), brown stool. consented for 2 units PRBCs, not yet received. also had episode of a. fib with RVR, resolved spontaneously. no steroids given yet. Vitals at time of transfer HR 98, 119/64, RR 20, 98% on 3 liters n/c. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. 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: GERD alcohol dependence Social History: widowed, wife passed away earlier this year from liver failure, ?autoimmune hepatits. lives alone in [Location (un) 1411]. no children. denies tobacco use, denies other drug/IVDU/past or present. former high school math teacher Family History: history of alcoholic liver disease in family Physical Exam: VS: 110/68 HR 90s, RR 20 98% 3 liters. GA: AOx3, NAD. fetor hepaticus. HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. marked scleral icterus. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: decreased breath sounds at right base, otherwise CTA Abd: soft, NT, +BS. no g/rt. neg HSM. neg [Doctor Last Name 515] sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT, pain, temperature, vibration, proprioception. cerebellar fxn intact (FTN, HTS). gait WNL. Exam at discharge: expired Pertinent Results: [2168-7-7] 11:20AM RET MAN-5.4* [2168-7-7] 11:20AM PT-29.5* PTT-49.3* INR(PT)-2.9* [2168-7-7] 11:20AM PLT SMR-LOW PLT COUNT-154 [2168-7-7] 11:20AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+ ACANTHOCY-1+ [2168-7-7] 11:20AM NEUTS-91* BANDS-0 LYMPHS-4* MONOS-4 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2168-7-7] 11:20AM WBC-12.1* RBC-1.69* HGB-6.9* HCT-19.5* MCV-116* MCH-40.8* MCHC-35.2* RDW-21.9* [2168-7-7] 11:20AM HCV Ab-NEGATIVE [2168-7-7] 11:20AM ASA-NEG ETHANOL-54* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2168-7-7] 11:20AM AFP-4.2 [2168-7-7] 11:20AM HBs Ab-POSITIVE HBc Ab-NEGATIVE IgM HBc-NEGATIVE [2168-7-7] 11:20AM TSH-1.2 [2168-7-7] 11:20AM AMMONIA-66* [2168-7-7] 11:20AM VIT B12-GREATER TH FOLATE-5.8 HAPTOGLOB-10* FERRITIN-217 [2168-7-7] 11:20AM ALBUMIN-2.7* CALCIUM-8.6 PHOSPHATE-2.2* MAGNESIUM-2.0 [2168-7-7] 11:20AM LIPASE-66* [2168-7-7] 11:20AM ALT(SGPT)-47* AST(SGOT)-79* LD(LDH)-230 ALK PHOS-112 TOT BILI-29.4* DIR BILI-17.8* INDIR BIL-11.6 [2168-7-7] 11:20AM estGFR-Using this [2168-7-7] 11:20AM GLUCOSE-113* UREA N-21* CREAT-0.6 SODIUM-129* POTASSIUM-2.9* CHLORIDE-92* TOTAL CO2-23 ANION GAP-17 [2168-7-7] 12:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2168-7-7] 12:00PM URINE OSMOLAL-385 [2168-7-7] 12:00PM URINE HOURS-RANDOM CREAT-236 SODIUM-<10 POTASSIUM-43 CHLORIDE-14 [2168-7-7] 12:43PM URINE MUCOUS-FEW [2168-7-7] 12:43PM URINE GRANULAR-0-2 HYALINE-[1-22]* [2168-7-7] 12:43PM URINE RBC-0-2 WBC-[4-28]* BACTERIA-FEW YEAST-NONE EPI-0-2 [2168-7-7] 12:43PM URINE BLOOD-SM NITRITE-POS PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-LG UROBILNGN-12* PH-6.5 LEUK-TR [2168-7-7] 12:43PM URINE COLOR-DkAmb APPEAR-Cloudy SP [Last Name (un) 155]-1.017 [2168-7-7] 06:19PM ASCITES WBC-61* RBC-325* POLYS-11* LYMPHS-32* MONOS-0 MESOTHELI-2* MACROPHAG-55* [2168-7-7] 06:19PM ASCITES TOT PROT-0.8 ALBUMIN-LESS THAN [2168-7-7] 08:45PM FIBRINOGE-141* [2168-7-7] 08:45PM PT-28.6* PTT-50.9* INR(PT)-2.8* [2168-7-7] 08:45PM PLT COUNT-102* [2168-7-7] 08:45PM WBC-13.3* RBC-2.10* HGB-8.0* HCT-22.1* MCV-105# MCH-38.0 MCHC-36.1* RDW-24.8* [2168-7-7] 08:45PM CALCIUM-8.2* PHOSPHATE-2.4* MAGNESIUM-2.1 [2168-7-7] 08:45PM ALT(SGPT)-45* AST(SGOT)-76* ALK PHOS-105 TOT BILI-29.6* [2168-7-7] 08:45PM GLUCOSE-109* UREA N-22* CREAT-0.4* SODIUM-131* POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-23 ANION GAP-16 [2168-7-7] 08:51PM LACTATE-3.7* [2168-7-7] 08:51PM TYPE-ART PO2-118* PCO2-30* PH-7.50* TOTAL CO2-24 BASE XS-1 . Labs at end of hospital course: . WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 20.6* 2.24* 8.1* 23.6* 106* 36.3* 34.4 23.0* 66* . PT INR(PT) 25.7* 2.5* . Glucose UreaN Creat Na K Cl HCO3 AnGap 100 87* 1.6* 143 4.2 108 27 12 . ALT AST AlkPhos TotBili 48* 139* 89 29.2* . RUQ u/s: IMPRESSION: 1. Shrunken, nodular liver with coarsened echotexture and areas of heterogeneity, consistent with cirrhosis. Patent umbilical vein and possible to and fro flow within the intrahepatic main portal vein suggests portal hypertension. Patent main portal vein. 2. Large amount of ascites . Renal u/s: IMPRESSION: 1. No evidence of hydronephrosis. 2. Large ascites. . TTE: The left atrium is mildly dilated. The right atrium is moderately dilated. The right atrial pressure is indeterminate. 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 root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([11-21]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Dilated ascending aorta. No pericardial effusion. . Chest AP portables: [2168-7-16]: FINDINGS: In comparison with the study of [7-15], the NG tube again extends to the body of the stomach. Slightly better inspiration with the cardiac silhouette now within normal limits. No definite pulmonary vascular congestion. There is an area of ill-defined opacification in the right mid lung zone, worrisome for developing pneumonia. Mild atelectatic changes are seen at the left base. The right hemidiaphragm is now quite sharply seen, though there is still some blunting of the costophrenic angle suggesting some pleural effusion on this side . [2168-7-17]: FINDINGS: In comparison with the study of [7-16], there is extensive opacification filling almost the entire right hemithorax. This is consistent with large pleural effusion with some compressive atelectatic change. The left lung remains essentially clear. . [2168-7-17]: FINDINGS: In comparison with earlier study, there is now complete opacification of the right lung with some displacement of the mediastinum to the left. This is consistent with a huge pleural effusion with some underlying volume loss. . [2168-7-17]: FINDINGS: As compared to the previous radiograph, the patient has been newly intubated. The tip of the endotracheal tube projects 7 cm above the carina. There is unchanged course and position of the left-sided PICC line. Nasogastric tube with unremarkable course, the tip is not visualized on the image. . In the interval, there has been a reduction in extent of the right pleural effusion and reexpansion of the right lung. However, the extent of the left pleural effusion is still substantial. . Moderate left basal atelectasis, no evidence of pneumothorax. Normal size of the cardiac silhouette. . [2168-7-18]: Large right pleural effusion has increased in size when compared to [2168-7-17] exam, now leading to complete opacification of the right hemithorax. Current imaging findings closely resemble [2168-7-16] radiograph. Mild left-sided mediastinal shift is noted. Left lung is clear. No left pleural effusion is present. No pneumothorax is identified. . ET tube is approximately 5.7 cm from the carina. Left PIC catheter tip projects over mid SVC. NG tube is in nondistended stomach, its tip out of view. . Micro data: peritoneal fluid was consistently negative for SBP, and did not have any culture growth . C. diff (-) . [2168-7-17] 10:09 pm SPUTUM Source: Endotracheal. . GRAM STAIN (Final [2168-7-18]): <10 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. QUALITY OF SPECIMEN CANNOT BE ASSESSED. . all blood cultures were pending or showed no growth . [2168-7-17] 9:44 am URINE Source: Catheter. FINAL REPORT [2168-7-18] URINE CULTURE (Final [2168-7-18]): NO GROWTH. Brief Hospital Course: #Acute hypoxemic respiratory failure - Due to volume overload and right-sided pleural effusion in the setting of oliguric renal failure and limited response to diuretic therapy. Intubated [7-11], extubated [7-12]. Patient redeveloped hypoxia on [2168-7-17]. Chest film showed collapsed right lung, thought secondary to mucous plug, with large right-sided pleural effusion. Patient was re-intubated on [2168-7-17] for hypoxic respiratory failure and respiratory distress. Broad-spectrum antiobiotics to cover for hospital-acquired pneumonia were restarted. Following discussion with family, decision was made to withdraw care, and patient was terminally extubated on [2168-7-18]. . #Acute alcoholic hepatitis - Treated with nutritional support and pentoxifylline. Steroids were deferred in the setting of possible infection and bleeding. Patient received three diagnostic and therapeutic paracentesis, all were negative for spontaneous bacterial peritonitis, and the first two did improve his respiratory mechanics. Patient was not a candidate for liver transplantation, as his last consumption of alcohol was on day of admission. . #Alcoholic cirrhosis - Treated with lactulose and rifaximin. Treated with paracentesis on [9-21], and [7-17], with removal of 5L each time, without evidence of SBP by peritoneal fluid analysis. . #Acute blood loss anemia - Guaiac positive stool but no overt signs/symptoms of GI bleeding. Received 6U pRBC and 5U FFP between [Date range (1) 59676]. Also given vitamin K to treat coagulopathy. No other blood products were given after [7-9]. . #Acute kidney injury - Attributed to decreased effective renal perfusion due to cirrhotic physiology and possibly abdominal comparment syndrome. Treated with paracentesis, albumin, and blood products. Treatment for hepatorenal syndrome was deferred based on recommendations from the consulting hepatology and nephrology teams. Urine output decreased and creatinine rose on [7-17], consistent with a second episode of [Last Name (un) ]/renal failure. . #Alcohol abuse - Monitored on CIWA, and given thiamine/MVI/folate. Did not show signs/symptoms of alcohol withdrawal. . As noted above, family meeting held on day after re-intubation, and decision was made to withdraw care and proceed with comfort measures only. The patient expired on [2168-7-19]. Medications on Admission: vitamin B12 Nexium PRN potassium PRN Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "511.9", "276.1", "263.9", "789.59", "584.9", "303.91", "038.9", "530.81", "934.8", "E915", "995.92", "599.0", "285.1", "518.0", "276.0", "571.2", "286.9", "572.2", "518.81", "571.1", "792.1", "427.31", "486", "572.4", "401.9", "291.81" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "38.91", "38.93", "54.91" ]	icd9pcs	[ [ [] ] ]	13009, 13018	10505, 12890	322, 427	13069, 13078	3087, 5843	13134, 13144	2340, 2386		12977, 12986		13039, 13048		12916, 12954	5860, 10482		13102, 13111								2401, 3045													3059, 3068					1692, 2026				275, 284														455, 1673													2048, 2073	2089, 2324
10,593	150,361	19282+19300	Discharge summary	report+report	Admission Date: [2146-3-5] Discharge Date: [2146-3-21] Service: [Last Name (un) ] [Last Name (un) ] HISTORY OF PRESENT ILLNESS: The patient is an 82 year old female with a history of chronic renal insufficiency who recently presented to [Hospital 1562] Hospital with sharp, acute, left sided, chest and abdominal pain. The patient was having lunch at the time when the pain started. In the E.D. chest x-ray showed no mediastinum and a small amount of pleural effusion. The patient was admitted the ICU to rule out for MI. Gastrografin swallow showed a possible esophageal tear and the patient was, thus, transferred to [Hospital1 346]. PAST MEDICAL HISTORY: Chronic renal insufficiency 3.0. Hypertension. Diverticulosis. Hemorrhoids. Gout. MEDICATIONS: Alprazolam 0.25 mg p.o. q.day, lisinopril, hydrochlorothiazide, allopurinol, calcium, Fosamax. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On exam the patient had anicteric sclerae. No lymphadenopathy was noted. Examination of the lungs revealed clear to auscultation bilaterally without wheezes. Examination of the heart revealed regular rate and rhythm without murmurs. Examination of the abdomen revealed soft, positive tender abdomen with few bowel sounds and mildly distended abdomen. Extremities revealed no edema and felt warm. HOSPITAL COURSE: The patient was admitted to the thoracic surgery service and taken emergently to the O.R. for emergency esophageal perforation repair. The patient underwent primary closure with intercostal muscle flap in place. The patient was then transferred to the ICU. In the ICU on post-op day one the patient had a run of SVT and metabolic acidosis. The patient received bicarb. Otherwise the patient remained afebrile with stable vital signs. The patient was continued on morphine and propofol for sedation and to control pain. The patient was on neo for pressure support. The patient was on antibiotics to treat esophageal rupture. The patient was also started on TPN for nutrition, otherwise was doing well. On post-op day two the patient went to the O.R. for placement of G-tube for drainage and J-tube for feeding. The patient's pain was well controlled and she was continued on IV antibiotics. On post-op day three the patient remained afebrile with stable vital signs. The chest tube was placed to suction. She was continued on antibiotics and was managing the pain. The patient was continued on TPN. On post-op day four the patient failed to extubate, thus, the patient was continued being intubated and continued respiratory support. The patient's tube feeds were started and continued on antibiotics and kept the NG tube to suction and plan for a trach. On post-op day five the patient had no issues overnight. The patient remained afebrile with stable vital signs. The patient was continued to be intubated. Sedation was decreased and the patient's secretions improved. The patient was continued on tube feeds. NG tube was to suction and G-tube was placed to gravity. The patient's antibiotics were continued. On post-op day six the patient once again failed to extubate. The patient remained afebrile with stable vital signs. The patient's creatinine elevated to 2.9 which was monitored. The patient's antibiotics were continued. The patient's tube feeds were put on hold for trach placement. The patient underwent bedside percutaneous trach. The patient was continued on tube feeds and continued on antibiotics. On post-op day eight the patient spiked a temperature up to 101.2. The patient was pancultured and Flagyl was changed to p.o. otherwise other vitals were stable. The patient was continued on tube feeds. The patient underwent aggressive pulmonary toilet. The patient's white count also was elevated to 15. CT scan showed bilateral small to moderate pleural effusion with possible loculated component with a high density lesion in the left lung base consistent with atelectasis versus consolidation. The patient had a soft tissue density around the lesion along the major fissure on the left consistent with loculated fluid. The patient also had high attenuation material present in the pleural space of the left lung base that was consistent with retained contrast from the prior fluoroscopy study. The patient also had a single prominent leukojejunum with some mild upper abdomen with no evidence of abdominal dilatation or wall thickening to suggest obstruction. On post-op day nine the patient had decrease in white blood cell count, remained afebrile with stable vital signs. On post-op day nine the patient remained afebrile with stable vital signs and was continued on supportive care. On post-op day 10 the patient had no major events overnight. She remained afebrile with stable vital signs. The patient was continued on morphine for pain. White count remained stable with stable hematocrit and creatinine. On post-op day 11 the patient remained afebrile with stable vital signs, was continued on J-tube feeds, was on trach mask. She had elevated creatinine and renal consult was obtained. She was continued on antibiotics. On post-op day 11 the patient had a bout of a-fib. The patient was continued on Lopressor. Otherwise the patient was doing well. On post-op day 12 the patient underwent a swallow study which showed no leak. The chest tube and the NG tube were removed. Otherwise she remained afebrile with stable vital signs. The patient was continued on tube feeds, critical care and received one unit of blood for low hematocrit. On post-op day 14 the patient was transferred to the floor with continuing the tube feeds and continuing the antibiotics, continue heparin subcu and continue the trach. The physical therapist was consulted as well. The patient remained stable throughout the night. On post-op day 15 the patient continued to do well, afebrile with stable vital signs. On post-op day 16 the patient remained afebrile with stable vital signs and waiting for rehab placement. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Extended care facility. DISCHARGE DIAGNOSES: 1. Esophageal rupture status post repair status post J-tube and trach placement. 2. Chronic renal insufficiency. 3. Hypertension. 4. Diverticulosis. 5. Hemorrhoids. 6. Gout. DISCHARGE MEDICATIONS: 1. Sliding scale insulin. 2. Amiodarone 400 p.o. q.day. 3. Flagyl 500 mg NG t.i.d. 4. Percocet p.r.n. 5. Metoprolol 12.5 mg p.o. b.i.d. 6. Alprazolam 0.25 mg p.o. t.i.d. 7. Nystatin 5 ml p.o. q.i.d. p.r.n. 8. Cipro 250 mg NG q.day. 9. Calcium acetate 667 mg p.o. t.i.d. with meals. 10. Lansoprazole 30 mg NG q.day. 11. Ampicillin 1 gm IV q.eight hours. FOLLOWUP: Please follow up with Dr. [Last Name (STitle) 952] in one to two weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3351], M.D. [MD Number(1) 3352] Dictated By:[Last Name (NamePattern1) 3118] MEDQUIST36 D: [2146-3-21] 09:21 T: [2146-3-21] 09:25 JOB#: [Job Number 52522] Admission Date: [2146-3-5] Discharge Date: [2146-3-23] Service: Thoracic Surgery ADDENDUM: Since the last dictation, the patient underwent a swallow evaluation and passed for pureed solids and thin liquids, and the patient may take oral medications by mouth with plenty of liquids. Thus, the patient's tube feeds were changed to be cycled at night from 6:00 p.m. to 8:00 a.m. DISCHARGE MEDICATIONS: Change amiodarone 400 mg p.o.q.d. to be continued for one week and then switched to 200 mg p.o.q.d. for one week and then stop. Continue ciprofloxacin, Flagyl and ampicillin for three more days, for a total of a three week course. FOLLOW-UP PLANS: The patient should also follow up with Dr. [First Name (STitle) 23081], the patient's primary care physician, [Name10 (NameIs) ] one to two weeks after discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3351], M.D. [MD Number(1) 3352] Dictated By:[Last Name (NamePattern1) 3118] MEDQUIST36 D: [2146-3-23] 10:48 T: [2146-3-23] 10:12 JOB#: [Job Number 52567]	[ "519.2", "401.9", "V46.1", "530.4", "038.9", "276.2", "427.31", "593.9", "997.1" ]	icd9cm	[ [ [] ] ]	[ "99.04", "99.15", "31.1", "34.3", "46.39", "38.91", "83.82", "42.82", "43.19", "33.23", "96.72" ]	icd9pcs	[ [ [] ] ]								6154, 6335	7512, 7745					1378, 6055																					958, 1360					7763, 8212																				157, 678													701, 935		6080, 6133
13,253	184,058	16144	Discharge summary	report	Admission Date: [2124-9-14] Discharge Date: [2124-9-19] Date of Birth: [2045-8-27] Sex: M Service: MEDICINE Allergies: Penicillins / simvastatin Attending:[First Name3 (LF) 16115] Chief Complaint: abdominal and suprapubic pain Major Surgical or Invasive Procedure: None History of Present Illness: 79 year old male, Cantonese-only speaking man with hypertension, hyperlipidemia, CAD s/p CABG ([2118]) with perc chole tube for cholecystitis/duodenitis and sepsis in [2124-6-4], recently discharged from [Hospital1 18] on [9-8] s/p chole and cholangitis treated with antibiotics -- now presenting with complaints of lower abdominal pain. The patient reports feeling well until 2-3 days ago, when he started having lower abdominal and suprapubic pain. Rates the pain as a [5-14] in the suprapubic area. He also believes he is retaining urine. Associated symptoms include chills, + urgency and dysuria. He also endorses hematuria with small clots in his foley bag -- but no stream of blood in the urine. He had a foley placed during his last hospitalization and he was suppose to see Urology as an outpatient for possible removal of foley today. He was also completing a course of antibiotics from his last hospitalization -- his last dose of clindamycin was today. Also reports loose stools. The patient denies fever, nausea, vomitting, SOB or cough. In the ED, initial vitals were 100.1 114 124/56 18 98%. Abdominal exam showed suprapubic tenderness, but no CVA tenderness. Labs showed WBC count of 21.8K with 96% neutrophils. Lactate was 1.5. LFTs showed alkaline phosphatase of 207, ALT of 42. Chest X-ray showed a left lower lobe consolidation. Urinalysis showed >182 WBCs, >182 RBCs, large leukocytes, moderate blood, 10 ketones, and 30 protein. Patient was started on vancomycin 1 gram IV x 1, ciprofloxacin 400 mg IV x 1. Vitals upon transfer were 95 105/51 16 96%. On the floor, vs were: T 100.3 P 100 BP 119/54 R 20 O2 sat 99RA. The patient endorsed ongoing abdominal pain. He rated the pain as a [2122-1-10], worse with movement. He expressed interest in having the foley catheter removed and trying to void on his own. He denied shortness of breath, difficulty breathing, wheezing, cough, or fevers. Reported intermittent sweating and chills. Past Medical History: - Coronary artery disease s/p CABG [3-/2119] (LIMA to the LAD and - separate SVGs to the PDA and an OM) - HLD - HTN - BPH - Emphysema per ct scan - TB many years ago, treated for 2 years - s/p cholecytectomy and cholangitis Social History: Prior 20 pack year smoker, quit 20 years ago. Retired CEO of auto parts business in [Country 651]. Lives with his wife and is independent with ADLs. Rare alcohol, denies illicits. Family History: Mother had hypertension and history of cancer. Physical Exam: PHYSICAL EXAM AT ADMISSION: Vitals: T: 100.3 BP: 119/54 P: 100 R:20 O2:99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, multiple brown macules on forhead and scalp Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally with the exception of decreased breath sound in left lower quadrant, no wheezes, rales, ronchi, no egophony CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, bowel sounds present, no rebound tenderness or guarding, no organomegaly, + tenderness to moderate palpation in suprapubic area and bilateral lower abdominal quadrants, +distended bladder Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema PHYSICAL EXAM AT DISCHARGE: Vitals: Tm 99.1 Tc 97.8 112/60 67 20 94-98%RA I/O: 8hr: [Telephone/Fax (1) 46127] 24hr: 2600/3550+BMx1 General: Alert, oriented, no acute distress HEENT: NC/AT, Sclera anicteric, MMM, Neck: supple, JVP not elevated, no LAD CV: RRR, II/VI SEM at LUSB, nl s1 s2 Lungs: Bilateral crackles [12-7] way up, good air movement Abdomen: S, NT/ND, BS+, no suprapubic tenderness GU: No Foley Ext: WWP no c/c/e Neuro: Alert, oriented, appropriate, non-focal Pertinent Results: Labs at admission: [2124-9-14] 09:03AM BLOOD WBC-21.8# RBC-4.22 Hgb-12.9* Hct-37.6* MCV-89 MCH-30.5 MCHC-34.2 RDW-14.9 Plt Ct-381# [2124-9-14] 09:03AM BLOOD Neuts-92.6* Lymphs-2.9* Monos-4.0 Eos-0.3 Baso-0.1 [2124-9-14] 09:03AM BLOOD Glucose-103* UreaN-13 Creat-1.0 Na-136 K-3.5 Cl-99 HCO3-25 AnGap-16 [2124-9-14] 09:03AM BLOOD ALT-42* AST-28 AlkPhos-207* TotBili-1.2 [2124-9-14] 09:03AM BLOOD ALT-42* AST-28 AlkPhos-207* TotBili-1.2 [2124-9-14] 09:23AM BLOOD Lactate-1.6 Discharge Labs [2124-9-19] 07:05AM BLOOD WBC-4.4 RBC-3.61* Hgb-11.0* Hct-32.4* MCV-90 MCH-30.5 MCHC-34.0 RDW-14.8 Plt Ct-305 [2124-9-19] 07:05AM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-139 K-3.9 Cl-103 HCO3-27 AnGap-13 [2124-9-19] 07:05AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.9 Imaging: CXR [2124-9-14]: IMPRESSION: Left lower lobe opacity concerning for pneumonia. Liver/Gallblader U/S (Preliminary Report) [2124-9-14]: IMPRESSION: 1. Patient is status post cholecystectomy. No fluid collections identified. No intrahepatic or extrahepatic biliary duct dilatation. 2. Heterogeneous echogenic liver consistent with fatty infiltration however other forms of more severe liver disease are not excluded. RENAL ULTRASOUND [2124-9-15] IMPRESSION: Simple renal cyst as on previous studies without evidence of renal abscess. Microbiology: [2124-9-14] Urine culture [2124-9-14] 8:16 am URINE FINAL REPORT [2124-9-16] URINE CULTURE (Final [2124-9-16]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Urine culture [2124-9-15] URINE CULTURE (Final [2124-9-17]): GRAM NEGATIVE ROD(S). ~5000/ML. Blood culture [2124-9-14]- NGTD [2124-9-15]- NGTD CDiff [2124-9-15]- NEGATIVE Blood culture [2124-9-16]: Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Anaerobic Bottle Gram Stain (Final [2124-9-16]): Reported to and read back by DR. [Last Name (STitle) 46128], SHINWA @ 1010PM [2124-9-16]. GRAM NEGATIVE ROD(S). Bld culture [2124-9-17], [2124-9-18], [2124-9-19] NGTD Urine studies: [2124-9-17] 06:53AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.004 [2124-9-17] 06:53AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [2124-9-17] 06:53AM URINE RBC-5* WBC-5 Bacteri-FEW Yeast-NONE Epi-0 [2124-9-14] 08:16AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.015 [2124-9-14] 08:16AM URINE Blood-MOD Nitrite-POS Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG [2124-9-14] 08:16AM URINE RBC->182* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 Brief Hospital Course: 79 year old male with significant PMH for hypertension, hyperlipidemia, CAD s/p CABG ([2118]) with perc chole tube for cholecystitis/duodenitis and sepsis in [2124-6-4], recently discharged from [Hospital1 18] on [9-8] s/p chole admitted with abdominal pain and found to have UTI and became septic with transfer to the ICU which stablized with IV hydration and found to have Ecoli bacteremia who was stablized and requiring IV cefepime at the time of discharge. ACTIVE ISSUES: # Pneumonia: At admission in the ED the patient presented with signs of infection including leukocytosis, low and grade temperature. CXR in ED was suggestive of left lower lobe consolidation. In the ED he was empirically treated with vancomycin, cefepime and cipro. Given that he was recently hospitalized and discharge he was treated for HCAP with Vanc/Cefepime. He will complete a 7 day HCAP treatment course on [9-20] (at which time he will stop his Vancomycin). While in the ICU he had a new oxygen requirement, hwoever this weaned off with IV abx and autodiuresis. He had no oxygen requirement at the time of discharge, and his lungs were clear. # UTI: At presentation in the ED the patient reported lower abdominal pain, urgency and dysuria. His urine in the ED was remarkable for nitrites, +180 RBCs and +180 WBCs. He was given vancomycin, cefepime and cipro in the ED. His greatest risk for developing UTI was that he had a foley placed during his last hospitalization. Urine grew E. Coli with multiple resistance but was sensitive to cefepime. Blood cultures came back positive for Ecoli that was also sensitive to cefepime and therefore likely urosepticiemia. #Urinary retention- patient was admitted with indwelling foley from his recent sugery leading to urinary retention. This was removed during his hospitalization and he was voiding without difficulty at the time of discharge. -Doxazosin was discontinued as he dropped his blood pressure while on this and was no longer having urinary retention at the time of discharge. #Ecoli Bacteremia-patient had blood cultures that grew EColi with similar sensitivities to -will need to finish Cefepime on [2124-9-23] for a 7 day course from day 1 of negative cultures on [2124-9-17] -blood cutlures from [9-17], 15, and 16 were NGTD at the time of discharge and final cultures will be monitored by his inpatient team and communicated with his PCP if they become positive # h/o cholangitis s/p chole: At admission the patient reported abdominal pain. Patient with recent cholecystitis requiring perc chole tube in [2124-6-4]. Did not have a cholecystectomy at that time due to inflammation but is now s/p choleocystectomy after having surgery earlier this month. In the ED he had RUQ U/S which was notable for no ongoing evidence of infection or fluid connection. In the ED his abdominal pain was treated with oxycodone. He was evaluted by surgery in the ED who found no acute surgical issues. Serial abdominal exams were unremarkable. CHRONIC ISSUES: # CAD s/p CABG: CAGB with LIMA to LAD and separate SVGs to PDA in [2118]. Denied symptoms of chest pain, chest pressure or fatigue at admission. He was dontinued home medications including his asa and statin. His antihypertensives (metoprolol and lisiopril) were held at admission as he was hypotensive to normotensive in the ED. His metoprolol was restarted on [2124-9-19] and switched from succinate to tartrate (12.5mg [Hospital1 ]). His Lisinopril was still held and will need to be restarted for cardioprotective effects once it is clear that he is tolerating his metoprolol -restart lisinopril 2.5 mg po qday if tolerating betablocker -consider switching metop tartrate back to succinate when discharged back home for convenience -continued aspirin and atorvastatin # Emphysema: Stable. H/o possible obstructive ventalitory defect on PFTs from [2117] and CT scan with evidence of emphysema. He was continued on tiotropium during this admission. # Hypertension: see above changes made -stopped doxazosin -switched -held lisinopril # Hyperlipidemia: Stable. Continued on home atorvastatin. # GERD: Stable. Continued on home omeprazole. # Restless leg: Stable. Continued on home ropinirole. TRANSITIONAL ISSUES: -continue cefepime IV through [9-23] -continue vancomycin IV through [9-20] -restart lisinopril 2.5mg po qday once blood pressure stable on metoprolol -Labs pending at the time of discharge (blood cultures from [9-17], [9-18], [9-19])- will be followed-up by inpatient team -> final results showed no growth Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver[Name (NI) 581]. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Doxazosin 4 mg PO HS 4. Omeprazole 40 mg PO DAILY Please take 30 minutes prior to meal 5. Ropinirole 1 mg PO TID 6. Acetaminophen 650 mg PO Q6H:PRN pain Please do not exceed 2g/24hrs 7. Docusate Sodium 100 mg PO BID 8. OxycoDONE (Immediate Release) 2.5-5.0 mg PO Q4H:PRN pain Please monitor and hold for sedation, RR<12 or AMS 9. Senna 1 TAB PO BID:PRN constipation 10. Tiotropium Bromide 1 CAP IH DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Lisinopril 2.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain Please do not exceed 2g/24hrs 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Omeprazole 40 mg PO DAILY Please take 30 minutes prior to meal 6. Ropinirole 1 mg PO TID 7. Senna 1 TAB PO BID:PRN constipation 8. Tiotropium Bromide 1 CAP IH DAILY 9. Vancomycin 1500 mg IV Q 12H To end on [9-20] 10. CefePIME 1 g IV Q12H to end on [9-23] 11. Metoprolol Tartrate 12.5 mg PO BID 12. Phenazopyridine 100 mg PO TID Duration: 3 Days Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - [Location (un) ] Discharge Diagnosis: EColi Bacteremia Urinary Tract infection and urosepsis Hospital-associated Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you at the [Hospital1 18]! You were admitted to the hospital because of abdominal pain. Here, we found that you had a urinary tract infection and a pneumonia. The bacteria from the urine was also found in your blood. We are treating you with IV antibiotics which you will need to continue through [2124-9-23] and you will receive these at rehab. Please keep all follow up appointments. Please take all medications as prescribed. Followup Instructions: Provider: [Name10 (NameIs) ] CARE CLINIC Phone:[Telephone/Fax (1) 600] Date/Time:[2124-9-27] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2385], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2124-12-19] 11:00	[ "600.01", "V45.81", "V15.82", "995.92", "272.4", "788.29", "530.81", "492.8", "401.9", "599.0", "486", "414.00", "038.9", "785.52", "599.71", "333.94", "276.1" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	14184, 14263	8323, 8802	317, 324	14392, 14392	4136, 6632	15071, 15337	2820, 2869		13643, 14161		14284, 14371		12954, 13620			14543, 15048								2884, 3635				6676, 8300									3649, 4117		12599, 12928							248, 279		8818, 11344												352, 2349								14407, 14519			11361, 12578		2371, 2601	2617, 2804
62,242	142,995	37685	Discharge summary	report	Admission Date: [2186-10-11] Discharge Date: [2186-10-13] Date of Birth: [2112-5-21] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Word finding difficulty, ? seizure Major Surgical or Invasive Procedure: Intubation History of Present Illness: Ms. [Known lastname 84480] is a 74 year old right-handed woman who presented today following an episode of confusion and incoherent speech at work. According to ED documentation, EMS was called a 9am and found the patient with difficulty speaking and possible diminished right sided movement. She was hypertensive 220/100 by and in atrial fibrillation with rapid ventricular response. Enroute to BIMDC she experienced a GTC seizure which lasted for [Known lastname 13835] 2-3 min. On arrival to the ED, a code stroke was called (although ED physicians did not identify any asymmetry on exam). She was intubated for airway protection and paralysed for CT head. Her CT head showed no hemorrhage but an area of L-occipital encephalomalacia with abnormal vascular structures suggestive of AVM. CTA did not reveal a vessel obstruction nor did perfusion scan show any deficit. Because of her paralysis, no formal neurologic evaluation could be performed. She was given a dilantin load and started on IV metoprolol for rate control. She was admitted to the ICU for monitoring. Currently, the patient is intubated and on propofol however she is awake and able to comply with exam. On limited review of systems, she denies any recent illness, changes in vision, sudden weakness or problems speaking. She denies pain or headache. She does not take any medications and denies any history of an irregular heart beat. Additional information from her family endorses this history- the patient has not had any complaints regarding her health. Past Medical History: No past medical history- the patient does not like doctors and [Name5 (PTitle) ] not been to a doctor [First Name (Titles) ] [Last Name (Titles) 13835] 40 years. Social History: Married. Has 3 grown daughters. She works as a school administrator. Family states she is very active at home, independent of ADLs. She has no history of tobacco, alcohol and drug abuse. Family History: Mother with stroke. Physical Exam: VITAL SIGNS: T=97.6 BP= 119/70 HR=101 PSV: [11-13] FiO2 40% RR 13 98% O2 PHYSICAL EXAM GENERAL: NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. MMM. Neck Supple, No LAD, No thyromegaly. No nuchal rigidity CARDIAC: Irregular rhythm. No murmurs, rubs or [Last Name (un) 549]. LUNGS: CTAB, good air movement bilaterally. ABDOMEN: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. Neurologic: Mental Status: Answers yes no questions appropriately. Able to follow both midline and appendicular commands. Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 3mm and [Last Name (un) 19912]. III, IV, VI: EOMI without nystagmus. Normal saccades. Difficulty maintaining attention to conduct VF testing. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. + gag reflex Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri IP Quad Ham TA L 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 Sensory: No deficits to light touch, vibratory sense. No extinction to DSS. DTRs: [Name2 (NI) ] with [Hospital1 ] Tri [Last Name (un) 1035] Pat Ach L 2+ 2+ 2+ 2+ 2+ R 2+ 2+ 2+ 2+ 2+ Plantar response was flexor bilaterally. Coordination: Not tested as pt was attempting to pull out ET tube Gait: Not tested given intubation. Pertinent Results: ADMISSION LABS: [2186-10-11] 09:35AM PT-13.0 PTT-18.1* INR(PT)-1.1 PLT COUNT-268 WBC-10.5 RBC-4.73 HGB-12.8 HCT-42.0 MCV-89 MCH-26.9* MCHC-30.3* RDW-12.6 TSH-2.6 ALBUMIN-4.7 cTropnT-<0.01 ALT(SGPT)-20 AST(SGOT)-17 LD(LDH)-173 CK(CPK)-59 ALK PHOS-70 TOT BILI-0.8 UREA N-16 CREAT-0.7 GLUCOSE-211* NA+-144 K+-3.4* CL--104 TCO2-18* [2186-10-11] 10:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.038* ECG Study Date of [2186-10-11] 9:50:52 AM Atrial fibrillation with rapid ventricular response and occasional aberrant conduction. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 149 0 88 318/473 0 70 -65 CT BRAIN PERFUSION Study Date of [2186-10-11] 9:44 AM IMPRESSION: 1. No evidence for acute ischemic event. No hemorrhage. 2. Endotracheal tube terminating within right bronchus. 3. Abnormal vascular structures in left occipital lobe likely represent AVM and associated encephalomalacia. CHEST (PORTABLE AP) Study Date of [2186-10-11] 10:17 AM IMPRESSION: Endotracheal tube tip just above the carina. Recommend pulling tube back [Date Range 13835] 2 cm. Hyperinflated ET tube balloon places mass effect on the trachea. Bibasilar atelectasis. **Right upper lobe 7 mm nodule. Recommend chest CT chest for further evaluation. MR HEAD W & W/O CONTRAST Study Date of [2186-10-11] 2:16 PM IMPRESSION: 1. No acute hemorrhage or infarction. 2. Left occipital AV malformation with evidence of shunt could represent AV fistula or possibly AVM. Conventional angiography can help for further assessment if clinically indicated. 3. No evidence for enhancing masses. Portable TTE (Complete) Done [2186-10-12] at 8:30:00 AM Conclusions The left atrium and right atrium are normal in cavity size. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels 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. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular systolic function. No significant valvular abnormalities. EEG ([2186-10-12]) FINDINGS: ABNORMALITY #1: There was intermittent focal slowing in the delta range seen in the left temporal areas. ABNORMALITY #2: There were several bursts of generalized slowing recorded throughout the tracing. BACKGROUND: A Hz predominant biposterior rhythm could sometimes be seen although most of the recording was obscured by excessive beta activity in a broad distribution. SLEEP: There were no normal sleep patterns seen in this recording. HYPERVENTILATION: Could not be performed. PHOTIC STIMULATION: Could not be performed. CARDIAC MONITOR: Showed an irregular rhythm. IMPRESSION: This is an abnormal routine extended EEG recording due to the bursts of generalized slowing suggestive of abnormality of central structures as well as due to left temporal focal slowing suggestive of a subcortical dysfunction in that area. There were no epileptiform features seen in this recording. Brief Hospital Course: Mrs. [Known lastname 84480] is a 74 year-old woman with no documented past medical history who was admitted with sudden onset of confusion, apparent word finding difficulties/speech impairment and possible right sided weakness/diminished movement. 1. Confusion and word finding difficulties. CT of the head was without evidence of hemorrhage but there were changes suggestive of a possible left occipital AVM. MRI showed no signs of ischemia, but again noted a L occipital AV malformation. She had an EEG which showed a focus of left temporal slowing. It was suspected that her episode was secondary to a seizure. She was initially started on Dilantin, but as she was also found to have atrial fibrillation and was started on Coumadin, she was switched to Keppra to minimize drug interaction. She should continue on Keppra, and should not drive for the next 6 months. 2. Atrial fibrillation. While hospitalized she was noted to be in atrial fibrillation. She had a TTE, which showed no sign of thrombus. She was started on metoprolol for rate control, and Coumadin, with a goal INR of 2.0-2.5, levels will be followed by her PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 1407*]. 3. Lung nodule. She had a chest x-ray, which incidentally showed a 7mm nodule in the right upper lobe. She does have a significant smoking history, and should have a CT scan of the chest to further evaluate this as an outpatient. Medications on Admission: NONE Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s)* Refills:1 2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Outpatient Lab Work Please check INR on [10-17] and have FAXed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1407] at [Telephone/Fax (1) 18702] 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Seizure Secondary: Atrial fibrillation Discharge Condition: Symmetric hyperreflexia with decreased position and vibration sense bilaterally. Discharge Instructions: You were seen following an episode of speech difficulty, followed by a seizure. You had a CT and MRI which showed no sign of a stroke, but did show a small AV malformation. You were started on Keppra to prevent further seizures. You were also found to have an irregular heart rate. Because of this you were started on Coumadin to thin your blood. You will need to continue on Coumadin with a goal INR of 2.0-2.5. You should have your INR checked on [10-17], and Dr. [Last Name (STitle) 1407] will adjust your dosage appropriately. If you notice new difficulty with speech, increased seizure activity, headache, or any other concerning symptoms, please return to the nearest ED for further evaluation. Followup Instructions: Please follow-up with your Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1407] on Tuesday [10-17], and have your blood drawn to check an INR at that time. You have the following Neurology follow-up appointment: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2186-11-14] 1:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "427.31", "796.2", "434.90", "V58.61", "747.81", "780.39", "518.89" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9730, 9736	7658, 9101	352, 364	9828, 9911	4044, 4044	10675, 10889	2362, 2384		9156, 9707		9757, 9807		9127, 9133			9935, 10652								2399, 2972																						278, 314													10912, 11163	392, 1939	3099, 4025				4060, 7635			2987, 3083					1961, 2137	2153, 2346
41,702	152,728	44724	Discharge summary	report	Admission Date: [2152-9-20] Discharge Date: [2152-9-27] Date of Birth: [2112-6-12] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1253] Chief Complaint: Abscesses, DKA Major Surgical or Invasive Procedure: 1. Incision and drainage of abdominal and perineal abscesses. 2. Operative debridement of abdominal and perineal abscesses. History of Present Illness: 40F with hx of IDDM with 2 prior episodes of DKA, history of skin abscesses, and depression presenting with abdominal and perineal skin abscesses and found to be in DKA. Per the pt, she developed an abdominal and a few perirectal abscessses about 2 weeks ago. She didn't do anything to them but noted that they started draining on their own. However, they became increasingly painful and so the pt presented to the ED today to have them treated. . Of note, the pt also states that she has been increasingly depressed lately about her finances and stress from her children. As a result she stopped taking her insulin a week ago, not in an effort to hurt herself but because she was in too much pain to take care of herself. She has had similar circumstances in the past which have resulted in admissions for DKA. . In the ED the pt was found 99.2 126 114/70 16 100%. Two large abscesses were identified, one in the abdomen and one in the perianal area and both were I&Ded and packed. Because of her previous admissions for poorly controlled diabetes, electrolytes were checked and the pt was found to have a gap of 26, with a glucose in the 400s, and ketonuria. She was given a 10u insulin bolus, started on an insulin gtt of 7, given NS with 40meq of K and a dose of vanco for abscesses. . On the floor,the pt was afebrile 114/73 102 99%RA. She was tearful, explaining that she was depressed, but not suicidal, and had forgone her insulin for at least the past week. She also endorsed multiple abscesses but denied fevers, chill, nightsweats. . 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 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: DM2 w/moderately severe B nonproliferative diabetic retinopathy HTN Depression w/SI, psychiatric hospital admission h/o EtOH abuse- never experienced withdrawal sx Social History: Drugs: Smokes marijuana occasionally. Tobacco: Currently smoking 1 cigarette daily. Alcohol: Drinks sometime, last drink 1 week ago Other: Lives with two of her four children, has family in the area. Family History: Mother with DM2, HTN. Physical Exam: Vitals: afebrile 114/73 102 99%RA General: Alert, oriented, tearful HEENT: very poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: large central abdominal abscess with packing, 1x2cm perianal abscess with packing, two other areas of induration in the perianal region, one with purulent drainage. Pertinent Results: Admission labs: [2152-9-19] 10:45PM BLOOD WBC-13.6# RBC-4.40# Hgb-13.2# Hct-38.0# MCV-87# MCH-30.0 MCHC-34.7 RDW-14.5 Plt Ct-435# [2152-9-19] 10:45PM BLOOD Neuts-72 Bands-0 Lymphs-14* Monos-9 Eos-1 Baso-0 Atyps-0 Metas-4* Myelos-0 [2152-9-19] 10:45PM BLOOD Glucose-419* UreaN-9 Creat-0.6 Na-134 K-3.6 Cl-96 HCO3-12* AnGap-30* [2152-9-20] 03:58AM BLOOD Calcium-8.7 Phos-1.8# Mg-1.3 [2152-9-20] 12:30AM URINE Color-Straw Appear-Hazy Sp [Last Name (un) ]-1.017 [2152-9-20] 12:30AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2152-9-20] 12:30AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-6 [2152-9-23] 07:23AM BLOOD %HbA1c-12.7* eAG-318* . Discharge labs: [2152-9-25] 05:40AM BLOOD WBC-6.4 RBC-3.44* Hgb-10.5* Hct-30.3* MCV-88 MCH-30.6 MCHC-34.8 RDW-14.8 Plt Ct-353 [2152-9-27] 06:15AM BLOOD Glucose-131* UreaN-8 Creat-1.6* Na-143 K-4.8 Cl-113* HCO3-23 AnGap-12 [2152-9-27] 06:15AM BLOOD Calcium-8.3* Phos-4.9* Mg-1.8 . Microbiology: . Blood cultures x2 [2152-9-20]: No growth. . Abdominal wound swab [2152-9-20]: BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . Perineal wound swab [2152-9-20]: STAPH AUREUS COAG +. HEAVY GROWTH. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. HEAVY GROWTH. _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S . Imaging: . CXR (portable AP) [2152-9-20]: No acute cardiopulmonary process. . Renal ultrasound [2152-9-26]: 1. Bilateral large echogenic kidneys. No hydronephrosis. 2. Patent renal veins. Brief Hospital Course: 40F with hx of IDDM with 2 prior episodes of DKA, history of skin abscesses, and depression who presents with multiple skin abscesses and DKA. She was initially admitted to the MICU for an insulin gtt. With resolutin of DKA, she was transitioned to subcutaneous insulin. Surgery was consulted for the patient's abscesses and performed operative incision, drainage, and debridement. With this treatment, the patient's blood sugars stabilized, and she was discharged on subcutaneous insulin and oral antibiotics. . # Diabetes mellitus, complicated by ketoacidosis: The patient initially presented in DKA with anion gap of 26, glucose of 419 and ketonuria. The etiology was thought to be medication non-adherence (the pt has not been using her insulin for at least a week), exacerbated by infection. She was treated with an insulin gtt until her ketoacidosis resolved, at which point, she was transitioned to glargine, with an insulin sliding scale. This was subsequently changed to 75/25, and then NPH. With titration, the patient's blood sugars normalized. She was discharge on NPH, 8 units before breakfast, and 4 units before dinner. . # Skin abscesses: The patient presented with a 2-week history of abdominal and perianal abscesses. She underwent incision and drainage in the emergency department. Surgery was subsequently consulted, and performed operative debridement on [9-20] and again on [9-21]. The patient was initially treated with vancomycin. Zosyn was added on [9-20]. On [9-22], zosyn was switched to Ceftriaxone/Flagyl and vancomycin was continued. Cultures grew MSSA, Streptococcus anginosus, beta Streptococcus Group B. ID was consulted on [9-24], and antibiotics were narrowed to cephalexin and levofloxacin, with a plan to treat for 10 days. Will complete antibiotics course [2152-10-3]. Wound care recs are Wet to dry packing changed once a day or as needed. The patient was given a small prescription of oxycodone to use during dressing changes. She was warned not to drive or participate in other hazardous activities while on oxycodone. General surgery follow-up was arranged. . # Depression: The patient complained of depression. Social work and psychiatry were consulted. Psychiatry felt that psych admission was not required. Paxil was increased to 20 mg daily per psych recs. Social work instructed the patient regarding how to set up psychiatric follow-up at [Hospital1 ]. . # Acute kidney injury: The patient was admitted with a creatinine of 0.6, from baseline 0.4 to 0.6. Shortly after admission, the patient's creatinine began to rise steadily, peaking at 1.5-1.6 at the time of discharge. Ins and outs were poorly recorded, but the patient did not seem to be oliguric. Urine sediment was bland. Renal ultrasound did not identify any abnormalities that would explain acute kidney injury. The patient was treated with IV fluids, without improvement in her creatinine. Nephrology was consulted on [2152-9-25], and they felt that the patient was prerenal. However, when the patient failed to improve with IV fluids, a diagnosis of resolving ATN was put forth. The patient will need to have her creatinine checked on [2152-9-29] to be sure that it is improving or at least stable. The patient will follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [Hospital1 ] on [2152-10-2]. The inpatient team contact[Name (NI) ] Dr. [First Name (STitle) ], who agreed to order and follow up on the [2152-9-29] labs. Nephrology follow-up was arranged. Medications on Admission: paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. insulin lispro protam & lispro 100 unit/mL (75-25) Insulin Pen Sig: as dir units Subcutaneous asdir: 28 units at breakfast, 30 units at dinner. Discharge Medications: 1. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig: as directed Subcutaneous as directed: Take 8 units in the morning and 4 units before dinner. Disp:3 pens Refills:2 3. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 4. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 6 days. Disp:18 Capsule(s) Refills:0 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for dressing changes: Do not drive or participate in other hazardous activities while on oxycodone. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: 1. Diabetic mellitus, complicated by ketoacidosis and hypoglycemia. 2. Multiple skin abscesses. 3. Acute kidney injury. 4. Depression. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because you had several abscesses on your skin. These infections, in combination with you having not taken insulin in several days, caused diabetic ketoacidosis (DKA), a dangerous condition that required you to be in the intensive care unit. Your DKA was treated with insulin and fluids. . Your abscesses were opened and drained in the emergency department. You were also seen by the surgery team, who performed two operative procedures to remove infected or devitalized tissue. You were started on 2 antibiotics (cephalexin and levofloxacin), which you will need to continue until [2152-10-3]. You will have a visiting nurse to help you manage your wounds. We have also arranged for you to follow up with a surgeon. . You had a decrease in your kidney function, for which you were seen by the kidney team. Your decreased kidney function was thought to be related to kidney injury that occurred when you had low blood pressures. You need to have your kidney function checked this Friday, [9-29]. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from [Hospital1 ] will follow up on these labs. You can get this done at any [Hospital1 18] lab. We have also arranged for you to see a kidney doctor in follow-up. . Your insulin was adjusted due to low blood sugars. You are on a new type of insulin called NPH, with a dose of 8 units in the morning and 4 units before dinner. It is vitally important that you take your insulin as prescribed. Diabetic ketoacidosis is a very serious condition that can be fatal. . You were seen by a social work and psychiatrist, who increased your dose of Paxil, and also provided you with information regarding getting a psychiatrist and social worker at [Name (NI) ]. . The following changes were made to your medications: CHANGE insulin to NPH 8 units in the morning and 4 units before dinner. This will be instead of your 75/25 insulin. START levofloxacin and continue this for 6 days. START cephalexin and continue for 6 days. INCREASE paroxetine (Paxil) to 20 mg daily. START oxycodone to use as needed with dressing changes. Be aware that this is a sedating medication, and that you should not drive or participate in other activities after using oxycodone. Also, do not combine oxycodone with alcohol or other sedating medications. . Please follow up as indicated below. Followup Instructions: Dr. [First Name (STitle) ] has arranged for you to get your kidney function checked at [Hospital1 ] this Friday, [9-29], and will follow up on this result with you. . Name: [Last Name (LF) ], [Name8 (MD) ] MD Specialty: INTERNAL MEDICINE Location: [Hospital 3578] COMMUNITY HEALTH CENTER Address: [Hospital1 3579], [Location (un) ],[Numeric Identifier 3580] Phone: [Telephone/Fax (1) 3581] Appointment: MONDAY [10-2] AT 2:45PM Please speak with your Dr [Last Name (STitle) ] the need for a psychiatry follow up within 2 weeks. . Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2152-10-10] at 1:30 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: RENAL When: WEDNESDAY [2152-10-11] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 21927], MD [Telephone/Fax (1) 87700] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "250.82", "566", "682.2", "041.09", "250.52", "362.06", "458.9", "275.3", "296.32", "V15.81", "305.00", "787.03", "584.5", "041.11", "250.12", "401.9", "285.9", "041.02", "305.1" ]	icd9cm	[ [ [] ] ]	[ "86.04", "83.39" ]	icd9pcs	[ [ [] ] ]	10541, 10598	5834, 9396	320, 446	10786, 10786	3616, 3616	13335, 14575	2908, 2931		9794, 10518		10619, 10765		9422, 9771			10937, 13312		4369, 5811						2946, 3597																		2038, 2486				265, 282														474, 2019					3632, 4353			10801, 10913					2508, 2674	2690, 2892
62,380	153,520	54870	Discharge summary	report	Admission Date: [2174-9-20] Discharge Date: [2174-9-27] Date of Birth: [2098-7-10] Sex: F Service: MEDICINE Allergies: Bactrim / diltiazem / hydrochlorothiazide Attending:[First Name3 (LF) 4095] Chief Complaint: abdominal pain, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 76-year-old female with CAD, paroxsymal atrial fibrillation, DM, COPD of home 02 and chronic prednisone, cor pulmonale, AAA repair transferred from OSH on [2174-9-20] with abdominal pain and hypotension. She was admitted to the vascular service for concern of rectus sheath hematoma. Surgery did not feel that AAA graft was infected. CTA showed retroperitoneal bleed without active extravasation (Hct was 33 on admission and nadired to 24). Hct now stable after 1unit PRBC transfusion at 30. She was subsequently found to have UTI and presumed urosepsis. Urine Cx grew proteus, blood cultures show NGTD. She has been on meropenem (ID following, plan for 7 day total course). She was also given stress dose steroids given chronic prednisone use. She also had hypoxia for which pulmonary was consulted. They thought this was due to pulmonary edema from initial aggressive IV fluid hydration. She received 40mg iv lasix this morning. Of note, she was also seen by cardiology on admission for ST depressions seen on ECG with slightly elevated troponin. They recommended medical management for likely demand ischemia She has had atrial fibrillation with difficult to control HRs. This morning, she had afib with HR 140s with concomitant SBP in the 80s transiently. Hypotension resolved when HR returned to 90s. Of note, she also has area of erythema on left elbow concerning for cellulitis; she has been on vancomycin with improvement. Review of systems: (+) Per HPI; reports increased cough, SOB, palpitations (-) Denies fever, chills, chest pain, abdominal pain, N/V, diarrhea Past Medical History: 1. CAD, details unknown 2. Hypertension 3. Hyperlipidemia 4. Type 2 diabetes mellitus 5. Paroxysmal atrial fibrillation, RBBB 6. Chronic kidney disease, baseline Cr ~2.2 mg/dL 7. Infrarenal AAA (5.4cm) s/p repair on [2174-7-22] 8. COPD on chronic steroids and home O2 9. Cor pulmonale 10. Asthma 11. Fibromyalgia 12. Polymyalgia rheumatica 13. h/o GI bleeding 14. h/o C. difficile infection 15. h/o MRSA colonization 16. h/o diverticulitis s/p left colectomy with loop ileostomy Social History: Recently in rehab post-discharge from LGH for UTI. Previously lived with her son in [Name (NI) 7661]. History of smoking and drinking alcohol; quit 15 years ago. Denies recreational drug use Family History: Non-contributory Physical Exam: On transfer to MICU: General: Alert, oriented x ~2 (knows self and hospital), no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: faint wheezes diffusely, rhonchi at bases L>R GU: foley Ext: bruising all over skin, diffuse edema Neuro: no focal neuro deficits Discharge: VS 98.3, 122/42, 99, 20, 100% 2L NC GEN Alert, oriented to person, place and year, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM course b/l rhonchi and poor air movement CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT RUE with large ecchymosis and decreased swelling, no longer weeping, edema 1+ b/l lower extremity NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Pertinent Results: On admission: [2174-9-20] 11:12AM BLOOD WBC-21.4# RBC-3.56 Hgb-10.2* Hct-33.3* MCV-94 MCH-28.7 MCHC-30.7* RDW-18.4* Plt Ct-263 [2174-9-20] 11:12AM BLOOD Neuts-83* Bands-0 Lymphs-6* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-9* Myelos-1* [2174-9-20] 11:12AM BLOOD PT-16.2* PTT-29.4 INR(PT)-1.5* [2174-9-20] 11:12AM BLOOD Glucose-98 UreaN-48* Creat-1.9* Na-143 K-4.1 Cl-110* HCO3-19* AnGap-18 [2174-9-20] 11:12AM BLOOD ALT-14 AST-17 AlkPhos-79 TotBili-0.2 [2174-9-21] 03:37AM BLOOD CK(CPK)-59 [2174-9-20] 11:12AM BLOOD Lipase-12 [2174-9-20] 11:12AM BLOOD cTropnT-0.12* [2174-9-20] 11:12AM BLOOD Albumin-2.6* [2174-9-20] 08:19PM BLOOD Calcium-7.5* Phos-4.0 Mg-1.3* [2174-9-21] 03:37AM BLOOD Amkacin-16.0* [2174-9-20] 04:31PM BLOOD Type-ART pO2-111* pCO2-42 pH-7.25* calTCO2-19* Base XS--8 [2174-9-20] 11:24AM BLOOD Lactate-2.5* [2174-9-20] 11:24AM BLOOD Hgb-8.7* calcHCT-26 [2174-9-20] 08:26PM BLOOD freeCa-1.15 Discharge: [2174-9-27] 06:10AM BLOOD WBC-12.4* RBC-3.67* Hgb-10.4* Hct-33.5* MCV-91 MCH-28.3 MCHC-31.0 RDW-18.5* Plt Ct-273 [2174-9-27] 06:10AM BLOOD Glucose-68* UreaN-34* Creat-1.7* Na-147* K-4.1 Cl-105 HCO3-33* AnGap-13 [2174-9-27] 06:10AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7 [2174-9-27] 06:10AM BLOOD Vanco-31.1* Urine: [2174-9-20] 11:50AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.016 [2174-9-20] 11:50AM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [2174-9-20] 11:50AM URINE RBC-13* WBC-93* Bacteri-MANY Yeast-RARE Epi-<1 [2174-9-20] 11:50AM URINE CastHy-8* [2174-9-20] 11:50AM URINE AmorphX-RARE CaOxalX-OCC [2174-9-20] 11:50AM URINE Mucous-RARE Microbiology: Time Taken Not Noted Log-In Date/Time: [2174-9-20] 1:21 pm URINE TAKEN FROM 65201R. FINAL REPORT [2174-9-23] URINE CULTURE (Final [2174-9-23]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 0.5 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- <=1 S [2174-9-20] 11:50 am BLOOD CULTURE FINAL REPORT [2174-9-26] Blood Culture, Routine (Final [2174-9-26]): NO GROWTH. [2174-9-24] 4:25 am BLOOD CULTURE Source: Line-central. Blood Culture, Routine (Pending): CXR [2174-9-23]: 1. New right-sided PICC line is in adequate position. There is no complication. 2. New pulmonary edema is mild. 3. Left lower lung collapse with moderate pleural effusion is stable. CTA abdomen/pelvis [2174-9-20]: 1. Left lower abdominal rectus sheath hematoma with a hematocrit level is grossly similar to this morning's exam at 8:30 a.m., and perhaps slightly larger. There is no active arterial extravasation. 2. Periaortic soft tissue density is attributable to postoperative fibrosis, as demonstrated by delayed mild enhancement. No evidence of contrast extravasation. 3. Small left lower lobe atelectasis and effusion. TTE [2174-9-21]: IMPRESSION: Small circumferential pericardial effusion with no echocardiographic evidence of tamponade. Mild to moderate regional left vetnricular systolic dysfunction c/w CAD. Right ventricular dilation and mild global hypokinesis. Mild aortic and mitral regurgitation. Mild pulmonary hypertension. UNILAT UP EXT VEINS US RIGHT Study Date of [2174-9-25] IMPRESSION: Partially occlusive thrombus in the right axillary vein. CHEST (PORTABLE AP) Study Date of [2174-9-25] FINDINGS: The IJ line has been removed. The right-sided PICC line is still in place. The tip is difficult to visualize on today's study, but is at least in the superior vena cava. There is a moderate left effusion and a tiny right effusion. There is volume loss in both lower lobes. There is pulmonary vascular redistribution and moderate cardiomegaly. Compared to the prior study, the effusion on the left is slightly larger and the volume loss on the right has increased. Brief Hospital Course: 76-year-old female with CAD, paroxsymal atrial fibrillation, DM, COPD of home 02 and chronic prednisone, cor pulmonale, AAA repair transferred from OSH on [2174-9-20] with abdominal pain and hypotension. Hospital course complicated by rectus sheath hematoma/ RP bleed, UTI, cellulitis, and now hemodynamic instability (tachycardia, hypotension). # Atrial fibrillation: Of note, during hospitalization in late [Month (only) 205]-early [Month (only) 216], patient had episodes of symptomatic bradycardia with HR in the 30s. At that time, she had been evaluated by cardiology. She was also seen by cardiology on admission this time due to EKG showing ST depressions and associated troponin leak. Cardiology felt that pt had demand ischemia and recommended that beta blocker be uptitrated as needed. While on the vascular surgery service, her home beta blocker was held due to concern for prior history of bradycardia. She subsequently went into afib with rvr with rates as high as 140s with concomitant drop in systolic blood pressures to 80s. She was transferred to the MICU for concern for hypotension. She was restarted on her home metoprolol at the MICU. HRs were better controlled and she did not have episodes of hypotension. On the general medical, she remained hemodynamically stable and did not have further difficulty. # Hypoxemia: Pulmonary was consulted for management of her COPD. Pulm felt that hypoxemia was likely due to volume overload and recommended gentle diuresis with net negative 500cc to 1L. Pt may also have PNA in left lower base, though being treated with vanc/[Last Name (un) 2830] already which should cover PNA (see below). She was given levo-albuterol and ipratropium nebs standing. She was diuresed with IV lasix. Her oxygen requirement was at goal at 2L. Of note, she had been on chronic prednisone 20mg daily. This should be re-addressed with her pulmonologist as evidence supporting chronic prednisone is lacking. If she does continue to require chronic steroids, she should be on PJP prophylaxis (has allergy to bactrim). # UTI: During initial presentation, there was concern for urosepsis given dirty U/A and hypotension. Urine culture grew proteus sensitive to meropenem. ID was consulted and recommended meropenem. She will be treated for a total of 14 days. Blood cultures showed NGTD. Hypotension was transient during episodes of afib with rvr but she remained largely hemodynamically stable without need for pressors. # Cellulitis: Pt had erythema of left forearm and swelling of left elbow. ID recommended vancomycin treatment for potential cellulitis. She will be treated for 14 days of vancomycin. # Rectus sheath hematoma/Retroperitoneal bleed: Noncontrast CT showed inflammation around AAA graft and pt was transferred to [Hospital1 18] to vascular surgery service for concern for graft infection. Per CTA repeated here, she had rectus sheath hematoma and RP bleed but no active extravasation. Hematocrit nadired at 24 but was stable at 30 after 1 unit packed red cells (also received 1unit at OSH). ID did not feel that prophylactic antibiotics for rectus sheath hematoma was warranted. Vascular surgery did not feel that she required surgical intervention. She was transferred to the MICU for better management of her afib/hypotension and ultimately transferred to the medical floor. # Elevated troponin: Pt presented with ST depressions on EKG with elevated troponin. Likely due to demand per cardiology. -appreciate cardiology recs -medical management per above, including aspirin and beta blocker -unclear why pt is not on statin # Chronic kidney disease: Cr ranged from 1.4 to 1.9, had been the same during last hospization. Transitional Issues: - blood cultures pending Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen [Telephone/Fax (1) 1999] mg PO Q6H:PRN fever, pain 2. Albuterol Inhaler [2-12] PUFF IH Q6H:PRN wheezing 3. Aspirin 325 mg PO DAILY 4. Citalopram 10 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Vitamin D 400 UNIT PO DAILY 7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [Hospital1 ] 8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing 9. Albuterol-Ipratropium [1-10] PUFF IH Q6H:PRN wheezing 10. Omeprazole 20 mg PO DAILY 11. PredniSONE 20 mg PO DAILY 12. Senna 1 TAB PO BID 13. Simvastatin 40 mg PO DAILY 14. Theophylline SR 100 mg PO DAILY 15. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 16. Furosemide 20 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [Hospital1 ] 3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing 4. PredniSONE 20 mg PO DAILY 5. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 6. Glargine 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Levalbuterol Neb NF 0.63 mg/3 mL Inhalation TID:PRN dyspnea Reason for Ordering: Patient canNOT tolerate albuterol (it is causing tachycardia in the 130s) and needs beta-2 agonistic therapy for COPD 8. Meropenem 500 mg IV Q8H Duration: 14 Days 9. Metoprolol Tartrate 12.5 mg PO BID hold for sbp < 100 or hr < 60 10. Acetaminophen [Telephone/Fax (1) 1999] mg PO Q6H:PRN fever, pain 11. Citalopram 10 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Furosemide 20 mg PO DAILY 14. Omeprazole 20 mg PO DAILY 15. Senna 1 TAB PO BID 16. Simvastatin 40 mg PO DAILY 17. Vitamin D 400 UNIT PO DAILY 18. Vancomycin 750 mg IV Q48H Duration: 14 Days Please check vancomycin level on [9-28]. If level is <20 please start at 750mg Q48H on [9-28]. If vancomycin level is not <20 start vancomycin on [9-29]. 19. Outpatient Lab Work Please check vancomycin level on [9-28]. If level is <20 please start at 750mg Q48H on [9-28]. If vancomycin level is not <20 start vancomycin on [9-29]. Discharge Disposition: Extended Care Facility: [Location (un) 7661] Health & Rehab Center Discharge Diagnosis: Primary: Retroperitoneal bleed, urosepsis (proteus) Secondary: 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: Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were admitted from rehab after having a bleed and a urinary tract infection. You were evaluated and treated by the vascular surgery service and found to collection of blood near your prior aortic repair that did not appear to be infected. You were found to have a serious urinary tract infection (urosepsis) that will require treatment with IV antibiotics. Please take your medications as prescribed and keep your outpatient appointments. You should follow-up with your vascualr surgeon. Followup Instructions: Department: VASCULAR SURGERY When: WEDNESDAY [2174-10-19] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD [Telephone/Fax (1) 2625] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "725", "599.0", "493.20", "996.64", "272.4", "518.4", "998.11", "276.2", "V58.65", "998.12", "E878.2", "V46.2", "276.69", "411.89", "041.6", "486", "414.01", "416.9", "995.92", "250.00", "785.52", "E879.6", "V49.86", "585.9", "427.31", "682.3", "038.9" ]	icd9cm	[ [ [] ] ]	[ "38.97", "38.91" ]	icd9pcs	[ [ [] ] ]	14231, 14304	8339, 12061	330, 336	14411, 14411	3618, 3618	15192, 15503	2681, 2700		12911, 14208		14325, 14390		12134, 12888			14587, 15169								2715, 3599										6679, 8316					12082, 12108			1819, 1945				263, 292														364, 1800							3633, 6644	14426, 14563					1967, 2452	2468, 2665
14,646	178,955	25668	Discharge summary	report	Admission Date: [2125-9-8] Discharge Date: [2125-9-18] Date of Birth: [2085-10-23] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 6346] Chief Complaint: Nausea/vomiting and abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 39 year old male who complained of having "the flu" for several days with cough, chest pain, malaise. One day prior to presentation, he had severe nausea and vomiting as well as right flank pain. The pain was constant, and localized to the right flank. No fever or chills. No prior episodes. He reports flatus and green bowel movements. He denied any blood, melena, dysuria. Past Medical History: His past medical history is significant for a history of alcohol abuse. Social History: He has not had any alcohol for the 2 weeks prior to admission. He quit smoking one year ago. He works as a painter and carpenter. Family History: His father and mother both died of cancer. Physical Exam: The patient's exam on admission was Temp 99.9, HR 98, BP 165/85, RR 18, SaO2 97% room air Tired, shaky Bilateral basilar crackles Regular rate and rhythm Hyperactive bowel sounds, palpable liver to umbilicus, firm, moderately tender, nondistended, no rebound or guarding, no [Doctor Last Name 515] sign Rectal tone normal, no mass, Guiac positive Extremities warm and well-perfused without edema Pertinent Results: Admission labs were significant for platelets 96, Na 123, K 2.3, HCO2 80, Cl 12, AST 144, ALT 213, T bili 2.7, Amylase 438, Lipase 1191, Lactate 1.4 CT abd/pelvis: fatty enlarged liver, diffuse pan-colitis, mild terminal ileum involvement, normal appendix, no free air Brief Hospital Course: The patient was admitted to the blue surgery service for treatment of pancreatits. He was kept NPO and maintained on IVF. Empiric antibiotics were initiated. A Foley catheter and NG tube were placed. On hospital day 2, he was intubated and sedated for tachycardia, agitation and confusion likely secondary to withdrawal. His stool tested positive for C. difficile and Flagyl was prescribed. He improved and was extubated on hospital day 4. An MRCP was obtained which showed normal biliary ducts and normal pancreatic duct. He was transferred out of the ICU to the floor on hospital day 6. The patient's diet was slowly advanced, his LFTs returned to [Location 213], and his clinical symptoms resolved. He was discharged on hospital day 11 with instructions to follow up with Dr. [Last Name (STitle) ] as an outpatient. Medications on Admission: None 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:10 Tablet(s) Refills:0 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Gallstone pancreatitis C. diff colitis Discharge Condition: stable Discharge Instructions: You may go home. Please continue to take your antibiotics until they are all gone. Please follow up in two weeks time with Dr. [Last Name (STitle) ]. You may continue to eat a regular diet, but please refrain from drinking any alcohol. As mentioned earlier, alcohol will make you very sick while you are taking some of the medications. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 2 wks. His office number is: [Telephone/Fax (1) 2363] Completed by:[2125-10-17]	[ "291.81", "008.45", "303.90", "577.0", "276.5" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "96.71" ]	icd9pcs	[ [ [] ] ]	3336, 3342	1808, 2636	348, 355	3425, 3434	1514, 1785	3826, 3972	1034, 1078		2691, 3313		3363, 3404		2662, 2668			3458, 3803								1093, 1495																						274, 310														383, 776													798, 871	887, 1018
18,900	137,371	7848	Discharge summary	report	Admission Date: [2168-10-21] Discharge Date: [2168-11-9] Date of Birth: [2095-6-14] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [Known firstname ] [Last Name (Titles) 22924] [Known lastname ] is a 73-year-old gentleman noted to have hemoccult positive stools endoscopy and was shown to have a lesion at a gastroesophageal junction which by biopsy on EGD was thought to be squamous cell carcinoma. PAST MEDICAL HISTORY: 1. Significant for coronary artery disease and myocardial infarction in the past in [2164-7-21] with an ejection fraction of 30% or so and a recurrent left sided pleural effusion. His exercise tolerance was well. He climbs well. 2. Hypertension. 3. Noninsulin dependent diabetes. 4. Chronic pleural effusion 5. Claudication. 6. Question of right thyroid lobectomy for a lesion in his past. HOME MEDICATIONS: 1. Synthroid 50 mcg once a day. 2. DiaBeta 10 in the morning and 5 in the PM. 3. Lasix 40 in the morning and 80 in the PM. 4. Norvasc 10 mg once a day. 5. Lisinopril 30 mg once a day. 6. Lopressor 50 mg p.o. b.i.d. 7. Lipitor 40 mg. 8. Baby aspirin. 9. [Name2 (NI) 19188]. A preoperative work up showed incidental left lipoma in the head and 50% stenosis of his left carotid artery. The patient was taken to the Operating Room by Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ] and Plastic Surgery on [2168-10-21]. He tolerated the procedure well. Please see the operation note for full details. [First Name9 (NamePattern2) 12351] [Doctor Last Name ] procedure was conducted. . The patient postoperatively was transferred to the Intensive Care Unit with full hemodynamic monitoring. HOSPITAL COURSE: 1. NEUROLOGICAL: Patient does not speak English and is difficult to communicate with given the lack of an interpreter, however he did not suffer any neurological deficits during his stay here. His pain was adequately controlled by Morphine elixir. Upon discharge he is moving all four extremities without any difficulty and has no focal neurological deficits. 2. CARDIAC: Patient had a Swan-Ganz catheter postoperatively for hemodynamic wondering and had several episodes of shortness of breath during his stay here for which he had repeated work ups which were negative for any evidence of a myocardial infarction. The patient was beta blocked and had an episode of supraventricular ectopy which was noted preoperatively as well. At no time during his hospital course did the patient become hemodynamically unstable. 3. RESPIRATORY: Patient had a right sided chest tube in place until late in postoperative week #2. The initial chest tube outputs remained quite elevated and the patient had chest x-rays done repeatedly during the course of the hospital stay which showed a stable pneumothorax of roughly 5% on the right side. A post pulled chest x-rays revealed the pneumothorax is stable in appearance and clinically there was no evidence of hemodynamic compromise. Patient had question of a pneumonia during his hospital stay for which he received a 5 day course of Levaquin without any difficulty. On discharge he is in no acute respiratory distress at all. 4. GI: Patient is now tolerating a postesophageal gastrectomy diet well. He had a swallow study done on postoperative day #5 which revealed no evidence of a leak or stricture with some delayed gastric emptying. Patient on the first couple days post beginning his diet had some vomiting due to delayed gastric emptying. Patient is being cycled on tube feeds at 105 cc an hour over 12 hours of ProMod with fiber. This should be adjusted as his p.o. intake increases and calorie count should be adjusted such that he is receiving 25 kilocalories per kilogram. Patient is passing gas and having bowel movements on discharge. 5. INFECTIOUS DISEASE: Patient received perioperative antibiotics and received a course of Levaquin while in-house for a suspected possible pneumonia which upon culture was negative. Antibiotics were all discontinued. He was afebrile upon discharge with no ID issues. His wounds are clean, dry and are healing. 6. RENAL: Patient's creatinine became somewhat more elevated off his baseline and has gone as high as 2.2 prior to discharge, however he is making urine and may have some insufficiency, however he is not by any means in any renal failure. Patient is continued on his diuretics. 7. WOUNDS: Patient's abdominal wound staples are discontinued and Steri-Strips were applied. His thoracotomy incision, he is healing well and his incision is clean, dry and well-approximated. 8. CARDIOLOGY: Cardiology was consulted during the his hospital here which agrees with our cardiology work up that he does suffer from supraventricular ectopy with no evidence of myocardial ischemia or infarction. 9. GU: Patient failed several attempted voiding trials while in house. The patient finally voided after a Foley was discontinued two days prior to discharge. He was started on Flomax 0.8 mg and has been able to void since. Patient on discharge is afebrile with stable vital signs. He was tolerating a diet. The wound was clean, dry and intact with no evidence of discharge or infection. He is having good bowel movements. He has no acute cardiac issues, no acute respiratory issues, no acute renal issues, no acute ID issues. The patient is doing well. He will follow up with Dr. [Last Name (STitle) ] after calling his office for an appointment. His tube feeds should continue and his caloric intake should be monitored. DISCHARGE MEDICATIONS: 1. Prevacid 30 mg via J tube every day. 2. Albuterol, Atrovent nebulizers every six hours as needed. 3. Colace 100 mg b.i.d. via J tube. 4. Levothyroxine 50 mcg q.d. via the J tube. 5. Metoprolol 75 mg twice a day via the J tube, hold for heart rate less than 65 or a systolic blood pressure less than 110. 6. Lisinopril 20 mg via the J tube once a day. 7. Norvasc 10 mg via the J tube once a day. 8. Glyburide 7.5 mg twice a day. 9. He should receive Lipitor 40 mg via the J tube once a day. 10. Morphine 5 to 10 mg PJTO or p.o. every six hours as needed. 11. Flomax 0.8 mg at bedtime. 12. Lasix 40 mg in the evening and 80 mg in the morning. 13. Reglan 10 mg q.i.d. He is to receive fingersticks every six hours or q.i.d. for which he should receive the Reglan on a sliding scale. Starting at 150, he should get two units or for 200 or higher, he should get four units and at 250 or higher should get six units. Over 300 the M.D. or the rehab facility should be contact. 14. The patient's tube feed should continue with ProMod with fiber 105 cc over 12 hours cycled at night and to be adjusted as his p.o. intake increases. CONDITION ON DISCHARGE: Patient is in good condition on discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 6066] Dictated By:[Name8 (MD) 16758] MEDQUIST36 D: [2168-11-9] 14:40 T: [2168-11-9] 14:59 JOB#: [Job Number 28296]	[ "511.9", "443.9", "512.8", "414.01", "151.0", "412", "250.00", "401.9", "E878.8" ]	icd9cm	[ [ [] ] ]	[ "33.23", "46.39", "43.99" ]	icd9pcs	[ [ [] ] ]									5625, 6765					1744, 5602													886, 1727																																	157, 443													465, 868		6790, 7095
27,851	159,162	12091+56325	Discharge summary	report+addendum	Admission Date: [2175-2-20] Discharge Date: [2175-3-14] Date of Birth: [2124-12-1] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: Large liver mass Major Surgical or Invasive Procedure: [2175-2-27]:Right hepatic trisegmentectomy and median sternotomy. History of Present Illness: This is a 50 year-old woman presenting with a large spindle cell carcinoma in her right hepatic lobe. The patient initially presented in [2174-12-24] with what she thought was a "pulled muscle". She felt a bulge in her RUQ which she thought might have been a hernia. She was seen in the melanoma clinic for evaluation of a possible melanoma metastasis. She was found to have a hepatic spindle cell carcinoma and was referred to the Transplant Surgery Clinic. She presented to [Hospital 1326] Clinic this morning to initiate evaluation for a possible hepatic lobe resection. Dr. [First Name (STitle) ] decided to admit the patient for preop workup and abdominal imaging. The patient denies abdominal pain, fevers, chills, shortness of breath, chest pain, nausea, vomiting constipation, diarrhea, hematochezia, melena, jaundice, scleral icterus or pruritis. She does state that her appetite has been the same but has early satiety. She also states that she gets bilateral lower extremity edema when sitting for long periods of time and cramping in her calves when she drives. She also has some complaints of lower back pain which she partially attributes to her job which requires her to sit for long perids of time. Past Medical History: slightly elevated blood pressure, melanoma on her back s/p wide excision w/ advancement flap [5-26], Lf great toe crush injury s/p surgical intervention in '[52] and '[53]. Social History: denies alcohol use, tobacco use and recreational drug use. She is currently married. Family History: N/C Physical Exam: Tc 96.5 HR 87 BP 135/84 RR 18 Sats 96% RA Wt 57.9kg GEN: WD, thin female in NAD, pleasant, cooperative HEENT: NCAT, EOMI, no scleral icterus CV: regular rate and rhythm, no murmurs, rubs or gallops Resp: clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: firm in RUQ extending into RLQ, nondistended, nontender, scaphoid in appearance, minimal bowel sounds auscultated, dull to percussion over RUQ and extending midway into RLQ, Ext: mild non pitting edema in bilateral lower extremities, no cyanosis, no clubbing Neuro: alert and oriented x 3 Pertinent Results: On Admission: [2175-2-20] WBC-12.3* RBC-4.05* Hgb-11.3* Hct-34.5* MCV-85 MCH-27.9 MCHC-32.8 RDW-14.5 Plt Ct-443* PT-14.2* PTT-28.2 INR(PT)-1.2* Glucose-75 UreaN-14 Creat-0.8 Na-139 K-4.3 Cl-100 HCO3-28 AnGap-15 ALT-59* AST-63* AlkPhos-466* Amylase-63 TotBili-0.7 Lipase-44 Albumin-3.5 Calcium-9.6 Phos-3.9 Mg-2.2 Iron-18* calTIBC-308 Ferritn-338* TRF-237 TSH-2.2 T3-96 Free T4-1.3 Brief Hospital Course: 50 y/o female admitted with liver mass. Initial abdominal CT report as follows: 1. Large heterogeneously enhancing lesion replacing segments 4a/4b/[6-1] of the liver, supplied by the right hepatic artery. Probable occlusion of the right portal vein. The left portal vein is patent. 2. There is a heterogeneously enhancing lesion within the right lobe of the thyroid corresponding to that described on recent PET-CT which is concerning for malignant process. 3. There is a small amount of simple-appearing free pelvic fluid and a heterogeneously enhancing structure within the lower pelvis which may represent a fibroid uterus; pelvic ultrasound is recommended for further assessement as indicated. A transvaginal U/S was performed showing Simple 2.2-cm cyst in the left ovary and free fluid in the pelvis. No other pelvic abnormalities were identified. On [2175-2-22] she underwent thyroid biopsy of right lower pole. Results were as follows: Atypical single cells with increased nuclear:cytoplasmic ratios, irregular nuclear contours and prominent small nucleoli. Abundant neutrophils. -Note: The atypical cells are too few to characterize. Clinical correlation is recommended. Cardiac Echo was performed in anticipation of surgery which was WNL with EF > 55% On day 4 of the hospitalization she spiked a fever to 101.9. She was pan-cultured with blood and urine cultures no growth on multiple exams. ID was consulted. She was treated with 5 days on Unasyn and fluconazole. On [2175-2-28] she was taken to the OR by Drs [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for Right hepatic trisegmentectomy and median sternotomy by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914]. Per Dr [Last Name (STitle) 37914] operative note there was a large mass replacing much of the segments [Doctor First Name ], IVB, V and VIII, as was seen on the pre-op CT. The left lateral segment was free of tumor by inspection, palpation and by intraoperative ultrasound. A right trisegmentectomy with clear gross margins was done. PLease see the operative note for surgical detail. Biopsies taken at the time of surgery were returned with the following: -Poorly differentiated spindle cell and epithelioid tumor, consistent with metastatic malignant melanoma. Note: The lesion is focally present at the cauterized parenchymal resection margin. -Immunostains of the tumor cells within the areas of epithelioid differentiation are diffusely and strongly positive for HMB45, Mart 1 and S100, and negative for actin, desmin, LCA, EMA and cytokeratin cocktail. Patchy staining for Ckit is identified. Within the spindle cell foci, the tumor cells are negative for all of the above immunostains (all controls are satisfactory). Given the patient's history of previously excised invasive malignant melanoma of the right mid-back (which also demonstrated epithelioid differentiation within the vertical growth phase; see prior report S02-[Numeric Identifier 37915]), the tumor morphology and immunophenotype support a diagnosis of metastatic malignant melanoma. -Portal lymph node, excisional biopsy: One lymph node with no malignancy identified. In the post op period, she remained afebrile. Drains were tested for bilirubin on POD 5 and found to be consistent with serum, the medial drain was removed on POD 7. The lateral drain continued to have outputs as high as 1900cc per day. IV fluid was restarted on POD 9 at 1/2 cc/cc as weight was down 8 kg after the surgery. The JP drainage trended down and on pod 13 ([3-13])drainage was 850cc. The JP was removed. Vital signs remained stable. Abdomen was non-distended with dry incisions. She was ambulatory and tolerating a regular diet with supplements. Of note, she did experience intermittent nausea unrelieved by zofran. IV reglan was used with improvement. Nausea resolved. She also experienced quite a bit of clear yellow fluid drainage from the previous left groin line site. This was sutured and drainage stopped. Site remained without redness. She was discharged home off antibiotics. She will follow up in 1 week with Dr. [Last Name (STitle) ] on [3-22]. Follow up with the melanoma clinic was to be arranged. Medications on Admission: MVI, Ca, Mg, Zn, VitC Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:30 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): stop if loose stool/diarrhea. Disp:60 Capsule(s) Refills:2 [Month (only) 116] resume vitamins previously taking prior to hospitalization Discharge Disposition: Home Discharge Diagnosis: malignant melanoma, s/p liver resction Discharge Condition: Good Discharge Instructions: Please call Dr.[Name (NI) 1369] office [Telephone/Fax (1) 673] if you have a fever > 101, chills, nausea, vomiting,abdominal distension, diarrhea, inability to take or keep down medications, yellowing of skin or eyes. Monitor the incision for redness, drainage or bleeding. You may shower, pat incision dry. Do not apply lotion/ointment to incisions. No heavy lifting Do not drive if you are taking pain medication Make sure you are taking in adequete nutrition. Try to have at least 3 supplements daily, especially if you do not have a good appetite. Try to take at least 1500 calories daily. Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9402], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2175-3-15] 2:30 DR. [Last Name (STitle) 3150] Phone:[Telephone/Fax (1) 22] Date/Time:[2175-3-15] 2:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2175-3-22] 11:40 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2175-3-14] Name: [Known lastname 2596],[Known firstname 739] M. Unit No: [Numeric Identifier 6846] Admission Date: [2175-2-20] Discharge Date: [2175-3-14] Date of Birth: [2124-12-1] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 48] Addendum: [3-11] an U/S was done to evaluate the hepatic veins given high JP drainage and concern for ascites. This demonstrated normal portal and arterial flow and waveforms. An ABD CT was done on [3-12] showing patent hepatic veins/arteries and IVC. Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 51] MD, [MD Number(3) 52] Completed by:[2175-3-14]	[ "V10.82", "241.0", "452", "197.7" ]	icd9cm	[ [ [] ] ]	[ "50.22", "77.31", "06.11", "40.29" ]	icd9pcs	[ [ [] ] ]	9707, 9867	2999, 7302	330, 402	7823, 7830	2590, 2590	8480, 9684	1987, 1992		7374, 7711		7761, 7802		7328, 7351			7854, 8457								2007, 2571																						274, 292														430, 1659							2604, 2976						1681, 1868	1884, 1971
10,217	136,740	50832	Discharge summary	report	Admission Date: [2123-11-12] Discharge Date: [2123-12-6] Date of Birth: [2055-8-5] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: Thank you for consulting on this 68 year old male struck by a vehicle on [2123-11-12]. Pt has GCS of 13 on the scene, 8 in the ED and was intubated for airway protection. Pt sustained small R occipital L frontal SAH, L temporal IPH, small R SDH, R occipital/temporal bone fx, R rib fx [4-3] and small liver lesions. Major Surgical or Invasive Procedure: Pt was extubated [2123-11-16] and transfered to floor on [11-18], but had respiratory distress due to pna on [11-20] and was intubated and transfered back to TSICU. Pt received a trach (#8 Shilley) and PEG [2123-12-1]. recovered from Pnuemonia History of Present Illness: Thank you for consulting on this 68 year old male struck by a vehicle on [2123-11-12]. Pt has GCS of 13 on the scene, 8 in the ED and was intubated for airway protection. Pt sustained small R occipital L frontal SAH, L temporal IPH, small R SDH, R occipital/temporal bone fx, R rib fx [4-3] and small liver lesions. Pt was extubated [2123-11-16] and transfered to FA 5 on [11-18], but had respiratory distress due to pna on [11-20] and was intubated and transfered back to TSICU. Pt received a trach (#8 Shilley) and PEG [2123-12-1]. rehab screen and placement undeway currently Past Medical History: PMH: diverticulosis, diverticulitis, hypercholesterinemia PSH: appy Social History: SH: no ETOH, >80 PY tob Family History: nc Physical Exam: .Injuries head lac L frontal SAH R occipital/temporal fx leading into carotid canal R rib fx 3-5m nondisplaced small liver lac vs. 3 nodules, no hematoma MAE left greater than right will intermittently fc on left able to handle secretionskung clear ABd: S-NT ND and no erythema at G tube site EXt non swollen and MAE Pertinent Results: [2123-11-26] 11:29 am BRONCHOALVEOLAR LAVAGE FINAL REPORT [2123-11-28] GRAM STAIN (Final [2123-11-26]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2123-11-28]): NO GROWTH. [2123-11-22] 11:01 pm SPUTUM Source: Endotracheal. FINAL REPORT [2123-11-26] GRAM STAIN (Final [2123-11-23]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2123-11-26]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 105704] ([2123-11-16]). [2123-11-23] 12:19 am BLOOD CULTURE FINAL REPORT [2123-11-29] AEROBIC BOTTLE (Final [2123-11-29]): NO GROWTH. ANAEROBIC BOTTLE (Final [2123-11-29]): NO GROWTH. [2123-11-20] 8:10 pm CATHETER TIP-IV Source: arterial line. FINAL REPORT [2123-11-23] WOUND CULTURE (Final [2123-11-23]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 1 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S [2123-11-28] 02:55PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.019 [2123-11-28] 02:55PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.019 [2123-12-6] 01:30AM BLOOD WBC-13.1* RBC-3.28* Hgb-9.7* Hct-30.4* MCV-93 MCH-29.5 MCHC-31.9 RDW-15.1 Plt Ct-528* [Known lastname ],[Known firstname ]:[Hospital1 18] Radiology Detail - CCC Record #[Numeric Identifier 105705] FINAL REPORT INDICATION 68-year-old male with left subarachnoid hemorrhage and continued mental status changes. Evaluate for interval change. TECHNIQUE: Serial axial CT images were obtained from the skull base to the vertex without intravenous contrast. FINDINGS: Compared to the prior study of [2123-11-18], there has been no significant interval change in a large left temporal intraparenchymal hemorrhage with area of associated edema. There is no evidence of midline shift or hydrocephalus. A small left subdural hematoma is again identified, unchanged. There is stable subarachnoid hemorrhage. No new areas of acute hemorrhage are identified. Previously seen bilateral scalp hematomas are unchanged. Opacification of the maxillary and paranasal sinuses are again identified. The osseous structures and multiple fractures are unchanged. IMPRESSION: Stable appearance of the brain with no new areas of hemorrhage or mass effect. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 7415] [Known lastname ],[Known firstname ]:[Hospital1 18] Radiology Detail - CCC Record #[Numeric Identifier 105705] FINAL REPORT INDICATIONS: Intraparenchymal hemorrhage. Assess for carotid traumatic injury. Note, this study was initially interpreted on [11-13], but is being dictated on the 17th now that multiplanar reformatted images have become available. TECHNIQUE: Volumetric CT imaging of the head was performed before and following the administration of 100 cc of Optiray contrast, per CTA protocol. Multiplanar reconstructions were made. COMPARISON: Head CT from [2123-11-12]. CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: The area of parenchymal hemorrhage in the left anterior temporal lobe is slightly larger. There is a questionable tiny right frontal subdural hematoma, and questionable parafalcine hematoma posteriorly, which is not significantly changed since the previous study. New subarachnoid blood is seen over multiple sulci and in the interpeduncular fossa. Possible evolving frontal contusions are present. At this time, there is no shift of normally midline structures. [Doctor Last Name ]-white matter differentiation remains preserved. There is no hydrocephalus, and basal cisterns are not effaced. There is no evidence of intraventricular hemorrhage. CAROTID CT ANGIOGRAPHY: Evaluation of the proximal right common carotid artery is limited due to extensive beam hardening artifact from dense contrast within the right subclavian vein. The more distal right common, external and internal carotid artery are widely patent. Atherosclerotic plaque is present in both carotid bulbs, much more so on the right than on the left. Both vertebral arteries are patent. There is no evidence of cervical carotid or vertebral dissection. Both petrous carotid segments and portions of the carotid arteries within the carotid canal are unremarkable. Supraclinoid internal carotid arteries are normal. The middle cerebral arteries and anterior cerebral arteries are unremarkable. The anterior communicating artery is visualized and is normal in caliber. Both posterior communicating arteries are probably visualized. The right posterior communicating artery is larger than the left. Both posterior cerebral arteries are normal in course and caliber. There is near complete opacification of the sphenoid sinus and a large fluid level within the right maxillary sinus and a right scalp hematoma as described on prior studies. IMPRESSION: 1. Increasing amount of left temporal parenchymal hemorrhage. Increasing amount of subarachnoid hemorrhage. No hydrocephalus or ventricular effacement. Basal cisterns remain patent. No shift of normally midline structures. 2. No evidence of traumatic injury to the internal carotid arteries. No aneurysm visualized. Results were discussed with Dr. [Last Name (STitle) 62533] at 6:45 a.m. on [11-13], [2123]. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name11 (Name Pattern1) 640] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9987] [Known lastname ],[Known firstname ]:[Hospital1 18] Radiology Detail - CCC Record #[Numeric Identifier 105705] FINAL REPORT INDICATION: MVA. COMPARISON: None. TECHNIQUE: Axial MDCT images were obtained through cervical spine without intravenous contrast. Additional coronal and sagittal reformations are provided. CONTRAST: No contrast was administered. CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is imaged from C1 through T2. No definite fractures are identified within the cervical spine. A questionable lucency within the right transverse process of C6 likely relates to degenerative change or artifact as no definite correlative abnormalities are identified on the sagittal and coronal reformations. There is grade I retrolisthesis of C3 on C4. There is multilevel degenerative change of the cervical spine, with loss of intervertebral disc space height and anterior and posterior osteophytosis, most prominent at C5-6 and C6-7. The visualized outlines of the thecal sac appear unremarkable. CT is limited in its ability to provide intrathecal detail. The prevertebral soft tissues appear unremarkable and endotracheal tube and nasogastric tube are in place. Again seen are fractures of the right temporal bone and right sphenoid [Doctor First Name 362] with questionable extension to the right carotid canal, as demonstrated on the CT of the head of same date. There is blood within the sphenoid and right maxillary sinuses as well as within the ethmoid air cells. IMPRESSION: 1. No definite fracture of the cervical spine. 2. Fracture of the right temporal and sphenoid bones with possible extension to the right carotid canal. These findings were discussed with the trauma team caring for the patient at the time of interpretation (9:25 p.m.). 3. Grade I retrolisthesis of C3 on C4, finding that could relate to degenerative change, although MR of cervical spine is recommended for further evaluation of ligamentous structures if clinically indicated. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name (STitle) 8913] R.M. SUN DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Known lastname ],[Known firstname ]:[Hospital1 18] Radiology Detail - CCC Record #[Numeric Identifier 105705] FINAL REPORT INDICATION: Status post MVC. Evaluate for injury. COMPARISON: None. TECHNIQUE: Axial MDCT images were obtained from the lung apices to the pubic symphysis following the administration of 150 cc of intravenous Optiray. Additional coronal and sagittal reformations are provided. CONTRAST: Intravenous nonionic contrast was administered due to the rapid rate of bolus injection required for this examination. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: An endotracheal tube and nasogastric tube are in place. There is a small amount of fluid within the trachea superior to the endotracheal tube cuff. There is no mediastinal hematoma. The aorta is normal in caliber and contour. There is no pathologic-appearing mediastinal, hilar, or axillary lymphadenopathy. The heart and pericardium appear unremarkable. Two 2 mm nodular opacities are seen within the left lower lobe. There are minimally displaced fractures of the right third, fourth, and fifth ribs. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Within segment VI of the liver, there is a wedge-shaped peripheral hypodensity that extends to the hepatic capsule. There are two additional rounded and oblong hypodensities within segment VII, the larger of which measures 11.2 x 2.1 cm. These are nonspecific in appearance and could represent hypodense hepatic lesions versus focal hepatic contusions. There is no evidence of perihepatic hematoma or fluid collection. The gallbladder is nondistended and contains calcified gallstones. The spleen, pancreas, and adrenal glands appear unremarkable. There are symmetric nephrograms bilaterally without evidence of perinephric hematoma. Tiny, rounded, hypodense lesions are seen within the upper pole of the right kidney and within the upper and lower poles of the left kidney. Two additional simple cysts are seen within the interpolar region and lower pole of the left kidney. The aorta is normal in caliber throughout with mural calcifications consistent with atheromatous disease. The celiac trunk, superior mesenteric artery, and inferior mesenteric artery appear patent proximally. There is no free intraperitoneal air. The large and small bowel loops are normal in caliber. There is diverticulosis of the colon. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley catheter. The prostate and seminal vesicles, rectum and sigmoid colon appear unremarkable. There is no pathologic-appearing pelvic or inguinal lymphadenopathy. BONE WINDOWS: Bone windows demonstrate nondisplaced fractures of 3 right- sided ribs. No other fractures are identified. MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate three hypodense regions within the right lobe of the liver, within segments VI and VII. The right-sided rib fractures are well delineated on the sagittal reformations. No fractures are appreciated elsewhere within the osseous structures, with no obvious displaced fractures of the thoracic or lumbar spine. IMPRESSION: 1. Three focal hypodensities within segments VI and VII of the liver, including a peripherally based hypodensity within segment VI that may represent hepatic contusion versus hypodense hepatic lesions. No perihepatic hematoma is identified. 2. No other evidence of solid organ injury or free air or free fluid within the abdomen. 3. Three right-sided rib fractures and questionable mild right upper lobe pulmonary contusion. 4. Two simple cysts within the left kidney and additional tiny, rounded, hypodense lesions, which are too small to accurately characterize. 5. Results discussed with the trauma team at the time of interpretation (9:45 p.m.). THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name (STitle) 8913] R.M. SUN DR. [First Name8 (NamePattern2) 4075] [Last Name (NamePattern1) 5999] Brief Hospital Course: [Known lastname ],[Known firstname ]: [Hospital1 18] Neurophysiology Detail - CCC Record #[/0-0-]J - CCC REPORT APPROVED DATE:[2123-11-29] TEST DATE: [2123-11-28] INTERPRETED BY: [Last Name (LF) ],[First Name3 (LF) 20] C. FINDINGS: ABNORMALITY #1: Throughout the tracing the background was slowed and disorganized generally in the [7-6] Hz theta range. With tactile stimulation, the patient was noted clinically to grimace but no change in the EEG rhythms was consistently seen with tactile stimulation. HYPERVENTILATION: Was contraindicated. INTERMITTENT PHOTIC STIMULATION: Was not performed because this was a portable study. SLEEP: Was not obtained. CARDIAC MONITOR: Showed a borderline tachycardia. IMPRESSION: Abnormal awake EEG due to diffuse background slowing suggestive of a mild to moderate encephalopathic process. No focal, lateralized, or epileptiform features were seen. OBJECT: R/O EPILEPSY IN A PATIENT WITH SUBARACHNOID HEMORRHAGE 68 year old male struck by a vehicle on [2123-11-12]. Pt has GCS of 13 on the scene, 8 in the ED and was intubated for airway protection. Pt sustained small R occipital L frontal SAH, L temporal IPH, small R SDH, R occipital/temporal bone fx, R rib fx [4-3] and small liver lesions. Pt was extubated [2123-11-16] and transfered to FA 5 on [11-18], but had respiratory distress due to pna on [11-20] and was intubated and transfered back to TSICU. Pt received a trach (#8 Shilley) and PEG yesterday, [2123-11-30]. Reintubated [2123-11-30]: Tracheostomy and PEG tube placement without complications. Medications on Admission: . 3. 1000 ml D5 1/2NS 4. Acetaminophen (Liquid) 5. Albuterol-Ipratropium 6. Ascorbic Acid (Liquid) 7. Bisacodyl 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10. Guaifenesin 11. Haloperidol 12. Heparin 13. HydrALAZINE HCl 14. Insulin 15. Lansoprazole Oral Suspension 16. Lorazepam 17. Metoprolol 18. Metoclopramide 19. Milk of Magnesia 20. Multivitamins 21. Propofol 22. Sodium Chloride 0.9% Flush 23. Sodium Chloride 0.9% Flush 24. Zinc Sulfate Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 6. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed for fever. 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-31] Puffs Inhalation Q4H (every 4 hours) as needed. 9. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 10. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO BID (2 times a day). 11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day) as needed. 15. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Intraparenchymal bleed, subarachnoid bleed, traumatic head injury 68M pedestrian struck by car, head hit windshield, LOC?, combative on scene and on transport, GCS 13 -> 8, intubated in [Last Name (LF) ], [First Name3 (LF) 2995]; c/b respiratory failure/re-intubation ([2123-11-20]) +BCltx r/o sepsis/pneumonia traumatic brain injury Discharge Condition: stable with residual head injury stable Discharge Instructions: neurologic rceovery is progressing slowly with left side moving forward in function expectant recovery pending D/c to rehab facility Followup Instructions: F/U with neurologic team 2-3 weeks NEUROLOGY n/a [Telephone/Fax (1) 16748] F/U in 4 weeks in trauma clinicInstitution ♦ TRAUMA CLINIC SURGICAL SPECIALTIES n/a [Telephone/Fax (1) 2359] f/U in 2- 3 weeks with neurology [First Name9 (NamePattern2) 105706] [Last Name (LF) ], [First Name3 (LF) ] MEDICINE/ [Numeric Identifier 22728] Completed by:[2123-12-6]	[ "518.81", "272.0", "482.41", "707.03", "803.41", "573.8", "807.03", "707.09", "861.21", "V12.79", "E814.7", "803.21" ]	icd9cm	[ [ [] ] ]	[ "31.1", "43.11", "96.72", "38.91", "96.6", "33.24", "96.04", "38.93" ]	icd9pcs	[ [ [] ] ]	18417, 18487	14894, 16509	637, 898	18877, 18919	2036, 14871	19100, 19495	1679, 1683		17008, 18394		18508, 18856		16535, 16985			18943, 19077								1698, 2017																						274, 599														926, 1531													1553, 1622	1638, 1663
71,127	123,482	31903	Discharge summary	report	Admission Date: [2168-6-15] Discharge Date: [2168-6-20] Date of Birth: [2103-5-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9853] Chief Complaint: Dizziness/Falls Major Surgical or Invasive Procedure: Central Line placement History of Present Illness: 65 y/oM pancreatic cancer currently day +21 of cycle 1 Docetaxel (taxotere(R)) whose course recently has been c/b diarrhea and syncope requiring recent OSH hospitalization, and mucocytis during the early course. For the past 2 days, he has been progressively more confused, with lightheadedness and falls, at least five times today. He has been more thirsty and had increased urinary frequency as well. His diarrhea has resolved he reports. According to his daughter and wife, he has been much more disoriented in the last day. His falls on the day of presentation have resulted in hitting his head, and a question of loss of consciousness. The other recent changes has been right sided flank pain about one week ago, but this has now resolved. Today, he was being evaluated in the clinic for the falls, he was found to be 60/20, 75/35 in the ED. He received 5L NS in the ED, had RIJ inserted. CXR negative, blood and urine cultures sent, and urinalysis returned positive. He was iniated on broad spectrum antibiotics with vancomycin and pip-tazo. He was critically hyperglycemic to 664, and an insulin gtt was initiated. Guaiac postitive brown stool. He received stress dose steroids (10mg dexamethasone) empirically for question of adrenal insufficiency due to the amount of dexamethasone he was taking peri-chemo. His pressures remained low with only IVF and he was initiated on norepinephrine. Past Medical History: Oncologic History: [2166-10-15] Whipple staged at T3N1 [2166-12-24] Gemcitabine x2 cycles [2167-2-25] capecitabine with oxaliplatin (Xelox) (rising CA19-9) [2167-9-2] Capcitabine alone (oxiplat d/c'd [2-22] neuropathy) [2168-5-26] Change to Taxotere, Rising CA19-9, 8mg dexamethasone [Hospital1 ] x3d around taxotere 1. Coronary artery disease. - Status post coronary artery stenting in [11-25]. 2. Hypertension. 3. Hyperlipidemia. 4. Torn rotator cuff. 5. Left inguinal hernia. 6. Status post TURP in [2165]. 7. Status post carpal tunnel surgery. 8. Status post bilateral total knee arthroplasty. 9. Status post pilonidal cyst removal. Social History: Lives in [Location 6151] with wife, [Name (NI) ] [Name2 (NI) ]; no smoking, etoh, or recreational drugs. Has 3 grown children. Family History: The patient's father died at age 83 of heart disease. His mother died in her 70s from ovarian cancer. His sister died in her 50s vascular related disease. Physical Exam: Transfer Physical: VITALS: Afebrile; 80, 113/70, 18, 96 % Room Air GENERAL: Well appearing, no acute distress HEENT: Fronto parietal superficial scalp laceration. EOMI, PERRL, OP has minor ulcerations in mucous membranes. Non erythematous. NECK: No cervical lymphadenopathy, no JVD, CARD: RRR, normal S1/S2, no m/r/g RESP: CTA bilaterally, no wheezes/rales/rhonchi ABD: Soft, nontender, distended, normoactive bowel sounds, no hepatosplenomegaly BACK: No spinal tenderness, no CVA tenderness EXT: No clubbing/cyanosis/edema, 2+ DP pulses NEURO: CN II-XII, A&O x 3, Strength 5/5 in both upper and lower extremities bilaterally, no sensory deficits, gait not tested PSYCH: Appropriate, normal affect Discharge Physical: Pertinent Results: ADMISSION LABS [2168-6-15] 10:45AM BLOOD WBC-18.4* RBC-2.86* Hgb-9.1* Hct-28.4* MCV-99* MCH-31.7 MCHC-31.9 RDW-15.9* Plt Ct-345 [2168-6-15] 07:40PM BLOOD Neuts-95.2* Lymphs-3.2* Monos-1.6* Eos-0 Baso-0.1 [2168-6-15] 06:20PM BLOOD PT-13.8* PTT-26.7 INR(PT)-1.2* [2168-6-15] 10:45AM BLOOD Gran Ct-[Numeric Identifier ]* [2168-6-15] 10:45AM BLOOD Glucose-664* UreaN-52* Creat-2.0* Na-122* K-4.4 Cl-91* HCO3-18* AnGap-17 [2168-6-15] 10:45AM BLOOD ALT-61* AST-24 LD(LDH)-220 CK(CPK)-37* AlkPhos-268* TotBili-0.6 DirBili-0.4* IndBili-0.2 [2168-6-15] 10:45AM BLOOD GGT-426* [2168-6-15] 10:45AM BLOOD CK-MB-3 cTropnT-0.01 [2168-6-15] 06:20PM BLOOD CK-MB-3 cTropnT-<0.01 [2168-6-15] 06:20PM BLOOD Calcium-7.6* Phos-1.8# Mg-1.6 [2168-6-15] 10:45AM BLOOD HDL-6 CHOL/HD-14.3 [2168-6-15] 10:45AM BLOOD TSH-0.80 [2168-6-15] 07:40PM BLOOD Cortsol-8.0 [2168-6-15] 10:45AM BLOOD CA125-10 [2168-6-15] 07:40PM BLOOD RedHold-HOLD [2168-6-15] 11:58AM BLOOD Lactate-1.8 [2168-6-16] 06:10AM BLOOD O2 Sat-84 [2168-6-15] 10:45AM BLOOD CA [78]-9 -Test [2168-6-15] 02:51PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2168-6-15] 02:51PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2168-6-15] 02:51PM URINE RBC-0-2 WBC-[12-9] Bacteri-FEW Yeast-MOD Epi-0-2 STUDIES CT HEAD [6-15] IMPRESSION: No acute intracranial process, including no hemorrhage, edema or mass. MR [First Name (Titles) 151] [Last Name (Titles) ] gadolinium is more sensitive for detection of intracranial metastatic disease. CHEST XRAY [6-15] EXAM: Portable AP chest, [2168-6-15]. INDICATION: Hypotension. FINDINGS: Comparison made to [2167-5-15]. Left subclavian central venous catheter is unchanged, tip in the lower SVC. Cardiomediastinal contours are normal and unchanged. Lungs are clear. There is no pleural effusion or pneumothorax. Surgical clips in the mid-abdomen are unchanged. IMPRESSION: No acute intrathoracic process. EKG [6-15] Normal sinus rhythm, rate 78. Q-T interval prolongation. Minor non-specific inferior repolarization abnormalities. Compared to the previous tracing of [2168-1-27] Q-T interval prolongation is new. Discharge Labs: Brief Hospital Course: 65 y/oM with pancreatic adenocarcinoma now on taxotere presents with falls in the setting of hyperglycemia and orthostatic hypotension. Course significant for 2 day ICU stay and afib on floors. Course and treatment outlined as follows: MICU Course: The patient was admitted from the ED with central line in place on levophed. Overnight his hyperglycemia and hypovolemia were managed with 1/2NS and insulin drip transitioned to NPH [Hospital1 ] when resuming PO intake. His metabolic derangements resolved. The patient was found to have a UTI and started on Vanc/Zosyn with levo for ? Legionella. The patient's hemodynamics improved, pressors weaned and he was called out to the OMED floor. While awaiting callout, the patient developed worsening hyperglycemia and was kept in the ICU overnight for management. He was then called out to the hospitalist service as OMED was full. HYPOTENSION: Hypotension most likely related to increased GU losses [2-22] to osmotic diurresis and possibly underlying infection such as C-diff; cardiogenic and adrenal shock were ruled out. The patient did not appear to be septic and was normotensive in ICU and on floor. C. diff: the patient's stool cultures were positive for C. diff so he was started on Flagyl. He will complete a two week course as an outpatient. URINARY TRACT INFECTION (UTI): There was initial concern for UTI however cultures did not grow. Antibiotics were empirically started given initial UA and CXR however cultures did not grow out legionella. FALL(S): The patients recent falls are most likely due to recent hypovolemia in the setting of hyperglycemia. His history of a-fib appear to be well controlled on his two beta blockers so this is less likely a reason. He did not appear dizzy or off-balance after his volume and electrolytes were repleted. Patient did have negative head CT, and nonfocal neuro exam. Additionally, his hyperglycemia was brought under control so that he did not continue to have osmotic diurresis. HYPERGLYCEMIA: The patient??????s hyperglycemia was likely due to pancreatic insufficiency in the setting of pancreatic cancer and s/p whipple. He was initially treated with Insulin Gtt and was successfully transitioned to NPH/SS. [Last Name (un) ] diabetes consult provided directed care in order for him to achieve a good insulin regimen and the patient received training on how to manage his blood sugars at home. He has close followup at [Last Name (un) ]. Mucocytis: Patient has chemotherapy induced mucocytis without neutropenia. This likely contributed to his hypovolumic state [2-22] to decreased PO intake due to discomfort ingesting fluids and food. ??????Magic Mouthwash?????? provided significant relief for the patient and he tolerated cardiac/diabetic healthy diet. CANCER (MALIGNANT NEOPLASM), PANCREAS: Likely he has increased tumor burden in setting of his h/o pancreatic cancer. His elevated CA [78]-9 demonstrated this finding. He will followup with his oncologists, who did not recommend any further inpatient management. HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY): resolved with glucose correction ANEMIA, ACUTE on CHRONIC: Anemia secondary to probable anemia of chronic disease and underlying infection and possible bone marrow suppression from chemotherapy. CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE): He was ruled out for MI and continued on his home dose of plavix. Additionally, given the a-fib event that he had on the floor, his aspirin was increased to 325 mg daily from his baby aspirin. ACUTE RENAL FAILURE: Resolved with Hydration A-Fib: Patient had one a-fib event on morning of 3rd hospital day that was not associated with chest pain, sob but was associated with fever to 101.7. He had otherwise stable vital signs and his afib tachycardia to the 160s was brought down with beta blocker therapy and by placing him on his home beta blocker regimen over the course of his stay. He converted back to sinus rhythm and was well rate-controlled for the remainder of his hospitalization. Medications on Admission: AMITRIPTYLINE - - 25 mg Tablet - 1 Tablet(s) PO daily PRN AMYLASE-LIPASE-PROTEASE [CREON 10] - - 249 mg (33,200 unit-[Unit Number ],000 unit-[Unit Number ],500 unit) Capsule, Delayed Release(E.C.) - 5 Capsule(s) PO w/ meals AND [2-23] WITH SNACKS CLOPIDOGREL [PLAVIX] - - 75 mg Tablet - 1 Tablet(s) PO daily GABAPENTIN - 300 mg Capsule - 3 Capsule(s) PO three times a day LISINOPRIL - - 40 mg Tablet - 1 Tablet(s) PO daily METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) PO four times a day METOPROLOL TARTRATE - - 50 mg Tablet - 1 Tablet(s) PO BID OMEPRAZOLE [PRILOSEC] - - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) PO daily PIROXICAM - - 20 mg Capsule - 1 Capsule(s) PO daily PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - 1 Tablet(s) PO Q6hr PRN for NAUSEA PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) PO q8hr SERTRALINE - - 50 mg Tablet - 1 Tablet(s) PO daily SIMVASTATIN - - 80 mg Tablet - 1 Tablet(s) PO daily SOTALOL - - 80 mg Tablet - 1 Tablet(s) PO BID ZOLPIDEM - - 10 mg Tablet - 1 Tablet(s) PO at bedtime PRN Medications - OTC ASPIRIN - - 81 mg Tablet - 1 Tablet(s) PO daily CYANOCOBALAMIN - (OTC) - 1,000 mcg Tablet - 2 Tablet(s)(s) PO daily EXCEDRIN ASPIRIN FREE - - Dosage uncertain PYRIDOXINE [VITAMIN B-6] - 50 mg Tablet - 2 Tablet(s) PO daily Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. Disp:30 Tablet(s) Refills:0 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hx of afib. 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Piroxicam 20 mg Capsule Sig: One (1) Capsule PO once a day. 8. Compazine 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for insomnia. 12. Cyanocobalamin 1,000 mcg Tablet Sig: Two (2) Tablet PO once a day. 13. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). 17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 18. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 19. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 20. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. Disp:1 month supply Refills:2 21. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous tidachs. Disp:1 month supply Refills:2 22. One Touch Ultra 2 Kit Sig: One (1) glucometer Miscellaneous four times a day. Disp:1 glucometer Refills:0 23. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscellaneous four times a day. Disp:120 lancets Refills:2 24. One Touch Ultra Test Strip Sig: One (1) strip In [Last Name (un) 5153] four times a day. Disp:120 strips Refills:2 25. Insulin Syringe Ultrafine [1-22] mL 29 x [1-22] Syringe Sig: One (1) syringe Miscellaneous five times a day. Disp:150 syringes Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 932] Area VNA Discharge Diagnosis: Primary: 1. C-diff GI infection 2. Hyperglycemia/new diagnosis of diabetes 3. Hypotension related to hypovolemia 4. Atrial fibrillation Secondary 1. Hypertension 2. Pancreatic cancer Discharge Condition: Stable to home with good glycemic control and heart rate. Discharge Instructions: You were admitted to the hospital for very low blood pressure and elevated blood sugar level. During your hospital stay, you were found to have a heart condition called atrial fibrillation which causes your heart to beat very fast. Your treatment included intravenous fluids for your low blood pressure, insulin for your elevated blood surgar levels, and beta blockers for the atrial fibrillation. During your hospital course you were found to have an infection in your gastrointestinal system called c-diff. You are currently taking antibiotics to treat this infection. You were instructed on how to manage your new diagnosis of diabetes and were seen by endocrinologists from the [Last Name (un) ] diabetes center. Your medication regimen was modified in the following manner: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hx of afib. Followup Instructions: You should keep the following appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[0-0-] Date/Time:[2168-6-23] 2:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4053], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2168-6-23] 3:00	[ "995.92", "584.9", "427.31", "401.9", "285.22", "528.01", "157.0", "785.52", "276.1", "250.00", "038.9", "577.8", "272.4", "414.01", "008.45", "599.0" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	13786, 13849	5946, 10010	330, 354	14083, 14143	3608, 5905	15152, 15481	2692, 2850		11385, 13763		13870, 14062		10036, 11362			14167, 15129		5923, 5923						2865, 3589																						275, 292														382, 1790													1812, 2518	2534, 2676
19,211	175,668	6269	Discharge summary	report	Admission Date: [2121-8-28] Discharge Date: [2121-9-10] Date of Birth: [2056-5-14] Sex: F Service: MEDICINE Allergies: Cephalexin Attending:[First Name3 (LF) 2186] Chief Complaint: CC: weakness Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 65 yr old female with hx of type I DM, hyperthyroidism, PVD who presents with weakness, difficulty controlling blood sugars. Pt states that her symptoms started on [8-17] when she noted severe fatigue. Since that time, her appetite has decreased but her fingersticks have been elevated, requiring higher doses of humalog. For example, this am, she required 45units (15U x 3) of Humalog for glucose>200 despite eating almost nothing. Pt also complains of dizziness, esp when standing, nausea and some mild lower abd cramping. No fevers, chills, night sweats, diarrhea, dysuria. Pt notes that her freq of urination has decreased and her po intake of fluids has also decreased as it causes nausea. Past Medical History: PMH: 1. Recurrent UTIs for which she takes prophylactic Bactrim. 2. type 1 diabetes. She was diagnosed 50 years ago. Her diabetologist is Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Last Name (un) ] Center. Recent HbA1c 9.0 3. hypothyroidism. 4. Peripheral vascular disease, status post left lower extremity bypass. 5. High cholesterol 6. Aortic stenosis 7. Osteopenia 8. hx of tick bite last year (treated empirically) Social History: no tobacco, no alcohol, lives alone (husband passed away sev months ago) Family History: DM; mother died of CHF, father died of lung dz Physical Exam: temp 98.6, BP 167/70 (lying) --> 166/80 (sitting), HR 100, R 12, O2 100% RA Gen: NAD, pleasant HEENT: PERRL, EOMI, MM dry Neck: jug veins flat CV: RRR, [4-6] harsh systolic murmur at RUSB, radiating to carotids Chest: clear Abd: +BS, soft, NTND Ext: no edema, 1+ DP on left, nonpalp on right; sensation intact Skin: tan but not hyperpigmented in creases; several areas of circular, blocthy erythema onn back, upper chest, legs, arms Neuro: CN 2-12 intact Pertinent Results: [2121-8-28] 11:59PM GLUCOSE-254* NA+-127* [2121-8-28] 11:55PM CK(CPK)-51 [2121-8-28] 11:55PM CK-MB-NotDone cTropnT-<0.01 [2121-8-28] 11:55PM WBC-12.4* RBC-3.95* HGB-11.5* HCT-32.5* MCV-82 MCH-29.1 MCHC-35.4* RDW-12.0 [2121-8-28] 11:55PM PLT COUNT-314 [2121-8-28] 07:40PM URINE HOURS-RANDOM UREA N-191 CREAT-35 SODIUM-27 POTASSIUM-19 TOT PROT-6 PROT/CREA-0.2 [2121-8-28] 07:40PM URINE HOURS-RANDOM [2121-8-28] 07:40PM URINE OSMOLAL-173 [2121-8-28] 07:40PM URINE GR HOLD-HOLD [2121-8-28] 07:40PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.006 [2121-8-28] 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2121-8-28] 05:35PM GLUCOSE-155* UREA N-12 CREAT-0.9 SODIUM-125* POTASSIUM-4.8 CHLORIDE-87* TOTAL CO2-24 ANION GAP-19 [2121-8-28] 05:35PM CK(CPK)-67 [2121-8-28] 05:35PM CK-MB-NotDone cTropnT-<0.01 [2121-8-28] 05:35PM TSH-4.4* [2121-8-28] 05:35PM CORTISOL-28.8* [2121-8-28] 05:35PM WBC-13.1# RBC-4.55 HGB-13.3 HCT-38.6 MCV-85 MCH-29.2 MCHC-34.4 RDW-12.3 [2121-8-28] 05:35PM NEUTS-86.4 BANDS-0 LYMPHS-9.6* MONOS-2.9 EOS-0.8 BASOS-0.3 [2121-8-28] 05:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2121-8-28] 05:35PM PLT SMR-NORMAL PLT COUNT-358# Brief Hospital Course: 65F with hx of DM type I, PVD, hypothyroidism who presents with weakness, dizziness, nausea and difficulty controlling blood sugars found to be hyponatremic. Trasfered back to the floor from MICU after desenstization for ceftriaxone to treat Lyme disease. . 1. Hyponatremia: In setting of weakness, anorexia, nausea, dizziness (esp on standing), inital concern for adrenal insufficiency however, pt with elevated BP and leukocytosis, both not typically seen with adrenal insufficiency. Pt appears hypovolemic on exam, UNa>20 indicating renal losses but FeNa <1% indicating kidneys avid for Na. Ddx includes renal losses (salt wasting nephropathy, adrenal insuff) vs extra-renal losses (inadequate intake). Sodium continued to decrease on [2121-8-30]. [Month (only) 116] be c/w siadh, ivf stopped and pt placed on fluid restriction. renal consulted on [2121-8-30] and recommended hypertonic saline at 20 cc/hr, for total 400 cc (started at 9pm on [2121-8-30]) and continued checking of sodium q6h. Given possible SIADH, patient had MRI [2121-8-31] 12:30am. MRI of head no lesion. Na Tread 123->125->124->123->123->122->125->126->126->124 >127->126->128-> 130->134->131 Upon discharge Hyponatremia believed to be secondary to SIADH, secondary to Lyme disease. . 2. Weakness, dizziness: Nonspecific complaints and without evidence of infection on exam, unclear what the significance is. As above, may be [3-5] adrenal insufficiency. [Month (only) 116] also be due to volume depletion. No evidence of neurologic deficits to indicate CNS process. Cardiac enzymes neg x 1 and no changes on EKG to indicate cardiac source. Upon discharge weakness was believed to be seconadary to Lyme disease . 3. Worsening Hyperglycemia: Pt requiring increasing doses of insulin for decrased po intake indicating worsening insulin resistance or decreased insulin secretion. Also pt notes increased ketones in urine. Relatively acute in nature (over past 1.5 weeks). Etiologies of worsening hyperglycemia include infection, stress. No evidence of infection on UA and no signs or sx on H&P to indicate clear source of infection or pancreatitis. CXR- benign. Question of infiltrative disease causing beta cell destruction. Continued [Last Name (un) ] consultation with recommended changes in insulin regimen. . 4. Leukocytosis with left shift: No source of infection, Bimanual exam no evidence of PID. UA neg, urine cx pending, CXR no evidence of pulmonary infection. Blood cultures to be sent [2121-8-29]. LP to be done [8-30] w/20 WBCs, lymphocytic [Last Name (un) 11840], gram stain pending. Discussed w/ID, will send csf for lyme, enterovirus, but no abx for now. [8-31] ID formally consulted recc sending Erhlichia antibody, peripheral blood smears for Babesia,added testing for HSV to CSF fluid collection. MRI of lumbar spine showed no abscess. Suspected lyme disease. EKG showed no AV block, so does not suggestive of cardic involvment. Patient started on Doxycycline 200 po qd [2121-9-2] IgM was positive for Lyme, IgG negative. Enterovirus negative. Positive IgM LYME on [2121-9-5].On [2121-9-6] patient noted to have left sided Bell's Palsy. Patient under desensitization with Cetriaxone on Sunday in MICU without complications. On [2121-9-7] patient noted to have left sided Bell's Palsy. CSF POSITIVE FOR LYME DISEASE Patient was will continue on Ceftriaxone (Day 4/21 days) . 5. Skin rash: Pt had recently received morphine for back pain and then noted circular patches of erythema soon after. However, given hx of tick bite (given empiric tx) last year, slight concern for lyme disease, although pt received adequate treatment. Patient given benedryl. . 6.Mitral Regurg, new from last Cardiology visit TEE [2121-9-2] showed no significant change from previous echo . 7. Hypothyroidism: TSH slightly changed than baseline. Increased levoxyl. . 8.Back pain MRI of lumbar spine showed: Mild degenerative changes at several levels, most pronounced (but still mild) at the L5-S1 level, with a disc bulge touching both S1 nerve roots. Patient recieved Tylenol, Percocet and Ultram for pain control. Patient will recieve Flexeril upon discharge. . 9.Support Social Work was consulted b/c pt husband passed away in past year and patient need help with paperwork. . 10.FEN: Patient was maintained on DM diet with fluid restrictions during hospitalization. Due to lack of peripheral access a PICC line was placed on [2121-9-2] Upon discharge patient will be maintained on fluid restrictions. . 11.Calf pain on [2121-9-8]: Patient was recieving SubQ heparin during hospitalization. The SubQ hep was stopped on[2121-9-7] on b/c PTT was 92 but patient had pneumoboots. On [2121-9-8] am patient complained of calf pain L>R. Negative [Last Name (un) 5813] sign. Bilateral doppler showed 12. Physical Therapy-required to increase mobility Medications on Admission: Meds: * AZITHROMYCIN 500MG--Take one pill one hour prior to dental procedures * BACTRIM SS qd * CALCIUM 500/VITAMIN D tid * HUMALOG sliding scale [First Name8 (NamePattern2) ] [Last Name (un) ] * LANTUS 17U qhs * LEVOXYL 50MCG qd * LIPITOR 20 mg qd (stopped 2 days ago) Discharge Medications: 1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [2-2] Drops Ophthalmic PRN (as needed). 7. Ceftriaxone Sodium 1 g Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 17 days. 8. Flexeril 5 mg qhs prn for 10 days Discharge Disposition: Extended Care Facility: [Hospital1 11057] Nursing & Rehabilitation Center - [Location (un) 3320] Discharge Diagnosis: SIADH secondary to Lyme infection with CNS involvement Discharge Condition: Stable (as of [9-8] NEEDS TO UPDATED) Discharge Instructions: Please call primary care physician or come to emergency room if have increasing weakness, increased blurry vision or difficulty closing eyes, fever, or any other concerning symptoms. Please call primary care physician or come to emergency room if have increasing weakness, increased blurry vision or difficulty closing eyes, fever, or any other concerning symptoms. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2322], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2121-10-21] 11:00 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 1401], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 2386] Date/Time:[2122-4-21] 11:30 Completed by:[2121-9-10]	[ "320.7", "250.01", "253.6", "443.9", "088.81", "272.0", "424.1", "351.0", "244.9" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]	9509, 9616	3587, 8504	284, 291	9715, 9758	2162, 3564	10172, 10587	1617, 1666		8833, 9486		9637, 9694		8530, 8810			9782, 10149								1682, 2143																						232, 246														319, 1030													1052, 1509	1526, 1600
78,686	176,448	40940	Discharge summary	report	Admission Date: [2190-5-27] Discharge Date: [2190-7-23] Date of Birth: [2139-6-11] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7567] Chief Complaint: worsening speech difficulties and decreased movement of the right arm Major Surgical or Invasive Procedure: lumbar puncture tracheostomy PEG tube History of Present Illness: The pt is a 50 year-old right-handed man with a recent history of HSV encephalitis who presents with worsening speech difficulties and decreased movement of the right arm. He was initially diagnosed with HSV 1 meningitis on [2190-4-23]. He presented after he was in an accident while driving from RI to VT, rented a second car, and was in a second accident, at which point he was brought to an outside hospital and eventually diagnosed with HSV meningitis. He was started on a course of IV acyclovir, and discharged to [Hospital 38] rehab. His rehab course was complicated by a lower extremity DVT, for which he was started on Coumadin, however on [5-15] there was concern that the clot was mobile, and on [2190-5-16] he had an IVC filter placed. Around this time he became febrile to 102.6, and on [5-18] was transferred to [Hospital1 18] for fever and worsening confusion. He was admitted from [Date range (1) 66375], during which time he underwent a repeat LP, which showed 56 WBCs and a protein of 83, but was HSV negative. He had blood and urine cultures that were also negative. His fevers resolved with restarting acyclovir, though his mental status continued to fluctuate, and he was sent back to rehab on [5-21]. His sister continued to visit him, and reports that even as recently as two days ago he was actually starting to improve. At his best he was reported to be communicative, with a slightly strange affect, and mild short term memory and executive function impairment. However, on [5-26] he was noted to be very unsteady with PT, and was found to be orthostatic as low of SBP of 60 when standing, and it was recommended that he start both fludrocortisone and midodrine. On [5-27] the patient was noted to be forcibly keeping his right eye closed, and also was felt to be more apraxic with worsening coordination. He was also felt to not be moving his right arm as frequently. For all of this he was transferred to [Hospital1 18] for further evaluation. Past Medical History: - Lyme disease, per sister s/p treatment years ago - Malaria, per sister s/p treatment years ago - Lumbar laminectomy Social History: Divorced, has a girlfriend. Previously worked as a fundraiser and ?park ranger equivalent in [Doctor Last Name ], in excellent physical health. No T/E/D that sister knows of. Family History: Blood clots in sister (unprovoked PE age 33) and father (multiple DVT post-op). Sister has also had 3 miscarriages. Physical Exam: ADMISSION EXAM: Vitals: T: 97.6 P: 77 R: 16 BP: 108/94 SaO2: 94% on RA General: Awake, cooperative, NAD. Intermittent twitching of the right cheek, biting of the lip, sharp intakes of breath, and automotisms of the left hand throughout the exam. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Mild stiffness and nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Exam fluctuates significantly throughout. Alert, oriented to self but states it is [Month (only) 956], then starts reciting [2184]..[2185]..[2186] when asked the year. Later can state [2190] and that the president is [Last Name (un) 2753]. States he is at [Hospital 38] Rehab. Has intermittent dysarthria, most notable with '[Name Prefix (Prefixes) ]' '[Last Name (Prefixes) ]' and 'ka' sounds, but this fluctuates. Can follow simple midline and appendicular commands, though with two step commands, such as 'take your left hand and touch your right ear' looks at his left hand, picks it up, then holds it over his head. When asked what he is supposed to be doing states 'I'm supposed to touch my right ear' but never actually does it, and when asked a minute later what he is supposed to be doing states 'picking my nose' (still with his left arm held suspended above his head). Able to read, though periodically adds the word 'hospital' into sentences (e.g 'near the table in the hospital dining room'). Can name the key, glove and feather on the stroke card, but says 'tetanus with a shower in between' for the cactus, a nonsensical word for the chair and 'nice...a mattress' for the hammock. Able to count to 20 forwards, but when counting backwards makes it to 12, then repeats 12, 13, 12, 11, 12, 13.... When asked to repeat a second time does the exact same thing. Unable to register even 1 of 3 objects. Is able to register my name, but when asked to produce it ~3 minutes later, pauses, and then names a friend of his, who he states looks like me. Has difficulty describing the events of his recent hospitalization, but is able to provide appropriate history prior to his illness (information about his life in [Location (un) 7188], his sister's family and his nephew, all confirmed by his sister). -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Keeps right eye squinted shut. Able to grossly count fingers in all quadrants with the left eye, and will look towards a moving finger in all fields, though will not fully cooperate with more formal testing. III, IV, VI: Will track objects to the right without difficulty, though takes significant prompting, including a $5 [Doctor First Name ] to look over to the left, and even then does not fully bury the sclera of the left eye. V: Facial sensation intact to light touch. VII: Left sided facial droop, and right eye slightly squinted at rest, though can open it volitionally. Intermittent twitching of the right check VIII: Hearing intact to finger-rub bilaterally. IX, X: Will not fully open mouth to assess palate. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Significant paratonia throughout, with limited cooperation for testing all muscle groups. When attempts are made to assess for pronator drift, holds both arms up over his head, and will not allow them to be repositioned. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 5 5 5 5 5 5 5 5 5 5 5 R 4+ 4+ 5 5 5 5 5 5 5 5 5 -Sensory: Reports vibration feels slightly less on the right knee compared to the left. Otherwise no reported deficits to light touch, pinprick, cold sensation, proprioception throughout. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: Poor cooperation with attempts at FNF. Eventually able to coerce him into giving 'high 5' on either side with no clear dysmetria. Also able to reach his toe to my hand on either side with no dysmetria. -Gait: Deferred given significant confusion, poor cooperation and impulsivity, with concern for fall risk. DISCHARGE EXAM: deceased Pertinent Results: ADMISSION LABS: [2190-5-27] 01:30PM BLOOD WBC-7.9 RBC-3.94* Hgb-12.3* Hct-33.4* MCV-85 MCH-31.1 MCHC-36.7* RDW-16.7* Plt Ct-289 [2190-5-27] 01:30PM BLOOD Neuts-73.8* Lymphs-18.4 Monos-5.2 Eos-1.8 Baso-0.8 [2190-5-27] 01:30PM BLOOD PT-34.5* PTT-32.0 INR(PT)-3.4* [2190-6-1] 06:23AM BLOOD WBC-6.7 Lymph-24 Abs [Last Name (un) ]-1608 CD3%-71 Abs CD3-1139 CD4%-44 Abs CD4-709 CD8%-27 Abs CD8-427 CD4/CD8-1.7 [2190-7-5] 09:34AM BLOOD WBC-4.9 Lymph-10* Abs [Last Name (un) ]-490 CD3%-85 Abs CD3-419* CD4%-43 Abs CD4-212* CD8%-42 Abs CD8-207 CD4/CD8-1.0 [2190-5-27] 01:30PM BLOOD Glucose-87 UreaN-20 Creat-1.2 Na-137 K-4.2 Cl-100 HCO3-27 AnGap-14 [2190-5-27] 01:30PM BLOOD ALT-40 AST-22 AlkPhos-42 TotBili-0.6 [2190-6-2] 10:40AM BLOOD TSH-4.9* [2190-6-30] 05:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2190-6-1] 06:23AM BLOOD IgG-805 IgA-125 IgM-126 [2190-7-6] 08:00PM BLOOD HIV Ab-NEGATIVE [2190-6-30] 05:30AM BLOOD HCV Ab-NEGATIVE HTLV I/II ANTIBODY, WITH Nonreactive QUANTIFERON(R)-TB GOLD NEGATIVE TETANUS ANTITOXOID AB 2.32 CSF STUDIES: [2190-6-1] 08:57AM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-3* Polys-1 Lymphs-96 Monos-0 Macroph-3 [2190-6-24] 12:56PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-10* Polys-0 Lymphs-97 Monos-3 [2190-6-1] 08:57AM CEREBROSPINAL FLUID (CSF) TotProt-88* Glucose-55 [2190-6-24] 12:56PM CEREBROSPINAL FLUID (CSF) TotProt-68* Glucose-76 Herpes Virus 6 DNA, Qualitative Real-Time PCR HHV-6 DNA Not Detected [Male First Name (un) 2326] Virus DNA Ultrasensitive Quantitative Real-Time PCR [Male First Name (un) 2326] Virus DNA, Ultra QN PCR Negative Herpes Simplex Virus PCR Specimen Source: Cerebrospinal Fluid Result ------ Negative on both [6-1] and [6-24] VARICELLA ZOSTER VIRUS (VZV) Not Detected Not Detected DNA, QL RT PCR CMV DNA, QL PCR NOT DETECTED [Doctor Last Name 3271] [Doctor Last Name ] Virus, Qualitative Real Time PCR EBV DNA, QL PCR Not Detected IMAGING: MRI/A BRAIN [2190-6-1] Bilateral temporal lobe enhancing signal abnormality with also extension into the bilateral insula and right cingulate gyrus. Encephalomalacic changes in the right temporal lobe suggest that this represents an acute on chronic infectious process, on the left, this appears to be acute. No evidence for acute ischemia or hydrocephalus. Unremarkable MRA of the head and neck. MRI C-SPINE 1. No abnormal spinal cord signal or enhancement to suggest an inflammatory process within the spinal cord. No evidence of osteomyelitis, discitis or epidural abscess. 2. Degenerative changes, particularly at C5-C6, where there is high-grade spinal canal narrowing. MRI BRAIN [2190-6-20] Substantial progression of brain abnormalities, which remain compatible with the stated clinical diagnosis of herpes simplex encephalitis. MRI BRAIN [2190-7-8] Unchanged encephalomalacia of the right temporal lobe with interval decrease in the extent of white matter edema in the brain. No areas of enhancement. MRI BRAIN [2190-7-12] Stable appearances of the diffuse white matter FLAIR hyperintensities since [2190-7-8], however, improved signal changes since [2190-6-20]. White matter signal changes could reflect two seizure episodes. Stable encephalomalacia in the right temporal lobe and enhancement along the right mesial temporal lobes and right frontal [Doctor Last Name 352] matter. No new intracranial abnormality. Brief Hospital Course: NEURO: SEIZURES: On initial EEG, he was thought to be in complex partial status, and was given a trial of ativan with electrographic and clinical improvement. He was increased on his Keppra from 500 mg [Hospital1 ] to 1500 mg [Hospital1 ]. He continued to have frequent R temporal complex partial seizures, characterized by focal rhythmic theta activity. Clinically, the seizures were characterized by L hand twitching movements, R facial twitching, and confusion. On [5-29], He was loaded on phosphenytoin and started on maintenance dosing with improvement in seizure frequency. On [6-1], he was loaded on vimpat 200 mg IV, and started on maintenance of 100 mg [Hospital1 ]. Patient had a very complicated course with many antiepileptic medications trialed. He was initially transferred to the ICU for hypotension and respiratory distress. His seizures were controlled with midazolam, then he was switched to propofol because midazolam was not providing sufficient sedation, and this was also effective in suppressing seizures. He then began having frequent nonconvulsive seizures, and was started on phenobarbital [6-6], and Depakote on [6-9]. He underwent trach and PEG [6-11]. Zonisamide and Topamax were also tried. He temporarily was able to be transferred to the neurology step down unit, but returned to the ICU for midazolam drip on [2190-7-4]. Nonconvulsive status epilepticus remained refractory. The seizures continued to originate from bilateral temporal lobes despite increasing serum levels of Dilantin (corrected 20-25) and phenobarbital (90-100) and midazolam drip. HSV ENCEPHALITIS: Patient had severe HSV encephalitis resulting in necrosis and cystic changes in bilateral temporal lobes. Serial MRIs also showed development of extensive vasogenic edema in bilateral cortices. There was concern for ADEM process, and patient was treated with 5 days high dose steroids. Repeat MRI did show improvement in the diffuse edema after steroids. Another repeat MRI done several days after stopping steroids appeared stable with no further improvement but no worsening. It was impossible to determine if the steroids would have improved his mental status, this the timing coincided with worsening of his seizures and starting midazolam drip. On [2190-7-21], a family meeting was held with the epilepsy team, palliative care, and the SICU team. It was decided that the patient would not want to go on with his current quality of life. It was then decided to make the patient comfort-measures-only with continuation of the antiepileptics and to pursue extubation on Friday [7-23]. The patient maintained off of intubation for several hours but ultimately passed away Friday night. ID: 1. HSV ENCEPHALITIS- ID was consulted on admission. Patient has completed 2 21 day courses of acyclovir. Repeat CSF HSV PCR was negative x 2. He underwent thorough workup for other coexisting viral infections which was negative (HIV, CMV, EBV, VZV, HTLV1, [Male First Name (un) 2326] virus). HIV viral load was also negative, so patient could not possibly be in the "window period" of acute infection. HSV culture was also negative from the CSF, so there was no evidence that the type of HSV was resistant to acyclovir, and thus no additional antiviral treatment was warranted. Brain biopsy was discussed several times throughout his course, but ultimately decided that there would be no diagnostic or therapeutic advantage from this. 2. FEVER OF UNKNOWN ORIGIN- Patient developed fever to 102 daily. He was initially treated with empiric course of vanco/zosyn but fevers persisted with no clear source and all cultures negative. ID ultimately thought this was either drug or central fever. He did also develop a mild maculopapular rash and elevated eosinophil count, which point toward drug fever. His seizure medications were likely culprit, but could not be stopped due to nonconvulsive status. The rash improved on its own and the fevers continued until discharge. 3. LYMPHOPENIA/LOW CD4 COUNT Patient developed lymphopenia and low CD 4 count (212 on [7-5]). This caused concern for HIV, but HIV antibodies and viral load were negative. Other possible causes such as CMV and HTLV1 were also negative. This may be due to chronic illness and bone marrow suppression from HSV infection. 4. UTI Urine culture from [7-9] grew >100,000 E coli, treated with ceftriaxone. 5. PNA Sputum culture from [7-9] grew Klebsiella, treated with ceftriaxone. GI: TRANAMINITIS- Patient had normal LFTs on admission but developed elevation in AST/ALT to 300-400 with no elevated bilirubin but with elevated ammonia. This was likely a medication side effect, and improved with stopping Depakote. There was then a second episode of LFT elevation that resolved with stopping zonisamide. HEME: 1. DVT- His prior rehab course was complicated by a lower extremity DVT and he was started on Coumadin. However, on [5-15] there was concern that the clot was mobile, and on [2190-5-16] he had an IVC filter placed. He was treated with therapeutic doses of Lovenox during this hospitalization, since coumadin was interacting with AEDs. 2. Anemia Hematocrit gradually trended down during admission from 33 at admission to 25. Hematology was consulted. There was no evidence of hemolysis or any other acute concerning process on peripheral smear. Iron studies were consistent with iron deficiency so he was started on ferrous sulfate daily. There was also likely contribution of bone marrow suppression from medications. RENAL: Acute kidney injury- likely due to acyclovir and hypotension on sedation and AEDs. Resolved. Medications on Admission: - Colace 100mg [Hospital1 ] - Finasteride 5mg daily - Fludrocortisone 0.1mg daily - Keppra 500mg [Hospital1 ] - Midodrine 5mg daily - Mirtazapine 15mg QHS - Pantoprazole 40mg daily - Senna 2 tablets daily - Tamsulosin 0.4mg daily - Coumadin - Acyclovir 500mg Q8hr Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: refractory status epilepticus from HSV encephalitis Discharge Condition: deceased Discharge Instructions: NA Followup Instructions: NA	[ "348.5", "263.9", "V12.03", "054.3", "345.71", "482.0", "E879.8", "041.4", "V58.61", "584.5", "453.51", "599.0", "999.31", "518.81", "E936.3", "285.29", "276.51" ]	icd9cm	[ [ [] ] ]	[ "31.1", "33.24", "96.72", "96.6", "43.11", "03.31", "33.29" ]	icd9pcs	[ [ [] ] ]	17053, 17062	11028, 16697	375, 414	17157, 17167	7475, 7475	17218, 17223	2827, 2945		17020, 17030		17083, 17136		16723, 16997			17191, 17195					5500, 7430			2960, 3609					7446, 7456																	266, 337														442, 2472					7492, 11005			3624, 5483					2494, 2614	2630, 2811
61,393	172,762	14340	Discharge summary	report	Admission Date: [2137-4-15] Discharge Date: [2137-4-25] Date of Birth: [2053-2-9] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10682] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: PICC line placement NG tube placement History of Present Illness: 84F, history of advanced dementia (nonverbal for 4 years and nonambulatory), DM2, hypertension, CHF (EF unknown) brought to [Hospital1 18] from [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] due to decreased responsiveness and admitted to the ICU for hyperglycemia. At baseline she has been minimally verbal, if at all, for 4 years, however she usually is able to respond somewhat to interaction with smile to facial recognition however for the last three weeks she has not been able to do this. Today patient was appearing leghargic and unable to swallow meds or food. She was febrile to 101 at the facility, and with a sodium of 160. She is currently being treated for UTI with IM ceftriaxone (day3). She has had poor PO intake for months and been losing weight. In the ED, 99.6 132 164/99 20 96% 3L RA. Labs notable for lactate 3.6, glucose 448, Na 162, INR 1.4, Cr 1.7, WBC 12.4, AG of 18, UA concerning for UTI. EKG showed NSR, CXR showed no infiltrate, head CT negative. She was given insulin gtt, Vanc/Zosyn, 2L NS, now getting NS with K. Vitals on transfer 111 154/66 26 100% on RA. Foley in and making urine. 1PIV will attempt second. On arrival to the ICU, vitals were T:97.2 P106 bp117/54 rr23 98%RA she was unresponsive and unable to contribute to the interview. Her daughter reported that she appeared to be at her baseline mental function. Review of sytems: unable to obtain Past Medical History: - Diabetes mellitus type 2 - Hypertension - dementia - congestive heart failure EF unknown - Chronic kidney disease, baseline creatinine unknown Social History: Born in [First Name8 (NamePattern2) 42531] [Last Name (NamePattern1) 3908], moved to [Location (un) ] as adult. No history of drinking or smoking. Retired nurse's aid. Lives in [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ]. Family History: Father Hypertension Denies history of diabetes, coronary artery disease. Physical Exam: ADMISSION Vitals: T:97.2 P106 bp117/54 rr23 98%RA General: Elderly cahcectic appearing female eyes and mouth open, unresponsive to verbal stimuli, no resp distress HEENT: Surgical pupils BL, L>R ansiocoria, aclera anicteric, mucous membs dry, poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Poor inspiratory result due to unresponsiveness. Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardiac, regular rate, normal S1 + S2, no murmurs, rubs, gallops Abdomen: midline surgical scar, soft, non-tender, non-distended, bowel sounds present, GU: foley in place Ext: BL contractures in hands, warm, well perfused, 2+ pulses, no edema. Neuro: unresponsive, moving all extremities withdrawing all ext to pain. Pertinent Results: ADMISSION LABS [2137-4-15] 01:20PM BLOOD WBC-12.3* RBC-4.58 Hgb-13.8 Hct-43.0 MCV-94 MCH-30.1 MCHC-32.1 RDW-14.4 Plt Ct-228 [2137-4-15] 01:20PM BLOOD Neuts-77.9* Lymphs-16.0* Monos-5.3 Eos-0.3 Baso-0.7 [2137-4-15] 01:02PM BLOOD Glucose-471* UreaN-47* Creat-1.7* Na-160* K-4.1 Cl-123* HCO3-18* AnGap-23* [2137-4-15] 06:51PM BLOOD Calcium-9.0 Phos-1.2* Mg-2.2 [2137-4-15] 01:20PM BLOOD Osmolal-375* [2137-4-15] 01:08PM BLOOD Lactate-3.6* CARDIAC ENZYMES [2137-4-15] 01:20PM BLOOD CK-MB-2 [2137-4-15] 01:20PM BLOOD cTropnT-0.04* [2137-4-15] 06:51PM BLOOD CK-MB-3 cTropnT-0.04* DISCHARGE LABS [2137-4-20] 04:47AM BLOOD WBC-5.0 RBC-3.17* Hgb-9.4* Hct-29.1* MCV-92 MCH-29.7 MCHC-32.3 RDW-14.1 Plt Ct-162 [2137-4-23] 05:03AM BLOOD Glucose-190* UreaN-10 Creat-0.7 Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 [2137-4-20] 04:47AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.7 Head CT [2137-4-15] FINDINGS: No hemorrhage, edema, large masses, mass effect, or acute infarct. Periventricular and subcortical white matter hypodensities are consistent with small vessel ischemic disease. Marked ventricular and sulcal prominence is increased from prior study and is related to global atrophy. No fracture identified. The mastoid air cells are clear. Large amount of cerumen noted in external auditory canal. Air-fluid levels and aerosolized secretions noted within the sphenoid sinus as well as partial opacification of the ethmoid air cells. No soft tissue swelling identified. The globes are unremarkable. IMPRESSION: No acute intracranial hemorrhage. Acute sinus disease CHEST (PA & LAT) Study Date of [2137-4-15] IMPRESSION: No acute cardiothoracic process. Brief Hospital Course: Assessment and Plan: 84 yo F with advanced dementia (nonverbal for 4 years and nonambulatory), DM2, HTN, brought from [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] for AMS and admitted to the ICU for hyperosmolar hyperglycemic state and sepsis secondary to UTI. # Delirium on Dementia: According to the report, patient is non-verbal at baseline; however, lethargy and inability to tolerate oral intake x 3 days represented an acute change. According to her daughter, she appeared close to baseline on admission to ICU though she was not tolerating oral intake. Head CT was negative for acute hemorrheagic stroke, TSH and B12 were normal. The delirium was attributed to hyperglycemia, hypernatremia, and urinary tract infection; however, despite corrections of her electrolytes, sugars, and treatment of her UTI, she still has not been able to demonstrate the ability to swallow safely. She was evaluated by speech and swallow therapist with the following recommedations: RECOMMENDATIONS: 1. PO diet: nectar-thick liquids, pureed solids. 2. Meds crushed with applesauce. 3. 1:1 supervision with all PO intake. 4. TID oral care. 5. Feed pt only when awake and participatory. 6. Check oral cavity for residue following POs. # Hyperosmolar hyperglycemic state/Diabetes mellitus type 2, uncontrolled, with complications: Patient had altered mental status, elevated seurm osms, and serum glucose with anion gap acidosis. Though urine was positive for ketones patient has had very poor oral intake x 3 days and decreased po intake x 1 month, ketonuria is related to starvation ketosis rather than DKA. She was treated with agressive fluid hydration and insulin drip. Her acidosis improved, anion gap closed and she was taken off of the insulin drip and changed to insulin sliding scale. # Urinary tract infection: U/A was grossly positive with leukocyte esterase, many WBC and bacteria. She has been treated with ceftriaxone IM x 3 days. Culture data from [Hospital3 ] revealed proteus sensitive to ceftriaxone. She briefly received meropenem while in the ICU until culture from [Hospital1 18] returned no growth. Antibiotics were then changed to ceftriazone IV to complete a 7 day course, final day [2137-4-21]. # Hypovolemic hypernatremia: Related to poor po intake and exacerbated by osmotic diuresis from hyperglycemia. On admission, sodium corrected for glucose is 168. Free water deficit was 3.5L. She was treated with aggressive fluid resuscitation as above and serum sodium trended down. # Acute on Chronic Renal insufficiency: According to past medical history from nursing home patient has CKD, baseline creatinine unknown. Creatinine trended down to 1.0 with fluids. # Chronic congestive heart failure: EF unknown. Patient appeared hypovolemic on exam on admission and was euvolemic on discharge. # Hypertension: She was gradually restarted on metoprolol and lisinopril as tolerated. # Goals of care: After several discussions, the patient's HCP [Name (NI) 42532] decided not to pursue PEG tube for further nutrition. I counseled the daughter to use morphine for any discomfort or shortness of breath. I also counseled the daughter that she can try to feed her mother for [Name2 (NI) ], but she may aspirate. Finally, the daughter agreed that rehospitalization would not further benefit her mother at this point. She would like to pursue hospice care at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ]. # Code: DNR/DNI # Communication: Patient daughter [Name (NI) 42533] (HCP) [Telephone/Fax (2) 42534]h [Telephone/Fax (2) 42535]c Medications on Admission: Multivitamin Daily glipizide 2.5 mg [Hospital1 ] Acetaminophen 650 mg [Hospital1 ] Calcium 600 + D(3) 600 mg (1,500 mg)-400 unit [Unit Number ] tab [Hospital1 ] Metoprolol tartrate 50 mg [Hospital1 ] Acetaminophen 650 mg Q6-8 hrs PRN bisacodyl 10 mg PR daily PRN Milk of Magnesia 400 mg/5 mL Oral Susp 30ml Daily PRN Fleet Enema Daily PRN no bowel movement to milk of mag. Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): as able. 2. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): as able. 3. insulin lispro 100 unit/mL Solution Sig: 0-10 units Subcutaneous ASDIR (AS DIRECTED). 4. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal TID (3 times a day) as needed for pain, fever. 5. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 5-15 mg PO q2 hrs as needed for pain or shortness of breath. Disp:20 mL Refills:0 Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] - [Location (un) 538] Discharge Diagnosis: Delirium on Dementia Hypernatremia Urinary tract infection Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: [Known firstname ] [Known lastname ] was admitted for increasing confusion and was found to have high sodium levels in her blood and a urinary tract infection. Both have been corrected; however, her mental status has not improved much. She was started on tube feeds through a nasogastric tube. The family has decided not to pursue a PEG tube. She will eat for [Known lastname ] only. Followup Instructions: She will be pursuing hospice care at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ].	[ "293.0", "784.59", "V49.84", "276.0", "707.22", "593.9", "599.0", "331.0", "585.9", "403.90", "428.0", "707.03", "294.8", "V49.86", "294.10", "250.20" ]	icd9cm	[ [ [] ] ]	[ "38.97", "96.6", "57.94" ]	icd9pcs	[ [ [] ] ]	9445, 9567	4830, 8467	313, 353	9670, 9670	3115, 4807	10230, 10341	2264, 2339		8911, 9422		9588, 9649		8493, 8888			9806, 10207								2354, 3096																						265, 275							1784, 1802							381, 1766								9685, 9781					1824, 1971	1987, 2248
16,075	153,746	9509	Discharge summary	report	Admission Date: [2120-3-10] Discharge Date: [2120-3-15] Service: MEDICINE Allergies: Penicillins / Bactrim Ds Attending:[First Name3 (LF) 905] Chief Complaint: CC: Fever, mental status change Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [Age over 90 ] yo M c hx squamous cell CA on scalp presenting from OSH with fever, mental status change and concern for sepsis. In [Name (NI) ], pt. placed on sepsis protocol and events as per [Hospital Unit Name 153] note. . In [Hospital Unit Name 153], bctx from OSH returned growing [4-23] GPC, later noted to be + MRSA. Pt. treated with IV vancomycin, remained HD stable off pressors. Pt. noted to be hypernatremic on presentation; likely [2-22] dehydration. Free water deficit corrected with D5W and on transfer, Na 143. Pt. received 2 u pRBCS in [Hospital Unit Name 153] for Hct drop to 19 from 28; noted to be guiaic negative and felt to have combination of iron deficiency and anemia of chronic disease. Acute renal failure thought [2-22] ATN vs. prerenal; urine lytes not revealing. On txf, Cr at 1.5 down from 2.3 in ED (baseline 1.1). Urine eosinophils rarely positive. Noted to be coagulopathic with INR 1.4. DIC considered and fibrinogen sent --> 531, PT, PTT modestly elevated, + schistoscytes on smear. Pt. noted to have neck mass; CT done --> difficult to r/o abscess but likely benign enlargement of submandibular gland Briefly started on tube feeds but on transfer, NG tube removed by pt. and pt. taking POs Past Medical History: 1. Multiple skin cancers: facial squamous cell carcinoma ([2118-4-11]) followed by dermatologist Dr. [First Name4 (NamePattern1) 32342] [Last Name (NamePattern1) 32343], plan for MOHS for removal by Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 4643] 2. H/o MRSA skin infection treated with Bactrim and Zyvox [10-24]. 3. Back pain (last hospitalization in [10-24], old compression fx of t12 l1 l2, dx most likely musculoskeletal) 4. Anemia ([2-22] bone marrow depression from extended course of bactrim and linezolid) 5. Macular degeneration 6. Prostate CA s/p TURP many years ago 7. Colon CA s/p resection many years ago Social History: uses wheelchair, was previously able to do transfers on his own. His family lives nearby. He does not smoke cigarettes or drink ETOH Family History: not assessed Physical Exam: VS - 97.3, Tm 98.8, 93, 141/58, 97% RA, 15 HEENT - 44 cm erythematous circular, raised lesion over anterior scalp, tender to palpation. OP dry, poor dentition, 2-3 cm neck mass over region submandibular gland, Telengectasias diffusely over face, lower R facial droop c nasolabial fold flattening. LUNGS - + Rhonchi on expiration, no wheeze, no crackles HEART - RRR, s1, s2, + 2/6 systolic murmur diff usely over chest (not noted on prior d/c summary) ABD - soft, NT, ND, BS+ [Month/Day (2) ] - R AKA; [5-24] MS [First Name (Titles) ] [Last Name (Titles) ], lower [Last Name (Titles) ]. [5-24] MS over L foot. No pain over hip. Pertinent Results: micro - [3-11] - DFA (-) influenza A/B [3-10] - Uctx p [3-10] - Uctx no growth [3-10] - Bctx 3 p [3-10] - CSF ctx no growth [3-10] - OSH Bcts, [4-23] + staph aureus, MRSA [3-10] - Urine ctx no growth. . CT NECK: 1. Asymmetric appearance of the submandibular glands, with the right gland larger than left with thickening of the adjacent skin. These are consistent with inflammatory change. No definite abscess is seen, although the evaluation is more limited given the lack of IV contrast. 2. Left thyroid nodule. Statistically, this is most likely benign, especially given the lack of invasion of surrounding structures. However, if further imaging evaluation is required, ultrasound could be performed. 3. Vascular calcifications at the carotid bifurcations. . ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. No definite vegetation seen but cannot exclude. . CT HEAD in ED 1. No acute hemorrhage. 2. Chronic microvascular ischemia. 3. No definite mass effect. If clinically indicated, the patient may be reimaged with his head in neutral position. 4. Large ventricles, which may be related to involutional change. Please correlate clinically to exclude communicating hydrocephalus. . ABDOMEN SINGLE SUPINE FILM History of inguinal hernia and fever. Gas and fecal residue are present throughout the colon. There are a few gas-filled loops of nondilated small bowel. No evidence for intestinal obstruction. There is a left-sided inguinal hernia. Right hip prosthesis in situ. . EKG Sinus tachycardia Frequent supraventricular extrasystoles ST junctional depression is nonspecific No previous tracing . ADMISSION LABS: [2120-3-10] 12:40PM WBC-21.5# RBC-2.27 HGB-7.2# HCT-22.4 MCV-99* MCH-31.6 MCHC-32.1 RDW-26.2* [2120-3-10] 04:00PM NEUTS-92* BANDS-0 LYMPHS-3* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [2120-3-10] 04:00PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+ TARGET-2+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [2120-3-10] 04:00PM PLT SMR-NORMAL PLT COUNT-339 [2120-3-10] 04:00PM PT-16.8* PTT-27.8 INR(PT)-1.6* [2120-3-10] 04:00PM FIBRINOGE-531* [2120-3-10] 12:40PM GLUCOSE-151* UREA N-83* CREAT-2.3# SODIUM-161 POTASSIUM-3.5 CHLORIDE-123* TOTAL CO2-26 ANION GAP-16 [2120-3-10] 12:40PM WBC-21.5# RBC-2.27 HGB-7.2# HCT-22.4 MCV-99* MCH-31.6 MCHC-32.1 RDW-26.2* [2120-3-10] 02:10PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-50 LYMPHS-13 MONOS-37 [2120-3-10] 02:10PM CEREBROSPINAL FLUID (CSF) PROTEIN-153* GLUCOSE-52 [2120-3-10] 10:30PM GLUCOSE-126* UREA N-73* CREAT-2.1* SODIUM-158* POTASSIUM-3.1* CHLORIDE-122* TOTAL CO2-25 ANION GAP-14 [2120-3-10] 10:30PM CALCIUM-7.2* PHOSPHATE-3.9 MAGNESIUM-1.3* [2120-3-10] 10:26PM URINE HOURS-RANDOM TOT PROT-57 [2120-3-10] 10:26PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO [2120-3-10] 10:26PM URINE EOS-POSITIVE [2120-3-10] 10:12PM TYPE-ART PO2-330* PCO2-35 PH-7.48* TOTAL CO2-27 BASE XS-3 [2120-3-10] 10:12PM LACTATE-0.9 [2120-3-10] 10:12PM O2 SAT-98 [2120-3-10] 07:55PM TYPE-ART TEMP-36.7 PO2-54* PCO2-41 PH-7.43 TOTAL CO2-28 BASE XS-2 INTUBATED-NOT INTUBA [2120-3-10] 04:00PM GLUCOSE-133* UREA N-74* CREAT-2.0* SODIUM-161* POTASSIUM-3.3 CHLORIDE-125* TOTAL CO2-24 ANION GAP-15 [2120-3-10] 04:00PM ALT(SGPT)-40 AST(SGOT)-36 LD(LDH)-183 ALK PHOS-190* AMYLASE-35 TOT BILI-0.6 [2120-3-10] 04:00PM LIPASE-12 [2120-3-10] 04:00PM TOT PROT-5.5* ALBUMIN-2.5* GLOBULIN-3.0 CALCIUM-7.2* PHOSPHATE-3.5 MAGNESIUM-1.4* IRON-12* [2120-3-10] 04:00PM calTIBC-90* VIT B12-664 FOLATE-9.7 HAPTOGLOB-206* FERRITIN->[2114] TRF-69* [2120-3-10] 04:00PM OSMOLAL-345* [2120-3-10] 04:00PM TSH-0.56 [2120-3-10] 04:00PM PEP-NO SPECIFI [2120-3-10] 04:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-10.1 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2120-3-10] 04:00PM URINE HOURS-RANDOM UREA N-530 CREAT-31 SODIUM-66 . DISCHARGE LABS: WBC 14, HCT 28, PLT 326, NA 142, K 4.3, CL 111, HCO3 27, BUN 32, CR 1.0 Last vanco level - [3-14] AM - 13.2 Brief Hospital Course: A/P: [Age over 90 ] yo M c hx squamous cell carcinoma over scalp, MRSA infections p/w likely MRSA sepsis discharged HD stable on vancomycin. . 1. MRSA sepsis: Ddx includes scalp lesion abscess, submandibular gland abscess, hip arthroplasty. Bladder unlikely given urine culture. Endocarditis also unlikely given ECHO report and negative follow up blood cultures though can't exclude with TTE. CT of neck showed swelling of R submandibular gland w/o evidence of abscess, unlikely cause of sepsis. We think the etiology of his MRSA sepsis is from skin infection; we obtained a skin swab of the lesion which grew staph aureus, coag +, senstivities pending. PICC placed; pt. will require 6 week course with regular follow up of levels and creatinine. Wound care for scalp lesion as directed. Seen by derm team in house; plan for MOHS under local anesthesia pending improval in mental status/ability to cooperate during procedure. If mental status does not improve, may require general anesthesia for procedure. Dr. [First Name (STitle) 4643] is aware of these plans. . 2. Acute renal failure: Ddx includes prerenal vs. ATN vs. AIN. Post renal unlikely given normal UOP. Resolved on discharge. Foley catheter left in on discharge to facilitate monitoring of UOP. Can remove 1-2 days post discharge. . 3. Heme: Anemia has improved. Drop to [6-7] have reflected fluid resuscitation. Initial drop to 22 on presentation may reflect transient hemolysis given schistoscytes. DIC unlikely given fibrinogen level. HCT stable on discharge at 28. . 5. Neck mass: As per [Hospital Unit Name 153] team, CT scan suggestive of benign process; unlikely to be abscess. Likely enlargement of submandibular gland. . 6. Back pain: continued oral morphine - fall precautions Medications on Admission: MEDS ON TRANSFER: Vancomycin 1000 mg IV q48h Heparin SC Pantoprazole 40 mg qd PO Docusate 100 mg [Hospital1 ] RISS MVI Citalopram 10 mg qd Ipratropium 1 neb q6h Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q48H (every 48 hours) for 6 weeks. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Morphine 10 mg/5 mL Solution Sig: Two (2) mg PO Q6H (every 6 hours) as needed for pain. 10. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [Location (un) 5481] TCU Discharge Diagnosis: Primary 1. MRSA bacteremia 2. Squamous cell carcinoma of scalp Discharge Condition: Good Discharge Instructions: This patient needs to be on IV vancomycin for 6 weeks. He should have vancomycin levels checked periodically (q3d) and the nursing home. He should also have his creatinine monitored periodically (q3d). He should return to the hospital/ER if he develops hypotension, light headedness, fever, worsening shortness of breath, chest pain, or other concerning problems. [Name (NI) ] should keep all his appointments and take medications as directed. He has an appointment with Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 4643] of dermatologic surgery in [Month (only) 958] for MOHS removal of the lesion on his scalp. Followup Instructions: after discharge. Your dermatology appointment is listed below. Provider: [First Name11 (Name Pattern1) 8122] [Last Name (NamePattern4) 8123], M.D. Phone:[Telephone/Fax (1) 2977] Date/Time:[2120-3-26] 2:15, [Hospital Ward Name 23] [Location (un) ] [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910]	[ "784.2", "995.92", "285.29", "V49.76", "038.11", "276.0", "280.9", "V10.05", "V10.46", "173.4", "584.9", "724.2", "286.9", "V09.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93", "99.04" ]	icd9pcs	[ [ [] ] ]	10928, 10983	7960, 9739	263, 270	11090, 11097	3123, 5456	11785, 12155	2421, 2435		9954, 10905		11004, 11069		9765, 9765			11121, 11762		7824, 7937						2450, 3104																						192, 225														298, 1570					5472, 7808								1592, 2253	2269, 2405		9783, 9931
8,244	189,569	11111+56206	Discharge summary	report+addendum	Admission Date: [2114-12-11] Discharge Date: [2114-12-18] Date of Birth: [2050-8-10] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 64-year-old gentleman with significant risk factors for coronary artery disease including increased blood pressure, high cholesterol, positive family history and tobacco abuse who presents with shoulder and jaw discomfort. His discomfort occurs with exertion but also occurs without any exertion at all. The patient had an episode of this pain last week. An exercise tolerance test showed [Street Address(2) 2051] depression inferiorly and a defect on the myocardial perfusion scan. The patient had a cardiac catheterization which revealed the left main coronary artery with a 40% distal lesion and a left anterior descending artery with a 70% occlusion distally and a 60% occlusion proximally. The right inferior artery had a 90% stenosis. The right coronary artery had an approximately 100% stenosis. PAST MEDICAL HISTORY: Left carotid stenosis with no history of transient ischemic attacks; peptic ulcer disease; high blood pressure; high cholesterol; status post pilonidal cyst removal. SOCIAL/FAMILY HISTORY: Family history of coronary artery disease. PHYSICAL EXAMINATION: Pulse 68, blood pressure 140/80. General: In no apparent distress. Skin is warm and well-perfused. Pulmonary: Scattered rhonchi. No wheezes or rales. Cardiovascular: Regular. Normal S1 and S2. No murmurs, rubs or gallops. Abdomen: Soft, non-tender and non-distended with normoactive bowel sounds. Extremities: No edema. Neurologic: Alert and oriented x3. Non-focal exam. PERTINENT LABORATORY STUDIES: Please refer to History of Present Illness. HOSPITAL COURSE: Mr. [Known lastname 2450] was admitted to [Hospital6 1760] on [2114-12-11] preoperatively for coronary artery bypass grafting. On the day of [2114-12-12], he went to the operating room with Dr. [Last Name (STitle) 70] where he had coronary artery bypass grafting of four vessels including a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the right posterior descending artery, RPL and R1. Please see the previously dictated Operative Note for more details. The patient tolerated the procedure well and was transferred to the Intensive Care Unit from the operating room in stable condition. On postoperative day #1, the patient was extubated in the Intensive Care Unit without incident. On postoperative day #2, the patient had his chest tubes removed. He continued to be stable with no cardio-active drips being required to maintain his hemodynamic stability. The patient was then transferred to the patient care floor. The patient's course was complicated only by a period of confusion early on the morning of postoperative day #3. The patient was unable to remember who he was. Otherwise, he was normal. Neurologic examination was non-focal. For this change in mental status, blood cultures and sputum cultures were sent along with a chest x-ray. This investigation only yielded one positive blood culture which was positive for gram positive cocci in pairs which were, at this point, thought to be a contaminant. The patient had a history of alcohol use and questionable abuse, he was started on 5 mg p.o. q6 hours of Valium. Also, the patient was prescribed one beer with meals. During the course of the hospitalization, the patient's pacing wires were removed on postoperative day #4 and he continued to do well. By postoperative day #5, the patient was ambulating and at approximately level IV activity. He had no problems. On postoperative day #6, the patient's pain was controlled. He was ambulating and tolerating p.o. He is to be discharged. Of note, the patient's white count continued to trend downward throughout the hospitalization and there were no further episodes of confusion. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: Status post coronary artery bypass grafting x4, performed on [2114-12-12]. DISCHARGE MEDICATIONS: Lopressor 12.5 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d. x1 week, KCL 20 mEq p.o. q day while on Lasix, Colace 100 mg p.o. b.i.d., aspirin 81 mg p.o. q day, Ibuprofen 400-600 mg p.o. q6 hours p.r.n., Percocet 1-2 tablets p.o. q4-6 hours p.r.n., Klonopin 0.25 mg p.o. b.i.d. p.r.n. anxiety. FOLLOW UP APPOINTMENTS: The patient will follow up with Dr. [Last Name (STitle) 70] in two weeks. The patient will also follow up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], in two weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 6355] MEDQUIST36 D: [2114-12-17] 12:05 T: [2114-12-17] 12:10 JOB#: [Job Number 35842] Name: [Known lastname ], [Known firstname 126] Unit No: [Numeric Identifier 6381] Admission Date: [2114-12-11] Discharge Date: [2114-12-19] Date of Birth: [2050-8-10] Sex: M Service: ADDENDUM: Mr. [Known lastname 6382] discharge was delayed until the day of [2114-12-19]. This delay was due to difficulty in finding an appropriate rehab facility for Mr. [Known lastname ]. At this point Mr. [Known lastname ] is going to [Hospital 4955] [Hospital 6383] Rehabilitation Center and will leave the hospital on [2114-12-19]. All follow-up and discharge medications remain the same. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 2728] Dictated By:[Last Name (NamePattern4) 6384] MEDQUIST36 D: [2114-12-18] 10:07 T: [2114-12-21] 11:21 JOB#: [Job Number 6385]	[ "298.9", "272.0", "414.01", "433.10", "401.9", "291.81", "305.1", "411.1", "443.9" ]	icd9cm	[ [ [] ] ]	[ "36.13", "88.56", "37.22", "39.61", "99.04", "36.15", "88.53" ]	icd9pcs	[ [ [] ] ]							1200, 1244		4100, 4389		3996, 4076			1748, 3940																					1267, 1730																					4414, 5922				162, 986													1009, 1183		3965, 3974
68,892	122,809	8384	Discharge summary	report	Admission Date: [2100-11-26] Discharge Date: [2101-1-13] Date of Birth: [2066-4-11] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7567] Chief Complaint: Seizures Major Surgical or Invasive Procedure: PICC line placement [2100-12-3] NGT placement x2 G-tube placement [2100-12-21] History of Present Illness: The pt is a 34 y/o woman with CP, spastic quadriparesis, developmental delay (non-verbal) with a history of epilepsy who comes in to the ED after a prolonged atypical seizure for 45 min at day care. The history was gathered from an employee at her group home but was not an eye witness to the event. He states that she typically has about [3-31] seizure clusters per month. The seizures are characterized by extension of her limbs lasting seconds but clustering [1-29] within a 10 min period. On the morning of presentation, it was noted that she was having rhythmic arm movements for 45 min. Oral ativan was given. She was brought to the ED for further evaluation and treatment. No abnomal movemenst noted by ED staff. At bedside is one of the staff members from the group home who noted a couple of times that she has forced left lateral gave a few times in the span of an hour. Otehrwise thinks she is at her baseline. Her baseline she is non-verbal, She will eat if fed (crushed meds/ blended diet). She will grab your hand and rub it. Wont track. Noted to be in status epilepticus on [11-28] pm and transferred to the TSICU for phenobarbital load and close monitoring. Pt had received a total of 5 mg of IV ativan, 1000 of IV Keppra and 200 IV phenobarbital prior to transfer. . INTERNAL MEDICINE TRANSFER HPI: In brief, Ms. [Known lastname 29608] is a 34F with cerebral palsy/global developmental delay (nonverbal), spastic quadriparesis, epilepsy, history prolonged atypical seizure, originally admitted to [Hospital1 18] on [2100-11-26], who was recently admitted to TSICU [11-29] for recurrent grunting and deep respirations concerning for seizure activity, transferred to SICU for new fever, sinus tachycardia, and hypophosphatemia. . She re-presented to the ED after a prolonged atypical seizure for 45 minutes at daycare. The history was gathered from an employee at her group home but was not an eye witness to the event. He states that she typically has about [3-31] seizure clusters per month. The seizures are characterized by extension of her limbs lasting seconds but clustering [1-29] within a 10 min period. On the morning of it was noted that she was having rythmic arm movements for 45 min. Oral ativan was given. She was brought to the ED for further evaluation and treatment. She will grab your hand and rub it, but will not track. Noted to be in status epilepticus on [11-28] and transferred to the TSICU for phenobarbital load and close monitoring. Patient had received a total of 5 mg of IV ativan, 1000 of IV Keppra and 200 IV phenobarbital prior to transfer. Per Neurology, etiology of her seizures is unclear, but in patient with significant seizure disorder. Resolved without major intervention. They increased dose of phenobarbital to 120mg qd. No obvious seizure activity currently, with huge amount of artifact from bruxism. In addition, patient was noted to have significant anion gap metabolic acidosis on [12-2], thought to be due to starvation ketoacidosis, which resolved with initiation of tube feeding. . In the SICU, her phosphate was noted to be 0.5 at 8pm on [12-2] and tubefeeds were started at slow rate (Fibersource, starting at 15ml/hr), unclear if advanced too quickly. There is some concern for poor nutrition at the daycare, with BUN of 1 and extremely low phosphate and ? refeeding syndrome. Electrolytes are now within normal limits. Patient is a terrible stick, PICC line placement was attempted today in the right arm, and is currently malpositioned in the left brachiocephalic. IV team is currently pulling back to midline position overnight, with plan to go to IR tomorrow for proper PICC positioning. In the meantime, patient has one peripheral IV in right hand. Patient was noted to be in sinus tachycardia, and was febrile to 100.5 yesterday, at this time cause unclear, but thought to be due to seizure activity. Urine culture, with UA unremarkable, has been sent, and one set of blood culture sent. CXR for PICC placement shows no evidence of infiltrate on my read, however patient has had productive cough over last 24 hours. No antibiotics have been started. Patient currently has a malpositioned PICC (in mid-line position) and a 22 gauge peripheral. IV Nursing will likely need to do all lab draws overnight, as patient has poor access. Seizure activity has abated, 24 hour EEG still being performed. Of note, LENIs were also performed on [12-2] and were negative for clot. . On the floor, VS: 96.3 121/80 108 18 93(RA). Patient appeared comfortable, is nonverbal, and does not track or respond to commands, but does respond to hand grip (may be reflex). Past Medical History: Cerebarl palsy with global developmental delay (non-verbal/ non-communicative) Spastic quadriparesis Scoliosis Epilepsy with several electrolyte abnormalities noted after seizures S/p G-tube placement [2100-12-21] Social History: Lives at a group home: [Location (un) 29609], which is part of [Location (un) 15953] Community Care. # [Telephone/Fax (1) 29610]. Director: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 29611] [Telephone/Fax (1) 29612]. Guardian is [Name (NI) ] [Name (NI) 29613] Family History: unknown, not in contact with family Physical Exam: Physical Exam on Admission: Vitals: T:97.5 P:82 R: 16 BP: 120/84 SaO2:98% General: Awake, NAD. HEENT: DRY MM Neck: Supple Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: soft. Skin: no rashes or lesions noted. Neurologic: Alert. eye open, not tracking. Will look away from the light, PERRL. Does not reach for me or at objects. She will grasp my hand if placed in her hand and rub it (b/l). Moving all four extremities. Increased tone throughout with contractures. The legs are able to fullly extend. Brisk reflexes throughout. Toes are upgoing. ----- Discharge Examination: General: Awake, NAD. Neck: Supple Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: soft, nontender Skin: no rashes or lesions noted Neurologic: Alert, eyes open, not tracking, but will look laterally intermittently. PERRL. Lifts both arms spontaneously against gravity at the shoulders and elbows, extends knees and flexes ankles against gravity spontaneously. Increased tone with spasticity in all four limbs. Pertinent Results: Labs on Presentation: [2100-11-26] 12:15PM BLOOD WBC-6.1 RBC-4.06* Hgb-13.2 Hct-40.5 MCV-100* MCH-32.6* MCHC-32.6 RDW-12.6 Plt Ct-368 [2100-11-26] 12:15PM BLOOD Neuts-42.1* Bands-0 Lymphs-46.5* Monos-5.7 Eos-4.6* Baso-1.0 [2100-11-26] 12:15PM BLOOD Glucose-88 UreaN-15 Creat-0.6 Na-146* K-4.3 Cl-109* HCO3-26 AnGap-15 [2100-11-26] 12:15PM BLOOD ALT-16 AST-20 AlkPhos-86 TotBili-0.2 [2100-11-26] 12:15PM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.2 Mg-2.1 [2100-12-7] 09:00AM BLOOD calTIBC-174* Hapto-286* Ferritn-65 TRF-134* [2100-12-1] 07:56PM BLOOD D-Dimer-1070* [2100-12-1] 12:45PM BLOOD TSH-0.53 [2100-12-1] 12:45PM BLOOD 25VitD-17* Micro: [2100-11-28] 9:12 am URINE Source: Catheter. FINAL REPORT [2100-11-29] URINE CULTURE (Final [2100-11-29]): BETA STREPTOCOCCUS. ~7000/ML. [2100-12-2] 11:55 am URINE Site: CATHETER Source: Catheter. FINAL REPORT [2100-12-3] URINE CULTURE (Final [2100-12-3]): STREPTOCOCCUS SPECIES. ~4000/ML. [2100-12-3] 1:11 pm BLOOD CULTURE Source: Line-right midline [Name8 (MD) ] MD. FINAL REPORT [2100-12-9] Blood Culture, Routine (Final [2100-12-9]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [2100-12-4]): Reported to and read back by [Doctor Last Name ] BRUSH @ 2107 ON [12-5] - [Numeric Identifier 29614]. GRAM POSITIVE COCCI. IN CLUSTERS. Cdiff [12-4] and [12-11] Negative Imaging: EEG [11-27]: IMPRESSION: This is an abnormal video EEG which captured prolonged runs of rhythmic 1.5 Hz low amplitude spike and wave discharges in the right frontal temporal region which did not have any clear clinical correlate. At other times, persistent delta frequency slowing was seen in the same region. These findings suggest a fixed structural defect causing both cortical and subcortical dysfunction. The background was otherwise slow and disorganized consistent with a moderate to severe encephalopathy. EEG [11-28]: IMPRESSION: This is an abnormal video EEG which captured 41 pushbutton activations, for 12 tonic seizures characterized by right frontal temporal 2 Hz delta frequency spike and wave activity evolving into generalized electrodecrement and superimposed fast activity. On video, the patient most often appears to have neck extension truncal extension and bilateral limb clonic jerking movements. The last seizure occurred at 18:16 after which no further seizure activity was seen. Interictal epileptiform discharges are seen frequently in the left frontal and frontal temporal region. The pushbutton activations during the second half of the recording and particularly towards the morning of [11-29] for labored breathing did not clearly show evolution of activity on EEG to suggest ongoing seizure activity. However, during this time, a significant tachycardia of up to 136 bpm were seen. Additionally, rhythmic 2 Hz spike and wave discharges were seen in the right frontal temporal region occurring in bursts without any clear clinical correlate. The background initially in the first half of the recording showed a 4 Hz activity which became more attenuated and slower with more diffuse generalized beta frequency activity during the second half of the recording is likely due to medication effect from benzodiazepines and barbiturates. EEG [11-29]: IMPRESSION: This EEG did not capture any electrographic seizures nor did it capture any clear interictal discharges. The record does give evidence for a diffuse disturbance of the background rhythm with no normal alpha frequency and periods of diffuse delta. There was no clear laterality to this. Pelvic US [11-29]: IMPRESSION: 1. No acute process including no evidence of free fluid. 2. Incidental note is made of a horseshoe kidney. CT Head [11-29]: CONCLUSION: Technically limited examination. No gross intracranial hemorrhage. Other findings noted above. LENI [12-2]: IMPRESSION: No signs of DVT in the lower extremities. TTE [12-7]: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. 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. IMPRESSION: Suboptimal image quality. Normal study. No valvular pathology or pathologic flow identified. [12-22] CT abdomen without contrast IMPRESSION: 1. Multiple 2-mm renal stones in the right kidney without hydronephrosis. 2. Severe dextroscoliosis. 3. Given the patient's severe scoliosis, bowel loops and liver are interposed between the stomach and the skin. . [12-22] IMPRESSION: Uncomplicated placement of a 12 French Wills-[Doctor Last Name 12433] gastrostomy catheter via a left upper quadrant approach under general anesthesia. The catheter may be used in 24 hours. . [2100-12-27] EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of 17 electrographic seizures. During these seizures, the EEG shows fast beta activity at onset, followed by a brief period of electrode decrement, evolving into sharply contoured rhythmic sharp waves that are quickly obscured by myogenic artifact. On video, most electrographic seizures correlate clinically with brief tonic flexion of the left arm, extension of the right arm, and neck hyperextension. Occasionally, there may be a few clonic jerks of the limbs toward the end of the seizures. These findings are consistent with tonic seizures. In addition, there are multifocal epileptiform discharges more prominently in the left frontal and right temporal regions indicative of highly epileptogenic foci in these areas. Otherwise, background is slow consistent with a moderate diffuse encephalopathy. . [2100-12-28] EEG IMPRESSION: This is an abnormal continuous ICU video EEG because of 42 electrographic seizures occurring in multiple clusters throughout the recording, lasting 5-10 seconds each in duration. During most of these seizures, the EEG shows a generalized discharge, brief semi-rhythmic delta, fast beta activity, followed by a brief period of electrodecrement, evolving into sharply contoured rhythmic sharp waves that are quickly obscured by myogenic artifact. Some seizures have a more subtle pattern characterized by fast activity at onset followed by electrodecrement. On video, most electrographic seizures correlate clinically with brief tonic flexion of the left arm, extension of the right arm, and neck hyperextension. Occasionally, there may be a few clonic jerks of the limbs toward the end of the seizures. These findings are consistent with tonic seizures. In addition, there are focal epileptiform discharges in the left frontal and right temporal regions indicative of highly epileptogenic foci in these areas. Otherwise, background is slow, consistent with a moderate diffuse encephalopathy. . [2100-12-29] EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of 100 electrographic seizures occurring in several clusters throughout the recording. The seizure frequency and duration decrease significantly after 18:04 with only 21 seizures occurring after this time. During most of these seizures, EEG shows a generalized sharp discharge, brief semirhythmic delta, fast beta activity, followed by a brief period of electrodecrement, evolving into sharply contoured rhythmic sharp waves that are abruptly obscured by myogenic artifact. Some seizures have a more subtle pattern that is fast activity at onset followed by electrodecrement. On video, most electrographic seizures correlate clinically with brief tonic flexion of the left arm, extension of the right arm, and neck hyperextension. Occasionally, there may be a few clonic jerks of the limbs toward the end of the seizures. These findings are consistent with tonic seizures which are occasionally followed by clonic activity. In addition, there are epileptiform discharges more prominently in the left frontal and right temporal regions indicative of highly epileptogenic foci in these areas. Otherwise, background is significantly slow consistent with a moderate diffuse encephalopathy. Compared to previous day's recording, the overall number of electrographic seizures is increased. However, after 18:04, the frequency and duration of seizures are decreased indicative of a better seizure control. . [2100-12-30] EEG IMPRESSION: This is an abnormal video EEG monitoring session because of abundant clinical and electrographic generalized tonic seizures as described above. The seizures are clinically characterized by head and eye deviation to the left, bilateral tonic posturing followed by flexion of the left arm and extension of the right arm with superimposed myoclonic twitching. The EEG shows an abrupt generalized electrodecrement with superimposed low voltage fast activity and occasional EMG artifact from clonic jerking at the end of the episode. The tonic seizures last between 10 and 40 seconds. There is a total of 55 tonic seizures of this type. In addition, there are frequent electrographic tonic seizures showing an electrodecrement with superimposed low voltage fast activity lasting 4-10 seconds, but no clinical change associated on video. These occur approximately two to five times per hour. Background activity is slow and low voltage, with abundant superimposed beta activity, indicative of moderate diffuse cerebral dysfunction which is etiologically non-specific. There is prominent bruxism artifact throughout the recording. Compared to the prior day's recording, the tonic seizures have decreased in frequency and duration. . [2100-12-31] EEG IMPRESSION: This is an abnormal video EEG monitoring session because of abundant clinical and electrographic generalized tonic seizures as described above. The seizures are clinically characterized by head and eye deviation to the left, left arm extension, then bilateral tonic posturing with occasional superimposed clonic jerking. The EEG shows an abrupt generalized electrodecrement with superimposed low voltage fast activity and occasional EMG artifact from clonic jerking at the end of the episode. The tonic seizures last between 10 and 40 seconds. There is a total of 74 tonic seizures of this type. In addition, there are frequent electrographic tonic seizures showing an electrodecrement with superimposed low voltage fast activity lasting 4-10 seconds, but no clinical change associated on video. These occur approximately two to five times per hour. Background activity is slow and low voltage with abundant superimposed beta activity, indicative of moderate diffuse cerebral dysfunction, which is etiologically non-specific. There is prominent bruxism artifact throughout the recording. Compared to the prior day's recording, the tonic seizures have again increased in frequency and duration. . [2101-1-1] EEG IMPRESSION: This is an abnormal video EEG monitoring session because of abundant clinical and electrographic generalized tonic seizures as described above. The seizures are clinically characterized by head and eye deviation to the left, left arm extension, then bilateral tonic posturing with occasional superimposed clonic jerking. The EEG shows an abrupt generalized electrodecrement with superimposed low voltage fast activity and occasional EMG artifact from clonic jerking at the end of the episode. The tonic seizures last between 10 and 40 seconds. There is a total of 125 tonic seizures of this type. Background activity is slow and low voltage, with abundant superimposed beta activity, indicative of moderate diffuse cerebral dysfunction which is etiologically non-specific. There is prominent bruxism artifact throughout the recording. Compared to the prior day's recording, the tonic seizures continue at high frequency. . [2101-1-3] EEG IMPRESSION: This is an abnormal video EEG monitoring study mainly due to numerous electrographic generalized tonic seizures the clinical manifestation. Several of these seizures are described above as examples. Based on the clinical and electrographic manifestations, the seizures can be categorized into three main groups. The first group is the longest, (14-28 seconds). EEG generally shows a diffuse epileptic discharge, then a brief period of rhythmic slowing, followed by electrodecrement, leading to fast activity with crescendo amplitude and terminates in diffuse myogenic artifact. An example of these is found at 05:03:30. On video, she is prone and appears in a sleep state, has a sudden arousal with tonic posturing of all limbs, followed by waxing and [Doctor Last Name 688] flexion of the right arm, flexion of the left arm, and myoclonic jerking of the leftsided limbs. The second group has a similar yet shorter electrographic pattern (6-10 seconds) and less prominent myogenic artifact. An example of these is at 7:21:43 (10 seconds) . On video, she has waxing and [Doctor Last Name 688] flexion of the right arm followed by extension of the left arm. The third group includes very brief electrographic seizures (three to four seconds) 8:50:07. On video, she has brief tonic flexion of the right arm and extension of the left arm. The third category includes very brief electrographic seizures (three to four seconds) with minimal to no clinical correlation. An example of these can be found at 11:14:56 (four seconds). EEG shows electrodecrement with superimposed low voltage beta activity and nearly no myogenic artifact. Background rhythm is generally slow and low voltage consistent with a moderate diffuse encephalopathy of non- specific etiology. There is intermittent bruxism related myogenic artifact throughout the recording which obscures part of the background and, therefore, limits interpretation. Compared to the prior day's recording, this study has not changed. . [2101-1-4] EEG IMPRESSION: This is an abnormal video EEG monitoring study mainly due to 46 generalized tonic electrographic seizures, mostly with clinical manifestations, and 13 right temporal electrographic seizures with no clinical manifestation. Examples of these seizures are mentioned above. In the electrographic tonic seizure group, EEG consecutively shows a generalized epileptic discharge, brief rhythmic slowing, electrodecrement, fast activity with crescendo amplitude and termination in myogenic artifact. The longer seizures in this group have more prominent clinical manifestations. An example of the longer seizures is at 10:56:16 (30 seconds). On video, she is supine, appears asleep, arouses with left head and gaze deviation, tonic posturing of four limbs, limbs flexion on the left and extension on the right that waxes and wanes combined with some myoclonic jerks, ending with flaccid limbs and right gaze preference. An example of shorter seizures in this group is at 15:52:41 (five seconds). EEG shows the same pattern seen in longer seizures. On video, there is minimal flexion of the left arm and extension of the right arm. For the second group, the example is found at 20:24:11 (33 seconds). EEG shows rhythmic medium amplitude sharp theta in the right temporal region with no clinical correlation. Background rhythm is diffusely slow and attenuated indicative of moderate diffuse encephalopathy of non-specific etiology. Throughout the recording, there are periods of prominent myogenic artifact related to bruxism limiting interpretation of the study. Compared to the prior day's recording, the tonic electrographic seizures are less frequent; however, there are new focal right temporal seizures that were not seen previously. [2101-1-11] Ferritin 8.3, Haptoglobin 8.3, Iron 33, TIBC 329, TRF 253, B12 1153, Folate 12.8, Reticulocyte count 2.5 [2101-1-13] Hgb 12.3/Hct 36.7 (after transfusion of two units pRBCs) Brief Hospital Course: 34F with global developmental delay/ spastic quadriparesis / epilepsy who comes in for prolonged atypical seizure. Transferred to the ICU [11-29] after recurrent grunting and deep respirations in the setting of tachycardia with concern for status epilepticus, and found to have several electrolyte abnormalities initially concerning for refeeding syndrome. Course complicated by ? episodes of aspiration, suspicion for CDiff, and inability to take PO's sufficient to meet her nturitional needs, therefore G-tube was placed. Thereafter had difficult nutritional course with diarrhea and unclear absorption of AEDs with increase in seizure frequency requiring transfer back to Neurology service. Patient was stabilized on AED regimen as well as bolus feeds and transfered back to group home. 1. Seizures: Patient was admited with prolonged atypical seizures and intially managed on the neurology service. Patient was subsequently transfered to the ICU after developing concern for status epilepticus. In the ICU, she was uptitrated on AEDs with boluses of IV phenobarbital resulting in sedation. These atypical episodes and grunting were later found not to correlate with seizures on EEG and there was no significant epileptiform discharges. Her AED regimen was adjusted several times through her >1 mo admission, and ultimately seizures were controlled on an IV regimen until a Gtube was placed, at which point Gtube was used for AED's. On the medical floor patient was noted to be persistantly tachycardic to the 140s in a sinus rhythm without alternative medical explanation. on [2100-12-29] patient underwent 24 hour EEG monitoring and found to have signficant seizure activity and found to have status eplilepticus. She was loaded with phenytoin, then with depakote and transfered to the neurology service. Her AED regimen at that point consisted of phenytoin, VPA, phenobarb, keppra. Over the course of several days, her AEDs were switched to VPA, phenobarb, keppra and Rufinamide. Although she continued to have a multiple of brief seizures with and without clinical correlates, the frequency of these events decreased remarkably. However excessive drowsiness led to the discontinuation of Keppra. She was maintained on VPA, phenobarbital, and Banzel/rufinamide with adequate seizure control (with continued events but overall return to baseline mental status). Seizures consisted mainly of leftward eye deviation, grunting, tonic arm stiffening and sometimes hip flexion (lifting right leg above her head), and other rhythmic facial movements. . 2. Electrolyte abnormalities: After initial stabilization of status epilepticus, several lyte abnmls were noted, including low HCO3, hypoK, hypoMg, and hypoPhos; renal was consulted and thought starvation ketoacidosis was etiology of the AG acidosis. Initially concerning for refeeding syndrome given pt's poor ability take PO's; lytes were managed with repletion and normalized. However, on the floor, her lytes were noted to have the same pattern after seizures, and therefore it was realized that refeeding syndrome was not likely, but more so electrolyte shifts during seizures. Patient had G-tube placed for improved long term nutrtion management. . The group home nurse provided an instruction sheet that she requested [Name8 (MD) ] MD sign off on which include free water boluses which were not provided during our hospitalization. Instead, free water was used with medication flushes and for medication delivery as she has a long medication list. This was explicitly documented on the instructions. This may need to be readdressed by her primary physician with possible need to follow her electrolytes. . 3. Sinus tachycardia: During seizures she becomes tachycardic to 140-150 that comes down after seizures (also transienty hypoxic); however her baseline also noted to be 90-120 bpm even when not seizing or resting, occasionally but not necessarily responsive to fluids, and during times when not felt to be acutely infected. Therefore, possibly her baseline given her habitus. She was started on metoprolol 25 mg [Hospital1 ] for prevention of tachymyopathy. Her sinus tachycardia continued with HR in the low 100s for most of the week prior to discharge with further normalization at the time of discharge. . 4. Nutrition: Initially NGT was placed and pt was receiving tube feeds. However in discussion with her group home, who had successfully been feeding her orally for quite a long time, she was given a chance to eat (i.e. an oral feeding challenge) but was not seen to take in enough nutrition to sustain herself. She was also noted to have ? aspiration episodes while on the floor; while CXR's did not demonstrate this, her lungs were frequently rhonchorous. Pt again made NPO and NGT placed for tube feeds, until the decision was then made to place a G-tube for long term feedings, which was done on [12-22]. She was provided multivitamin, thiamine, folate throughout entire hospitalization. NG tube feeds were decreased as residuals were high but increased back to TwoCal HN bolus feeds to meet caloric demands. She was discharged on a bolus tube feeding regimen. . At discharge, our team was informed that her pharmacy might not cover the tube feeds. She was provided with a three day supply. Our case manager contact[Name (NI) ] the primary care physician's office to help coordinate obtaining the supply from a medical equipment company. . 5. Fevers, leukocytosis: While on the medicine floor, noted to have brief episode of fever, leukocytosis. Cultures were all negative except one blood culture with coag negative Staph that quickly cleared and was more likely contaminant. TTE showed no endocarditis. She was given 8d of Vancomycin/Zosyn. Given increased diarrhea episode, treatment was started with PO Vanco for CDiff, despite two negative CDiff tests. Alternatively, could have been due to aspiration given rhonchorous lungs, however CXR consistently showed no pneumonitis nor pneumonia. She was treated with a 14 day course of PO vancomycin while in house. Her diarrhea resolved. 6. Anemia: On arrival, Hgb was 13.2 and had gradually decreased to 8.0 by discharge. There was no evidence of blood loss, and the RBCs were normocytic with normal RDW. Iron studies initially indicated mild anemia of chronic disease, no iron deficiency and no evidence of hemolysis. Retic index is inappropriately low at 0.92. Most likely etiology of anemia was recurrent phlebotomy in the setting of menses and poor nutritional status. Thought unlikely to have marrow suppression with only one cell line down and no peripheral eosinophilia. However, repeat studies indicated severe iron deficiency anemia. Her guaiac was negative, although one guaiac was positive in the setting of menses. 7. Diarrhea: She had multiple loose stools which were negative for C-diff. This fact led to suspicion of poor AED absorption and increased seizure frequency so AEDs were temporarily switched to IV form. Nutrition was consulted and recommended adding banana flakes to feeds and standing colace was stopped. Her stools decreased in frequency thereafter and were thought normal prior to discharge. TRANSITIONAL ISSUES: [ ] Patient was listed as a full code during this admission, code status should continue to be reassessed given her co-morbidites and as she is unlikely to tolerate cardiopulmonary resusitation. [ ] Please observe Ms. [Known lastname 29615] behavior and record her seizures. Please report this information to Dr. [Last Name (STitle) 29616] so that Dr. [Last Name (STitle) 29616] can assess her seizure frequency and decide whether or not to change the dosing of her medications. [ ] Dr. [Last Name (STitle) 29616] or her Primary Care Physician can schedule Ms. [Known lastname 29608] to have lab checks for a COMPLETE BLOOD COUNT (CBC) as often as every two weeks to monitor her blood counts. She received a blood transfusion during this hospitalization to replenish her blood cell counts which had been low due to iron deficiency anemia, likely from phlebotomy/frequent lab draws during her long hospitalization. Her discharge Hgb was 12.3 and Hct 36.7. [ ] PCP [Name Initial (PRE) ] [Name10 (NameIs) ] she was being discharged, we were contact[Name (NI) ] by the patient's pharmacy who indicated that they might not be able to provide the tube feeds. We sent her back to the group home with a three day supply. Please make arrangements for getting her the tube feeds. [ ] PCP [Name Initial (PRE) ] [Name10 (NameIs) 357] review and revise the tube feeding and free water bolus schedule as indicated. Consider following her serum electrolytes and discussing with a nutritionist if issues arise. PENDING STUDIES: [ ] EEG reports from [Date range (1) 24388] Medications on Admission: Phenobarbital 105mg QPM Tegretol 400mg TID Ativan 1mg PRN Ca/Vit D Zantac 150mg [Hospital1 ] Milk of magnesia Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): crushed, mix 8AM meds in total 100 cc warm water and administer via PEG, then flush 30 cc water after. Disp:30 Tablet(s) Refills:2 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): crushed, mix 8AM meds in total 100 cc warm water and administer via PEG, then flush 30 cc water after. Disp:30 Tablet(s) Refills:2 3. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day: crushed, mix 8AM meds in total 100 cc warm water and administer via PEG, then flush 30 cc water after. Disp:30 Tablet(s) Refills:2 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): crushed, mix with 8AM and 8PM meds in total 100 cc warm water at each time and administer via PEG, then flush 30 cc water after. Disp:60 Tablet(s) Refills:2 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily): crushed, mix 8AM meds in total 100 cc warm water and administer via PEG, then flush 30 cc water after. Disp:30 Tablet(s) Refills:2 6. phenobarbital 30 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime): crushed, mix 8PM meds in total 100 cc warm water and administer via PEG, then flush 30 cc water after. Disp:120 Tablet(s) Refills:2 7. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1) teaspoon PO TID (3 times a day): flush PEG with 30 cc water before and 30 cc water after. Disp:90 teaspoon Refills:2 8. rufinamide 400 mg Tablet Sig: Three (3) Tablet PO twice a day: seizure maintenance, crushed, mix with 8AM and 8PM meds in total 100 cc warm water at each time and administer via PEG, then flush 30 cc water after. Disp:180 Tablet(s) Refills:2 9. valproic acid (as sodium salt) 250 mg/5 mL Solution Sig: One (1) see instructions PO Q8H (every 8 hours): 500mg at 8AM and 12 midnight, 375mg at 4PM, seizure maintenance, flush PEG with 30 cc water before and 30 cc water after. Disp:135 teaspoons Refills:2 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): crushed, mix with 8AM and 8PM meds in total 100 cc warm water at each time and administer via PEG, then flush 30 cc water after. Disp:60 Tablet(s) Refills:2 11. TwoCal HN 0.08-2 gram-kcal/mL Liquid Sig: One (1) can (see schedule) PO three times a day: Bolus tube feeding: Two Cal HN Full strength; Additives: Banana flakes, 3 packets per day; # of cc per feeding: as directed below; # of feedings/day: 3; Advancement: Start at goal; Residual Check: Before each feeding; Hold feeding for residual >= 200 ml; Flush w/30 ml water before & after each feeding; Other instructions: 1 can at breakfast, [12-27] can at lunch and 1 can at dinner. Disp:90 cans Refills:2 12. banana flakes Packet Sig: One (1) packet PO three times a day: with TwoCal tube feed boluses. Disp:90 packets Refills:2 13. syringe (reusable) 30 mL Syringe, Reusable Sig: One (1) syringe Miscellaneous three times a day: for use with water flushes. Disp:90 syringes Refills:2 14. syringe (reusable) 5 mL Syringe, Reusable Sig: One (1) syringe Miscellaneous three times a day: for use with administering valproic acid, ferrous sulfate, or other liquid medications. Disp:90 syringes Refills:2 15. acetaminophen 650 mg Suppository Sig: One (1) suppository Rectal every six (6) hours as needed for pain: as needed for pain. Disp:120 suppositories Refills:2 16. multivitamin Tablet Sig: One (1) Tablet PO once a day: crushed, mix 8AM meds in total 100 cc warm water and administer via PEG, then flush 30 cc water after. Disp:30 Tablet(s) Refills:2 17. lorazepam 4 mg/mL Solution Sig: One (1) mg Injection every 4-6 hours as needed for seizure lasting more than 3 minutes or more than 3 seizures in one hour. Disp:20 mL Refills:2 18. lorazepam 2 mg/mL Syringe Sig: 0.5 mL Injection every [4-1] hours as needed for seizure lasting more than 3 minutes: may administer 1 mg as intramuscular injection for prolonged seizure. Disp:10 syringes Refills:3 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Seizures/Status epilepticus Secondary Diagnosis: Electrolyte abnormalities due to seizures, Diarrhea, Possible Clostridium difficile infection Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neurologic: Awake, alert, no vocalization, does not follow commands, spasticity in all four limbs with some antigravity spontaneous movement Discharge Instructions: Mrs. [Known lastname 29608] was admitted to [Hospital1 18] with prolonged seizures. After these were controlled, it was noted that she had electrolyte problems with her potassium, magnesium, and phosphorous. This was likely due to the seizures themselves and not from "refeeding syndrome" as originally thought. She had some episodes of fevers and diarrhea for which she was started on oral Vancomycin for possible colitis. She received a G-tube for enteral nutrition because she was not able to take in enough nutrition on her own. Her anti-epileptic medications were converted to G-tube administration, and her seizures were controlled (although she continues to have seizures intermittently). She is likely at her baseline now which includes several subclinical seizures (without outward symptoms or actions) daily. She is being discharged back to her group home and with her outpatient Dr. [First Name8 (NamePattern2) 440] [Last Name (NamePattern1) 29616] (Partners/[Name2 (NI) 883] Hospital) continuing her care. The following changes were made to her medication regimen. - Once daily medications can be given at 8AM. Twice daily medications can be given at 8AM and 8PM. Three times a day medications can be given at 8AM, 4PM, and MIDNIGHT. 8AM medications can be crushed in 100 ml of warm water, administered via the PEG, and then flushed with 30 ml of clear water. The same can be repeated at 8PM. For liquid formulation medications at other times, the PEG can be flushed with 30 ml of clear water before and after administration of the liquid medication. - START Banzel/Rufinamide 1200 mg twice daily - START Valproic Acid 500 mg at 8AM and 12 midnight and 375 mg solution at 4PM - CHANGE Phenobarbital 105 mg qPM to 120 mg at bedtime - STOP Tegretol 400 mg - START Thiamine - START Multivitamin - START Folate - START Metoprolol 25 mg twice daily - START Cholecalciferol - START Calcium - START Ranitidine 150 mg twice daily - START Ferrous Sulfate solution three times daily - START TwoCal tube feeds three times daily (1 can in AM, 0.5 cans at noon, 1 can in PM) The patient will followup with Dr. [First Name8 (NamePattern2) 440] [Last Name (NamePattern1) 29616], her Neurologist/Epileptologist, as listed below. IMPORTANT: [ ] Please observe Ms. [Known lastname 29615] behavior and record her seizures. Please report this information to Dr. [Last Name (STitle) 29616] so that Dr. [Last Name (STitle) 29616] can assess her seizure frequency and decide whether or not to change the dosing of her medications. [ ] Dr. [Last Name (STitle) 29616] or her Primary Care Physician can schedule Ms. [Known lastname 29608] to have lab checks for a COMPLETE BLOOD COUNT (CBC) as often as every two weeks to monitor her blood counts. She received a blood transfusion during this hospitalization to replenish her blood cell counts which had been low due to iron deficiency anemia, likely from phlebotomy/frequent lab draws during her long hospitalization. Followup Instructions: NEUROLOGY FOLLOWUP - Dr. [First Name8 (NamePattern2) 440] [Last Name (NamePattern1) 29616], Partners/[Name2 (NI) 882] Hospital/[Hospital1 ], [Telephone/Fax (1) 29617], Appointment: [2100-2-3] at 12 NOON Please have your group home schedule a follow up appointment with your primary care doctor in the next couple weeks.	[ "742.9", "754.2", "345.3", "783.7", "315.8", "280.8", "780.60", "788.30", "427.89", "343.2", "008.45", "288.60", "306.8", "275.3", "345.81", "996.1", "285.29", "276.2" ]	icd9cm	[ [ [] ] ]	[ "96.6", "89.19", "38.97", "43.19" ]	icd9pcs	[ [ [] ] ]	36352, 36358	23331, 30517	315, 403	36564, 36564	6781, 23308	39910, 40258	5703, 5740		32304, 36329		36379, 36379		32166, 32281			36880, 39887								5755, 5769															30538, 32140							267, 277														431, 5121			36447, 36543			36398, 36426	5783, 6762	36579, 36856					5143, 5363	5379, 5687
30,261	117,206	34641	Discharge summary	report	Admission Date: [2167-7-30] Discharge Date: [2167-8-6] Date of Birth: [2089-4-25] Sex: F Service: CARDIOTHORACIC Allergies: Atorvastatin / Percocet Attending:[First Name3 (LF) 165] Chief Complaint: angina Major Surgical or Invasive Procedure: [2167-7-30] cabg x2/IABP (LIMA to LAD, SVG to OM) History of Present Illness: 78 yo female complained of SSCP on the afternoon of [7-30]. Taken to ER at [Hospital ] Hosp. Given ASA, nitro, and started on dopamine drip for hypotension SBP 70. Ruled in with troponin of 3.57. Transferred here for cath which revealed 80% LM. IABP placed in cath lab.IV heparin started and plavix given. Past Medical History: CAD s/p cabg x2 NSTEMI CHF HTN hiatal hernia PSH: bladder suspension Social History: retired no tobacco use occasional ETOH lives with sister-in-law Family History: unknown Physical Exam: 98.0 117/57 RR 14 HR 82 63.6 kg 62" skin/HEENt unremarkable full ROM neck, no carotid bruits appreciated CTAB RRR no murmur soft, ND no varicosities neuro grossly intact IABP right fem, left 2+ DP 2+ bil. PTs non-palp Pertinent Results: Conclusions PRE-BYPASS: 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. There is severe regional left ventricular systolic dysfunction with akinesis of the apex and hyperkinesis of the basal and mid segments. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. Mild to moderate ([12-31]+) mitral regurgitation is seen. There is no pericardial effusion. POST BYPASS: Marginally improved focal LV systolic function. Intraaortic balloon pump in good position. There is still inducible [Male First Name (un) ] with systolic BP in the range of 90-110 with moderate MR. [First Name (Titles) ] [Last Name (Titles) ] systolic function. No other changes. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD, Interpreting physician [Last Name (NamePattern4) ] [2167-7-30] 15:47 [2167-8-5] 05:25AM BLOOD WBC-11.1* RBC-3.11* Hgb-9.5* Hct-28.0* MCV-90 MCH-30.5 MCHC-33.9 RDW-14.9 Plt Ct-218# [2167-8-5] 05:25AM BLOOD Glucose-112* UreaN-17 Creat-0.6 Na-139 K-3.9 Cl-103 HCO3-31 AnGap-9 Brief Hospital Course: Ms. [Known lastname 45419] was admitted on the morning of [7-30] and went to the catheterization lab. IABP placed and taken to tht OR that morning for an emergency coronary bypass graft x2 (left internal mammary artery to left anterior descending artery and saphenous vein graft to obtuse marginal artery)with Dr. [First Name (STitle) ]. She tolerated the procedure well and was transferred to the CVICU in critical but stable condition on phenylephrine and propofol drips. She was extubated the morning of POD #1 and her drips were weaned. Gentle diuresis commenced. Her chest tubes and wires were removed. She was placed on amiodarone for atrial fibrillation and converted to sinus rhythm. She was transferred to the surgical step down floor, where she was seen in consultation by the physical therapy service. By post-operative day 8 she was ready for discharge. Medications on Admission: digitek 0.25 mg daily lasix 40 mg daily K CL 10 mEq daily prevacid 20 mg daily ASA 81 mg daily centrum Ferrous sulfate 325 mg daily zetia 10 mg daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg (2 pills) daily for one week and then 200mg (1 pill) daily . Disp:60 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking pain medication. Disp:60 Capsule(s) Refills:0 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:0 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:35 Tablet(s) Refills:0 5. 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:0 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. 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:0 8. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0 11. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: for urinary tract infection. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: CAD s/p cabg x2 NSTEMI CHF HTN hiatal hernia PSH: bladder suspension Discharge Condition: good Discharge Instructions: shower daily and pat incisions dry no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness or drainage Followup Instructions: see Dr. [Last Name (STitle) 65217] in [12-31] weeks see Dr. [Last Name (STitle) ] in [2-1] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2167-8-6]	[ "427.31", "414.01", "285.9", "599.0", "553.3", "428.0", "788.5", "998.11", "429.3", "738.3", "272.4", "401.9", "428.21", "E878.2", "410.71", "998.0" ]	icd9cm	[ [ [] ] ]	[ "37.61", "39.61", "99.05", "88.56", "99.20", "36.15", "37.23", "36.11" ]	icd9pcs	[ [ [] ] ]	5600, 5651	2941, 3825	295, 352	5764, 5771	1151, 2918	6028, 6338	884, 893		4025, 5577		5672, 5743		3851, 4002			5795, 6005								908, 1132																						249, 257														380, 695													717, 787	803, 868
6,081	179,050	25733	Discharge summary	report	Admission Date: [2186-7-13] Discharge Date: [2186-7-26] Date of Birth: [2124-11-14] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: 61 y/o male adm. to OSH 12 days PTA w/C/O abd. bloating, LE edema & fatigue, found to be in CHF, natrecor started. Cath revealed LM & 3vCAD, transferred to [Hospital1 18] for CABG Major Surgical or Invasive Procedure: CABG X 4 ([2186-7-17]) History of Present Illness: The patient is a 61-year-old man who presented with congestive heart failure, left lower extremity edema and ascites. He has a history of cirrhosis and liver dysfunction. It was elected to proceed with bypass surgery. The patient was transferred to the [Hospital1 69] from [Hospital ] Medical Center and was treated for heart failure and liver dysfunction prior to surgery. A Cardiac catheterization revealed three vessel coronary artery disease with an ejection fraction of 25%, He was thus referred for CABG Past Medical History: Hepatitis B Cirrhosis venous stasis disease CAD Social History: Occas. ETOH Smokes [2-5] PPD Family History: non-contributory Physical Exam: Neuro: alert, oroented in NAD Pulm: crackles bilat Cor: gr [4-9] syst. murmur Abd: soft, mod. distended Ext.: min. edema Pertinent Results: [2186-7-25] 04:25PM BLOOD WBC-7.5 RBC-3.40* Hgb-11.0* Hct-34.1* MCV-100* MCH-32.2* MCHC-32.1 RDW-16.8* Plt Ct-264 [2186-7-25] 04:25PM BLOOD Plt Ct-264 [2186-7-25] 04:25PM BLOOD PT-12.3 INR(PT)-1.0 [2186-7-25] 04:25PM BLOOD Glucose-106* UreaN-32* Creat-1.2 Na-150* K-4.0 Cl-108 HCO3-33* AnGap-13 [2186-7-25] 04:25PM BLOOD ALT-19 AST-22 LD(LDH)-207 AlkPhos-122* TotBili-0.8 Brief Hospital Course: Admitted to hospital, on cardiac surgery service. Heart failure service consulted, recommended diuresis pre-operatively. He was subsequently started on a Lasix drip. Hepatology also consulted, recommending preoperative ultrasound and abdominal CT scan. The RUQ ultrasound showed normal portal venous flow and two small gallbladder polyps. The abdominal scan was essentially unremarkable - there was no focal liver lesions, with only a small amount of perihepatic ascites. He otherwise remained stable on medical therapy and was eventually cleared for surgery. On [7-17], Dr. [Last Name (STitle) ] performed four vessel coronary artery bypass grafting utilizing the left internal mammary artery to the diagonal branch of left anterior descending artery, saphenous vein graft to the distal left anterior descending artery, saphenous vein graft to the obtuse marginal branch of the circumflex, saphenous vein graft to the posterior descending coronary artery. Postoperative echo was notable for a LVEF of 20% with no mitral regurgitation or aortic insufficiency. After the operation, he was brought to the CSRU. Within 24 hours, chest tubes were removed and he was extubated. He was slow to wean from inotropic support and initially required AV pacing for junctional rhythm. Beta blockade was initially withheld. The EP service was consulted to evaluate for permanent pacemaker plus/minus AICD(given his severely depressed LV function). He concomitantly experienced aphonia. Bedside swallow examination showed bilateral vocal cord paralysis, diffuse pharyngeal weakness and silent aspiration. He was subsequently made NPO and started on tube feedings. Over several days, his native heart rate improved to the 80's. Epicardial wires were eventually removed without complication. He otherwise remained stable on medical therapy. It was decided that a pacemaker was not indicated at this time but the need for an AICD will need to be assessed three months postoperatively. On postoperative day five, he transferred to the Step Down Unit. He continued to require diuresis and remained stable from a cardiac and liver standpoint. Beta blockade was not resumed. Over several days, he made clinical improvements as he worked daily with physical therapy. At discharge, his oxygen saturations were 99% on room air. His aphonia gradually improved. Repeat bedside swallow examination showed no signs of aspiration with pureed diet. Aspiration was however noted with thin liquids. Videofluroscopic evaluation on [7-24] confirmed aspiration but functional swallow was achieved with pureed/ground solids and honey thick liquids. Medications were subsequently crushed in puree and repeat videoswallow was recommended in one week to evaluate for diet advancement. By discharge, he was tolerating solids without difficulty. He was eventually cleared for discharge on postoperative day five. He will follow up in [Location (un) 37361], RI on [7-27] and again in two weeks. Medications on Admission: Aldactone Accupril Digoxin Aspirin Lamivridine Insulin Coreg Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 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. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [2-5] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 MDI Refills:1 5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 7. Protonix 40 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 Discharge Disposition: Home Discharge Diagnosis: CAD post-op dysphagia Discharge Condition: good Discharge Instructions: no lifting > 10# or driving for 1 month may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions Followup Instructions: with Dr. [Last Name (STitle) ] tomorrow in [Location (un) 37361], and again in 2 weeks with Dr. [Last Name (STitle) 64132] in [3-9] weeks Completed by:[2186-7-26]	[ "571.5", "V58.67", "414.01", "414.8", "784.41", "428.0", "272.4", "784.5", "427.89", "070.1", "583.9", "443.9", "355.9", "305.1", "401.9", "250.00", "789.5" ]	icd9cm	[ [ [] ] ]	[ "39.61", "39.64", "96.6", "36.15", "36.13", "99.04", "88.72" ]	icd9pcs	[ [ [] ] ]	5852, 5858	1817, 4799	507, 536	5924, 5930	1401, 1794	6112, 6297	1222, 1240		4910, 5829		5879, 5903		4825, 4887			5954, 6089								1255, 1382																						283, 469														564, 1084													1106, 1156	1172, 1206
77,149	119,960	50371	Discharge summary	report	Admission Date: [2141-4-6] Discharge Date: [2141-4-14] Service: MEDICINE Allergies: Quinidine / Propranolol / Heparin Agents / Warfarin / Zolpidem Attending:[First Name3 (LF) 14961] Chief Complaint: hypotension, hip fracture, renal failure Major Surgical or Invasive Procedure: Left ORIF [2141-4-7] History of Present Illness: Mr. [Known lastname ] is an 87 yo male with a history of diastolic CHF (EF 65% 1/10), AFib not on coumadin, mild AS, stage IV CKD, and HTN, who presented from acute rehab after falling at his nursing home. Yesterday he had been feeling well, walking with PT (using a walker) and feeling well. Today he was reaching onto a shelf for batteries when he turned too quickly and twisted his left foot under him, falling on his left side and left arm. He was sent from rehab to the ED. On exam, his hip was externally rotated and shortened. He had no other complaints and denied loss of consciousness or hitting his head on the fall. Hct was 29.6 at rehab, Na 142, K 4.0, BUN 51, Creat 2.1, WBC 6.8, Plt 215. . In the ED, triage vs were: T 96.3 P 60 BP 107/62 R 16 O2 sat 96% on RA, but he was then found to have systolic BP of 83-90s on exam. He had good peripheral pulses. He was evaluated for trauma and plain films of the left hip and femur were completed, showing multiple comminuted fractures for which the patient would need a THR. CT C-spine showed no fracture or malalignment, and moderate multilevel degenerative change on preliminary read. CT head without contrast showed no fracture or hemorrhage (preliminary read). . The patient was given 1L IVF and fentanyl 100 mcg for pain. His SBPs persisted in the 80s/90s. His Hct was found to be 24, down [4-3] points. CT ab/pelvis was performed in the setting of the Hct drop, showing left hip intertrochanteric fracture, a large retroperitoneal mass likely from left adrenal gland (non-urgent MR recommended for further evaluation), and no retroperitoneal hematoma on preliminary read. He was found to be guaiac negative. He continued with HR in 60s and systolics in 90s, received an additional 1L IVF (and a second liter was begun prior to transfer), and was typed and crossed for 2 units pRBC. CXR showed a retrocardiac opacity and he was given levofloxacin 750 mg for empiric pneumonia coverage after a single blood culture was drawn. A Foley was placed. Transfer vitals in the ED were HR 64, RR19 100% on 4L (desatted after NS to low 90s), 88/48. . The patient was admitted to the MICU, where initial vitals were HR 69 BP 102/63-120/75, RR 32-20, SpO2 100% on 1L NC. . On ROS, the patient denies any LOC, dizziness/lightheadedness, recent diarrhea (though had diarrhea in prior admission). +cough with small amounts of yellowish sputum but not in past few days. No fevers. Past Medical History: -Congestive heart failure with preserved LVEF (65% 1/10) --> per DCS from [2-8], thought to have left HF leading to right HF without primary pulm HTN -Chronic Atrial fibrillation, not on warfarin given recent UGIB ([2-8]) -Pulmonary artery hypertension (30mmHg + RA [11-6]) -Mild MR, moderate TR, mild AI, mild AS (peak 25 mmHg [11-6]) -Mild ascending aortic dilatation (3.7 cm) -Left ventricular hypertrophy -Prostate enlargement (followed by Dr. [Last Name (STitle) ] [Last Name (STitle) 79]) -Hypertension -Hypercholesterolemia -Severe essential tremor, since [2076] (WWII) -Venous stasis, followed by Dr. [Last Name (STitle) ] [Name (STitle) 104985] hernia repair -Anemia, multifactorial (chronic illness, CKD, recent GIB) -Hemorrhoid repair -History of MRSA cellulitis ([2-7]) -Chronic Renal Failure [1-31] poor forward flow from CHF: Stage IV with eGFR of 24 ml/min (MDRD). Near dialysis. Recommend to check PTH every 3 months with target of 70-110. -Left foot abscess s/p I&D -Multiple episodes of C. Diff colitis (third episode this year during [3-17] hospitalization) -GIB ([2141-3-17]) with guaiac positive stools, but no endoscopy performed . Recent hospitalizations: [2140-12-29] to [2141-1-4] -- for CHF exacerbation, given lasix ggt -- left foot cellulitis/fluid collection managed medically with Vanc/Cipro/Flagyl -- AFib subtherapeutic on Coumadin so bridged with Heparin with subsequent rectal bleeding, traumatic hematoma, oozing from newly placed PICC line -- incidentaloma seen in pancreas on RUQ u/s without further w/u . [2141-1-31] to [2141-2-15] -- also for CHF exacerbation, given lasix ggt and metolazone -- supratherapeutic INR on admission, complicated by epistaxis and melena (GI followed but endoscopy was deferred) -- C diff colitis treated with ? both Po flagyl and vancomycin, course should have been completed [2141-2-19] . [2141-3-7] to [2141-3-10] -- Unresponsive while sleeping after trazadone; negative infectious work up -- 16 beat run of VT -- Decreased metoprolol from 12.5mg->6.25mg [Hospital1 ] -- Renal failure attributed to torsemide and pre-renal . [2141-3-17] to [2141-3-31] -- Sent in by rehab for sleepiness, low Hct, weight gain, cough. -- C. Diff colitis -- GIB (Guaiac positive, had been on coumadin until [Month (only) 956] when had presumed UGIB requiring 1U pRBC); transfused for Hct 23.5 (but near baseline of 24) -- Hypotension to the 70s systolic (baseline 90-100s) -- CHF -- UTI -- Acute on chronic kidney disease -- Pancytopenia: found to be HIT antibody positive but serotonin assay negative so not likely HIT; nonetheless heparin products were avoided. Pancytopenia improved over hospital course; thought to be infection related. -- Increased AP and GGT with elevated lipase and an abnormality on ultrasound suggestive of a pancreatic mass. GI was consulted and recommended an outpatient MRCP. Social History: Usually lives with wife, married for >50yrs, currently at [Hospital 100] Rehab. 3 children. No tobacco, EtOH, IVDU. Retired, formerly worked manufacturing and distributing batteries. He smoked cigars for 2-3 years and quit >45 years ago. He has not smoked cigarettes. He does not drink alcohol on a regular basis. Denies IV, illicit, or herbal drug use. Family History: Parents are both deceased. Father (73 years; "heart" disease); Mother (48 years; stomach cancer). He has 2 siblings (80- breast cancer, brother with ? abdominal cancer). He has 3 children (55, 53, 49 years; all well). A son [Doctor Last Name ] has atrial fibrillation. Physical Exam: T 91.2 (axillary) HR 69 BP 102/63-120/75, RR 32-20, SpO2 100% on 1L NC. Wt 167. General: Alert, oriented, breathing heavily and appears in pain HEENT: Sclera anicteric, MMM Neck: supple, JVP 11 cm Lungs: Clear to auscultation bilaterally anteriorly but difficult to assess with much transmitted upper airway sounds, no wheezes, rales, ronchi CV: Irregularly irregular rhythm, normal rate, distant heart sounds, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: foley Ext: cool, 2+ DP pulses bilaterally, no clubbing. [2-1]+ pitting edema bilaterally; lower legs wrapped in ACE bandages. Multiple small ecchymoses on UE bilaterally. Left leg externally rotated and shortened, with ecchymosis noted on lateral hip area. . On discharge: VSS, BPs in 80s-100s systolic. Jaundiced with icteric sclera. JVP at earlobe. Lungs clear, irregular rate, LE edema improved, surgical scar covered. Pertinent Results: Labs on admission: . [2141-4-6] 10:35PM URINE HOURS-RANDOM UREA N-323 CREAT-26 SODIUM-78 [2141-4-6] 10:35PM URINE COLOR-HAZY APPEAR-PINK SP [Last Name (un) 155]-1.008 [2141-4-6] 10:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2141-4-6] 10:35PM URINE RBC-388* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [2141-4-6] 10:35PM URINE HYALINE-2* [2141-4-6] 08:20PM SODIUM-140 POTASSIUM-5.1 CHLORIDE-101 [2141-4-6] 08:20PM PHOSPHATE-5.0* MAGNESIUM-2.1 [2141-4-6] 08:20PM CORTISOL-26.4* [2141-4-6] 08:20PM WBC-8.2 RBC-2.61* HGB-7.8* HCT-22.8* MCV-87 MCH-29.8 MCHC-34.1 RDW-18.7* [2141-4-6] 08:20PM PLT COUNT-128* [2141-4-6] 07:32PM COMMENTS-GREEN [2141-4-6] 07:32PM LACTATE-0.9 [2141-4-6] 03:05PM GLUCOSE-78 UREA N-65* CREAT-2.7* SODIUM-140 POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-28 ANION GAP-18 [2141-4-6] 03:05PM estGFR-Using this [2141-4-6] 03:05PM WBC-6.4 RBC-2.74* HGB-8.1* HCT-24.8* MCV-90 MCH-29.6 MCHC-32.8 RDW-18.6* [2141-4-6] 03:05PM NEUTS-87.8* LYMPHS-7.5* MONOS-3.1 EOS-1.0 BASOS-0.4 [2141-4-6] 03:05PM PLT COUNT-163 [2141-4-6] 03:05PM PT-13.0 PTT-31.3 INR(PT)-1.1 . Labs on discharge: . WBC 5.4, HCt 28.7, platlets 162 BUN 75 Creat 3.5 Na 147 K 3.8 cl 108 Hco3 24 ALT 14 AST 55 APhos 405 amylase 58 tot bili 13.6 dir bili 10.6 PTH 267 Cortisol 26.4 . Radiologic Studies: [4-6] CT Ab/pelvis w/o contrast: 1. Left intertrochanteric hip fracture. 2. Large left adrenal mass, which is not characterized on non-contrast examination. However, the imaging features are not consistent with an adrenal hematoma. A nonurgent adrenal MR recommended for further characterization. 3. Cholelithiasis. 4. Atherosclerotic calcification of the abdominal aorta and its branches. 5. No evidence of retroperitoneal hematoma. 6. Prostatic enlargement. . [4-6] Plain film hip - LEFT HIP, TWO VIEWS: There is a comminuted and impacted intertrochanteric fracture of the left femur with superior displacement of the fracture fragments and varus angulation of the femoral shaft. The femoral head remains seated within the acetabulum. The SI joints and right hip joint remain preserved. There is no pubic symphysis diastasis. The distal left femur and proximal tibia appear unremarkable without fracture or malalignment. A focal sclerotic lesion projecting over the right acetabulum is unchanged since at least [2139]. Incidental note is made of vascular calcifications. IMPRESSION: Comminuted and impacted intertrochanteric fracture of the left femur. . [4-6] CXR - CHEST, SINGLE VIEW: Evaluation is significantly limited by patient rotation. Within that limitation, there is stable mild cardiomegaly with likely tortuous descending aorta. Increased retrocardiac opacity likely represents atelectasis in the left lung base. A small left pleural effusion likely persists. The right lung appears clear. There is no pneumothorax or pulmonary edema. No acute displaced fracture is identified. IMPRESSION: Limited study demonstrates stable cardiomegaly with likely persistent left pleural effusion with basilar atelectasis. Concurrent underlying infection cannot be excluded. If clinically indicated, repeat study may be obtained with PA and lateral views and optimized technique. . [4-6] CT C-spine w/o contrast - 1. No fracture. 2. Multilevel degenerative change. 3. Grade I anterolisthesis of C7 on T1 and T1 on T2, presumably degenerative in nature. . [4-6] CT head w/o contrast - There is no hemorrhage, edema, mass effect, shift of midline structures, or evidence of major vascular territorial infarction. There is no acute fracture. There is prominence of ventricles and sulci consistent with age-related parenchymal involutional change. There is periventricular hypodensity consistent with chronic small vessel ischemic change. There is a subcentimeter right frontal sinus osteoma (2:16). . STUDY: Left humerus two views [2141-4-8]. HISTORY: 87-year-old man with mechanical fall, now with shoulder pain. Evaluate for fracture. FINDINGS: Two views of the left humerus demonstrate no fractures or dislocations. Left shoulder and elbow joints are grossly intact as well. The visualized left lung apex is clear. . [4-7] CXR: Left lower lobe atelectasis or consolidation. Persistent cardiomegaly and moderate left effusion. . [4-8] CXR: There is cardiomegaly which is stable when compared to the prior study from [2141-4-7]. There is a left retrocardiac opacity, which is likely due to atelectasis or consolidation. There is also a small left-sided pleural effusion. There are no signs for overt pulmonary edema. The right lung is grossly clear. There is a small right-sided pleural effusion that has developed in the interim. . [2141-4-8] Humerus AP and lat: Two views of the left humerus demonstrate no fractures or dislocations. Left shoulder and elbow joints are grossly intact as well. The visualized left lung apex is clear. . [2141-4-9]: renal US 1. No evidence of hydronephrosis. 2. Left adrenal mass. Recommend MRI for further evaluation. . [2141-4-12] liver and gallbladder US 1. Cholelithiasis with gallbladder sludge and mild gallbladder wall thickening as well as pericholecystic fluid. All of these findings were seen on the prior CT from [2141-4-6]. The lack of son[Name (NI) 493] [Name2 (NI) 515] sign suggests the GB findings as detailed are chronic. If needed, a HIDA scan may be performed to confirm. 2. Echogenic right kidney compatible with chronic medical renal disease. . Urine/blood cxs: pending . CMV: pending Brief Hospital Course: Mr. [Known lastname ] is an 87 yo male with a history of diastolic CHF (EF 65% 1/10), AFib not on coumadin, mild AS, stage IV CKD, and HTN, who presents from acute rehab after falling at his nursing home and was found to have a left intertrochanteric fracture initially admitted to the MICU for hypotension, fracture repaired, floor course complicated by renal failure, persistent hypotension and hyperbilirubinemia. . # HYPOTENSION/ACUTE BLEED/HEMATURIA. Baseline bp per [3-31] discharge summary is sbp 90s-100. Patient found to have sbp in 80s in ED, improved to 100s with IVF. Ddx = septic shock (given hypothermia, but this is pt??????s baseline per wife and chart and he has no WBC), no evidence of bleed, vasovagal in setting of severe pain, cardiogenic in setting of severe CHF, adrenal insufficiency (cortisol normal). Most likely due to combination of dehydration +/- acute bleed in setting of poor cardiac function. Infx w/u was negative and pt pressures stabilized with fluid and blood products. Aspirin was initially held out of concern for bleed but was restarted on dc. . # LEFT HIP FRACTURE: s/p ORIF with TFN. Pt recovered well with adequate pain control on oxycodone. He was started on enoxaparin which will be continued through [2141-5-9]. Pt to f/u with ortho 2 wks after dc. . # CKD - stage IV, likely due to hypotension, ATN. UOP minimal during the hospitalization. Creatinine baseline 2.0, elevated to high of 4 during this admission and decreased to 3.5 on dc. Pt seen by renal, no urgent indications for dialysis and pt does not wish to undergo dialysis. Diuretics were held, he was provided with gentle hydration. Pt will require frequent monitoring of lytes while in rehab. . # HYPERBILIRUBINEMIA: direct>indirect with elevated alk phos, however no evidence of obstruction on US. Pt was seen by liver consult team who thought that it may be effect of vancomycin, however recommended continuing the medication for tx of cdiff. F/u liver tests ordered, including autoimmune serologies, hepatitis serologies, iron studies, which will requrie f/u on discharge. Pt has scheduled follow up with liver clinic on discharge. . # LEFT ARM/SHOULDER PAIN: Patient may have injured LUE during fall ?????? he landed on his left side, but is unable to recall whether he had pain in his arm at that time. Limited internal/external rotation of L shoulder on exam. Plain films of shoulder with no fracture or dislocation, pt was treated with pain control . # CHF - endstage, pt followed by Dr. [Last Name (STitle) 696] who saw him while in the hospital. Difficult to titrate meds in setting of CKD, however no evidence of volume overload while on the medicine floor. His diuretics were held while in the hospital and on discharge in the setting of hypotension and renal failure, however may need to be restarted on discharge. His BBlocker was continued while in the hospital, however often was held due to hypotension. Aspirin was restarted on dc, statin held in the setting of liver disease. . # HYPERKALEMIA: likely secondary to hemolysis post-transfusions, improved throughout the admission, required dose of kayexylate . # RETROPERITONEAL MASS: Adrenal mass seen on CT this admission (8x6.2 cm). Non-urgent adrenal MRI recommended by radiology for further characterization. Not evident on prior MRI [2-7], but "Large but poorly assessed hypoechoic area (4 cm) in the region of the left upper pole, for which differential considerations include an adrenal or renal mass, or a renal cyst" seen on abdominal ultrasound [1-8]. Cortisol wnl. Pt will require non-urgent MRI as an outpt. . # POSSIBLE PNEUMONIA. Initial CXR concerning for retrocardiac opacity. Pt received levofloxacin in ED. No WBC, no respiratory symptoms, therefore further abx were held and pt remained stable with no further respiratory complaints. Legionella was negative. He was treated symptomatically with nebs. . # THROMBOCYTOPENIA. Had pancytopenia at prior admission, normalized during admission. HIT ruled out, but heparin products avoided because initial GP4 antibody positive (Serotonin assay negative). DDx dilutional (most likely) vs consumptive vs chronic disease. . # RECURRENT C. DIFF INFECTION. On PO Vanco taper. No diarrhea currently. Vanco was continued, liver consulted in setting of hyperbili but agreed with continuation. . # Atrial Fibrillation. Initially held ASA in setting of low Hct; not on Coumadin due to GIB, aspirin restarted on DC and metoprolol continued. . # CHRONIC ANEMIA. Baseline Hct 30; likely secondary to CKD/chronic disease, improved and stabilized after transfusions. . # CHRONIC VENOUS STASIS: tx'd with wound care while inpatient. . # NASAL CONGESTION: saline, flonase . # Code: DNR/DNI Medications on Admission: -Vicodin 5/500 2 tabs qd -Pantoprazole 40 mg Tablet qd -Vancomycin 125 mg PO Q6H; taper as follows: [Date range (1) 10275] 125mg Q6H; [Date range (1) 86878] 125mg Q12H; [Date range (1) 68651] 125mg daily; [Date range (1) 46556] 125mg; every other day [Date range (1) 96735] 125mg; every third day; then stop. -Ativan 0.125 mg tid prn -Ammonium Lactate 12% Lotion Topical [Hospital1 ] -Ipratropium Bromide 0.5 mg Neb Inhalation Q6H PRN SOB/Wheezing. -Torsemide 40 mg PO BID (if weight > 160lbs, increase to 80mg in the morning and 40mg at night; if weight < 145lbs, decrease torsemide to 40mg daily) -Spironolactone 25 mg Tablet PO DAILY -Metoprolol Tartrate 12.5 mg PO BID -Simvastatin 40 mg PO qpm -Ergocalciferol (Vitamin D2) 5,000 unit po weekly -Bisacodyl suppository 10 mg qd prn -Senna qd prn -Aspirin 81 mg po qd -Acetaminophen 325 mg 1-2 Tablets PO Q4H prn pain / fever. -Tums [Hospital1 ] -Cadexomer iodine topical gel q3d topical -Dextromethorphan-Guaifenesin 30 mg q12hr prn Discharge Medications: 1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO as directed: [Date range (1) 86878] 125mg Q12H; [Date range (1) 68651] 125mg daily; [Date range (1) 46556] 125mg; every other day [Date range (1) 96735] 125mg; every third day; then stop. . 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Ativan 0.5 mg Tablet Sig: [12-31] Tablet PO three times a day as needed for anxiety. 4. Ammonium Lactate 12 % Cream Topical 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Ergocalciferol (Vitamin D2) Oral 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 13. Cadexomer Iodine Topical 14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q12H (every 12 hours) as needed for cough. 15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-31] Sprays Nasal TID (3 times a day) as needed for congestion. 19. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 20. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours) for 1 months: last day [2141-5-9]. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: Primary: hip fracture . Secondary: hypotension, renal failure, hyperbilirubinemia 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 for a hip fracture and treated for hypotension and renal failure while in the hospital. Additionally, your heart failure was managed and a work-up was initiated to determine the cause of your elevated bilirubin. . The following changes were made to your medications: -Your diuretics (torsemide, spironolactone) were held because you were hypotensive -Your statin was held out of concern for liver disease -Start taking lovenox for 1 month . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: We are working on a follow up appointment with Dr. [Last Name (STitle) 696] in Cardiology within 4-8 days. The office will contact you with an appointment. If you have not heard or have any questions please call [Telephone/Fax (1) 62]. . Also, please follow-up in the liver center and with orthopedics as outlined below: . Department: LIVER CENTER When: FRIDAY [2141-5-5] at 10:50 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: ORTHOPEDICS When: TUESDAY [2141-4-25] at 2:45 PM With: [Known firstname ] [Last Name (NamePattern1) 2235], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "428.0", "600.00", "428.32", "276.7", "789.39", "574.20", "511.9", "427.31", "285.21", "276.51", "459.81", "287.5", "518.0", "E885.9", "729.1", "416.8", "584.9", "403.90", "599.70", "585.4", "820.21", "008.45", "440.0", "458.9", "333.1" ]	icd9cm	[ [ [] ] ]	[ "79.35" ]	icd9pcs	[ [ [] ] ]	20891, 20985	13123, 17876	311, 337	21111, 21111	7453, 7458	21860, 22781	6174, 6449		18967, 20868		21006, 21090		17902, 18944			21287, 21837								6464, 7267														7281, 7434								231, 273						8705, 13100								365, 2806							7472, 8686	21126, 21263					2828, 5782	5798, 6158
5,886	141,426	53501	Discharge summary	report	Admission Date: [2181-6-16] Discharge Date: [2181-6-21] Date of Birth: [2127-3-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: CC:[CC Contact Info ] Major Surgical or Invasive Procedure: Intubation History of Present Illness: HPI: 54 yo M with h/o HCV, hepatocellular ca, cirrhosis, ascites who has been living in a nursing home transitioning to hospice. Plan was for patient to go back to [Country 4812] where he would likely die soon. Instructions were that he wanted to remain full code in hopes that he would be able to make it back to [Country 4812]. On DOA pt was noted to have MS changes and was sent to ED. On arrival he was noted to have sBP in 60's and was started on levophed and bolused with IVF. Lactate was 10.6. ECG showed peaked t waves and K was 6.8. An NG tube was placed to give him kayexalate and coffee ground material was aspirated. He was given IV protonix, vanco, levofloxacin, flagyl and albumin in the ED. LFT's were c/w cholangitis and RUQ U/S showed no significant change from prior exam. Surgery was consulted but felt that pt was not a surgical candidate given comorbidities and overall dismal prognosis. This was communicated to the patients friends who accompanied him in the [Name (NI) ], but they felt uncomfortable changing his code status. His brother is flying to [Name (NI) 86] from [Country 4812] and the wish was expressed that the patient be supported fully, including intubation if necessary, until his brother arrives tomorrow ([6-17]). Past Medical History: Past Medical History: -Hepatitis C (unclear how he got it); HIV negative -Etoh abuse; stopped Febr 06 -s/p R-humerus fracture (ORIF - [2180-1-5]) -R ankle arthritis -hepatocellular ca, diagnosed [4-9]; non-surgical; plans on going back to [Country 4812] in [Month (only) 116] -esophagitis [4-9] -portal vein thrombosis -chronic LLE swelling Social History: He emigrated from [Country 4812] in [2162] and lived in [Country 2784] a few years before moving to USA about 10 years ago. He was formerly an artist educated in [Country 4812] but left during political unrest. He is single and currently unemployed. He used to live at the [Company 3596], currently lives at a NH. He has a sister that lives in town. He was never married and has no children. He denies excessive drinking but does admit to getting drunk on the weekends. He drinks beer regularly and whiskey on the weekends until [Month (only) 956]. No IVDU. No smoking. Family History: noncontributory Physical Exam: VITALS: T 95.8 HR 109 BP 97/50 RR 26 sO2 95% on 4L NC, CVP 12, MAP 61 GEN: ill-appearing male w/ NG tube in place, uncomfortable and breathing rapidly. Understands simple english SKIN: cool, dry HEENT: mmm w/ dried blood at gumline, scleral icterus, arcus senilus NECK: prominent venous pulsations, no LAD; no carotid bruits; neck supple LUNGS: bilateral rales by anterior exam; no wheezes or rhonchi HEART: tachycardic, could not appreciate murmur ABDOMEN: faint bowel sounds, soft, tender at RUQ, distended, liver palpable (about 1cm under costal margin) EXTREMITIES: edema 1+R, 2+L (chronic); marked asterixis NEURO: alert, intermittently answering questions. oriented to place - names [Hospital3 ] Pertinent Results: Labs: Notable for lactate 10.6, WBC 13.3, K 6.8, T. bili 18.5, INR 2.1 . Studies: CXR ([2181-6-16]) 6:49 p.m.: There are multiple new ill-defined patchy opacities throughout both lungs, perihilar haze, and an effaced right diaphragmatic border. This is secondary to multifocal pneumonia, asymmetric pulmonary edema, or combination. A small right pleural effusion is also present. The cardiac size continues to be normal, and the mediastinal contours are normal. An NG tube is located in the stomach. IMPRESSION: Multifocal pneumonia, asymmetric pulmonary edema, or combination. . CXR (5/13/06)7:57 p.m.: In the one hour interval, a right internal jugular central venous catheter has been placed with the tip projecting over the cavoatrial junction. There is no evidence for pneumothorax. Opacification of both lungs appears to be worsening. IMPRESSION: Worsening bilateral opacification with new central venous line provjecting over cavoatrial junction. . RUQ U/S ([2181-6-16]) - prelim read: 1. Portal vein thrombosis with apparent cavernous transformation. Unchanged compared to prior examination of [4-17], [2181]. 2. Heterogeneous right liver lobe lesions consistent with HCC. 3. Minimal amount of ascites. 4. Gallbladder wall thickening with no evidence of acute cholecystitis. Brief Hospital Course: A/P: 54 yo M with h/o HCV, hepatocellular ca, cirrhosis, ascites who presents with sepsis, hyperkalemia and ARF. . # septic shock: The patient was admitted with concern for septic shock of a cholagitis or lung origin. BP remained low. Pressers were eventually weaned down and off for a short period of time and then eventually were restarted. . # hypotension: Pt's BP at presentation was 70s/palp. Differentials include sepsis, 3rd space fluid shift resulting from hypoalbuminemia; less likely from GI bleed. BP increased over subsequent days and pressors were decreased. . # hypoxemia: Pt was initially hypoxemic - this then resolved. . # MS changes: The pt was unresponsive off sedation, likely due to hepatic encephalopathy but intracranial process is another possibility. . # GI bleed: Pt reported to have coffee-ground material from NG aspirate. Pt has known cirrhosis and portal vein thrombosis which has likely resulted in the development of porto-caval anastomosis and varices. Of note, pt had EGD in [4-9] which did not show any evidence of varices. . # ARF: Creatinine was 4.2 at presentation; baseline <1.0. This improved with hydration. . # ?ST depression: there was no CE elevation . # coagulopathy: INR elevated to 2.1 - likely due to liver failure. Pt got vitamin K but coagulopathy worsened. Eventually, he began bleeding profusely and could not be resucitated effectively and care was withdrawn (see below). . # HCC: Pt has a large liver mass and elevated alpha-fetoprotein. Patient is not a candidate for surgery or transplant due to the size of his mass, and the presence of cirrhosis and portal venous involvement. Not a candidate for chemotherapy given poor performance status. This was the underlying cause of his worsening status over this hospital stay. . The patient was treated supportively. Though his ARF improved, his mental status did not, nor did his liver function. On the final day of hospitalization he developed bleeding from the ETT, line site, and HCT dropped. He became tachycardic, hypotensive, and remained unresponsive. His brother was notified of his status change and, despite efforts to resuscitate his blood volume, he remianed hypotensive. His brother was [Name (NI) 653] and agreed with withdrawal of resuscitative measures and focus on comfort. The ETT was withdrawn and the patient developed cardiopulmonary failure within 15 minutes. He died at 11:05 pm on [2181-6-21]. Medications on Admission: Meds on admission: Nystatin 5 mL p.o. q.i.d. Protonix 40 mg p.o.daily, Lasix 40 mg p.o. daily, spironolactone 50 mg p.o. daily, bisacodyl p.r.n. lactulose 30 mL t.i.d. levofloxacin 500 mg p.o. once daily lorazepam 0.5 mg p.o. q.4-6h. p.r.n. Colace 100 mg p.o. b.i.d. ibuprofen 800 mg p.o. q.8h. as needed, morphine sustained release tablets 30 mg p.o. b.i.d. oxycodone 5 mg p.o. q.2-4h. p.r.n. Zofran 8 mg p.o. q.8h. p.r.n. nausea Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased Completed by:[2181-6-22]	[ "578.9", "286.9", "995.92", "785.52", "276.7", "155.0", "584.9", "038.9", "070.71", "518.81", "410.71", "576.1", "571.5", "486", "452" ]	icd9cm	[ [ [] ] ]	[ "96.71", "99.07", "96.04", "99.04" ]	icd9pcs	[ [ [] ] ]	7713, 7722	4759, 7204	340, 352	7774, 7784	3432, 4736	7841, 7880	2671, 2690		7685, 7690		7743, 7753		7230, 7235			7808, 7818								2705, 3413																						276, 302														380, 1659							7249, 7662						1703, 2044	2060, 2655
28,154	176,957	2437	Discharge summary	report	Admission Date: [2180-2-19] Discharge Date: [2180-2-28] Date of Birth: [2117-4-10] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2180-2-21] Aortic Valve Replacement with 23mm St. [Male First Name (un) 923] mechanical and Mitral Valve Replacement [Street Address(2) 12523]. [Male First Name (un) 923] mechanical History of Present Illness: 62 y/o male with h/o rheumatic heart disease with aortic and mitral valve stenosis. He also has h/o CAD with LAD stenting in [2175], complete heart block w/ ppm placed in [2174] and PAF. Recent echo showed severe aortic and mitral stenosis with increased gradients. Past Medical History: Rheumatic heart disease, Aortic Stenosis, Mitral Stenosi, Coronary artery disease s/p stent, Hypertension, Hypercholesterolemia, PAF, Complete Heart Block s/p pacemaker, Pneumonia [2177] Social History: Married lives with his wife and children. He has a daughter who works at [Hospital1 18]. Quit smoking 20 years ago. Social drinker. No other signficant drug use history. Family History: Not contributory Physical Exam: VS: 70 irregular 110/78 Gen: NAD Skin: Venous stasis changes in LE HEENT: EOMI, PERRL, OP benign Neck: Supple, FROM -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR +murmur Abd: Soft, NT/ND +BS Ext: Warm -edema Neuro: A&O x 3, non-focal Pertinent Results: [2-23] CXR: In comparison with study of [2-21], the patient has taken a much poorer inspiration. The endotracheal tube and nasogastric tube have been removed. Swan-Ganz catheter has been removed and the right IJ sheath remains in place. Atelectatic changes persist at the left base with blunting of the right costophrenic angle suggesting pleural fluid in this region. [2-21] Echo: Pre Bypass: Poor transgastric windows and significant artifact limit this study. The left atrium is moderately dilated. Smoke is seen in the left atrial appendage. The right atrium is moderately dilated. The left ventricle is not well seen. with normal free wall contractility. Estimated LVEF 50%The ascending aorta is moderately dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. The mitral valve shows characteristic rheumatic deformity. There is severe valvular mitral stenosis (area <1.0cm2). Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Post Bypass: Patient is on epinepherine 0.4 mcg/kg/min, phenylepherine infusions, V paced. Preserved biventricular function. LVEF 50-55%. There is a mechanical Aortic valve instu with normal bileaflet motion. It appears well seated with no perivalvular leaks and normal washing jets seen. Peak gradient 5, mean gradient 1 mm Hg. There is a mechanical Mitral prosthesis insitu with a mean gradient 4 mm hg. Bileaflet motion is normal. No perivalvular leaks seen. Normal washing jets seen on the mitral prosthesis. Aortic contours intact. TR remains 2+. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [2-20] CXR: Moderate cardiomegaly is stable. Lungs are clear and there is no pleural effusion. Transvenous right atrial and right ventricular pacer leads follow their expected courses continuously from the left axillary pacemaker. [2180-2-19] 06:50PM BLOOD WBC-6.7 RBC-4.57* Hgb-13.8* Hct-41.3 MCV-90 MCH-30.2 MCHC-33.4 RDW-12.6 Plt Ct-204 [2180-2-25] 06:40AM BLOOD WBC-13.6* RBC-3.29* Hgb-10.1* Hct-29.6* MCV-90 MCH-30.6 MCHC-34.1 RDW-13.1 Plt Ct-168# [2180-2-19] 06:50PM BLOOD PT-15.6* PTT-27.9 INR(PT)-1.4* [2180-2-25] 01:10PM BLOOD PT-18.6* PTT-59.6* INR(PT)-1.7* [2180-2-19] 06:50PM BLOOD Glucose-166* UreaN-18 Creat-1.0 Na-141 K-4.4 Cl-103 HCO3-30 AnGap-12 [2180-2-25] 06:40AM BLOOD Glucose-103 UreaN-24* Creat-1.1 Na-136 K-4.3 Cl-97 HCO3-32 AnGap-11 Brief Hospital Course: Mr. [Known lastname 12524] was admitted pre-operatively secondary to being on Coumadin. Upon admission he was started on Heparin and appropriately work-up prior to surgery. On [2-21] he was brought to the operating room where he underwent a aortic and mitral valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on diuretics and gently diuresed towards his pre-op weight. On post-op day to Coumadin was initiated with a Heparin bridge for his mechanical valves. Chest tubes and epicardial pacing wires were removed on this day. On post-op day three he was transferred to the telemetry floor for further care. Over the next several days he remained relatively stable while receiving Coumadin and awaiting his INR to increase to therapeutic level. On post-op day seven he was discharged home with the appropriate medications and follow-up appointments. [Doctor First Name ] at Dr. [Last Name (STitle) 12525] office will resume coumadin management. Medications on Admission: Aspirin 325mg qd, Zocor 80 mg qd, Toprol 50mg qd, Lasix 40mg qd, Diovan 160mg qd, Coumadin qd (last dose 2/19) Discharge Medications: 1. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 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:0 3. Toprol XL 50 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:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO ONCE (Once) for 1 doses: 7.5 mg; Check INR [2-29] with results to Dr. [Last Name (STitle) 12525] office. . Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Rheumatic Heart Disease/Aortic Stenosis/Mitral Stenosis s/p Aortic Valve Replacement and Mitral Valve Replacement Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 8499] will be following your INR and adjusting your Coumadin accordingly [Last Name (NamePattern4) 2138]p Instructions: [Hospital Ward Name 121] 6 for wound check in 2 weeks Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) 911] in [1-30] weeks Dr. [Last Name (STitle) 8499] in [12-29] weeks Completed by:[2180-2-28]	[ "285.9", "V58.66", "396.0", "398.90", "272.0", "V58.61", "V45.01", "427.31", "401.9", "V15.82", "V45.82", "414.01", "458.29" ]	icd9cm	[ [ [] ] ]	[ "39.63", "88.72", "35.24", "35.22", "39.61" ]	icd9pcs	[ [ [] ] ]	6748, 6806	4306, 5502	301, 501	6963, 6969	1517, 4283		1225, 1243		5663, 6725		6827, 6942		5528, 5640			6993, 7558			7609, 7848					1258, 1498																						242, 263														529, 804													826, 1018	1034, 1209
81,817	135,016	53967	Discharge summary	report	Admission Date: [2162-4-5] Discharge Date: [2162-4-6] Date of Birth: [2132-12-25] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: GIB Major Surgical or Invasive Procedure: [2162-4-5] Upper endoscopy, 2 endoclip placement over the duodenal ulcer History of Present Illness: 29M with no significant PMH presents after 5 days of dark black stool and abdominal cramping, noted to have ? flecks of bile vs. food vs. coffee ground in the vomitus at triage, hyotension, tachycardia, and anemia. Per patient, he took Pepto-Bismol 3 times earlier in the weeks for 3 days. He started because of gas discomfort. He stopped after he noticed dark black stool. He reports [1-15] time bowel movement daily which is unchanged. He was seen at [Hospital1 2177] on Friday and was suppose to see his PCP today for [Name Initial (PRE) ]/u. He was prescribed a medication but he has not started it. He was told that he could try Gas-X, but he also did not start it. He denies a hx of heavy EtOH use, prior GI bleeds or any medical problems. [Name (NI) ] reports drinking last night. He reports taking Excedrin about 2 weeks ago for headahce. He drinks 1 extra-large coffee a day In the ED, initial VS were BP 74/46 with HR 60 in the setting of ongoing emesis. He was triggered for hypotension which was thought to be vasovegal. He apparently became unresponsive and passed out. This rapidly improved to 109/56 102 29 98% RA by the time he left triage. Guaiac was noted to be positive brown stool. EKG was reported to be sinus with TWI throughout and no ST changes. Later, he received 1L IVF, however remainined hypotensive to SBP 70s, mentating well. Therefore, he was given 2 liters of IVF and 1 units of uncross-matched blood given. 18 g x2 IV placed. Protonix bolus and gtt were started. GI was made aware of him. ICU transfer was therefore initiated. On arrival to the MICU, patient is feeling well except for the dark black stool and intermittent gas discomfort Past Medical History: - Headache Social History: - works as a CNA - denies tobacco and drugs - reports EtOH 2.5 servings on weekends only - lives by self, separated, has a 2.5 yo son, has a girlfriend Family History: - denies IBD and other GI disease - denies bleeding disorder - denies CVA, cardiac, DM family history Physical Exam: Admission exam Vitals: 98.3 F, HR 102, BP 119/68-> sitting 110/60s with HR up to the 110s, RR 20, O2Sat 100% RA, weight 90.6 lb General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, 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, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding Rectal: dark brown liquid stool, guaiac + GU: no foley 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. Discharge exam Tmax: 37.1 ??????C (98.7 ??????F) Tcurrent: 36.9 ??????C (98.4 ??????F) HR: 84 (79 - 104) bpm BP: 116/71(80) {97/44(64) - 131/85(93)} mmHg RR: 15 (0 - 23) insp/min SpO2: 99% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, 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, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding Rectal: dark brown liquid stool, guaiac + GU: no foley 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 Pertinent Results: Admission labs [2162-4-5] 05:05AM BLOOD WBC-10.7 RBC-3.71* Hgb-9.6* Hct-29.0* MCV-78* MCH-25.8* MCHC-33.0 RDW-15.0 Plt Ct-290 [2162-4-5] 05:05AM BLOOD PT-11.6 PTT-22.9* INR(PT)-1.1 [2162-4-5] 05:05AM BLOOD Glucose-119* UreaN-34* Creat-0.8 Na-142 K-3.3 Cl-104 HCO3-22 AnGap-19 [2162-4-5] 05:05AM BLOOD ALT-31 AST-28 TotBili-0.1 [2162-4-5] 05:05AM BLOOD cTropnT-<0.01 [2162-4-5] 12:10PM BLOOD cTropnT-<0.01 [2162-4-5] 05:05AM BLOOD calTIBC-280 VitB12-703 Folate-7.6 Ferritn-126 TRF-215 Discharge labs [2162-4-6] 01:40PM BLOOD Hct-35.9* [2162-4-6] 04:01AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-141 K-3.6 Cl-106 HCO3-26 AnGap-13 EGD Findings: Esophagus: Lumen: A small size hiatal hernia was seen. Mucosa: Localized erythema of the mucosa with no bleeding was noted in the gastroesophageal junction. These findings are compatible with Mild esophagitis. Stomach: Mucosa: Localized erythema and congestion of the mucosa with no bleeding were noted in the cardia. These findings are compatible with possible MW tear. Localised erythema in antrum complatible with mild-moderate gastritis. Duodenum: Excavated Lesions A single cratered 1.5 cm ulcer was found in the duodenal bulb. An adherent clot suggested recent bleeding. Two endoclips were successfully applied to the Duodenal bulb ulcer for the purpose of hemostasis. Impression: Mild esophagitis Small hiatal hernia possible MW tear Mild-moderare gastritis Ulcer in the duodenal bulb (endoclip) Otherwise normal EGD to third part of the duodenum Recommendations: The findings account for the symptoms. The duodenal ulcer is likely NSAID induced. But H. Pylori possible too. Antireflux regimen: Avoid chocolate, peppermint, alcohol, caffeine, onions, aspirin. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. Prilosec 40 mg po BID Liquid diet and advanced as tolerated. Check H. Pylori Ab in serum and treat if positive. Serial Hct. Avoid all NSAIDs. Avoid Excedrin. Brief Hospital Course: 29 M with no significant PMH who p/w 1 week of dark black stools and coffee ground emesis at 3AM on day of admission, found to be to have PUD and upper GI bleed. . # GIB/PUD. He had a brisk bleed, in the ED was hypotensive to SBP 70's, and got 2 units there. He had innapropriate bump to this, and got 2 more units in the MICU. PPI was started. An endoscopy was done that showed peptic ulcer disease and a possible MW tear. He had 2 endoclips placed to ulcer in duodenal bulb. Unclear what his risk factors for PUD are, as he takes excedrin, though minimally, and does not drink excessive etoh or smoke. He was started on a PPI. H pylori serologies are still pending at time of discharge, and if they return positive he should be treated. NSAIDs should be avoided. Upon discharge his hct was stable, he was hemodynamically stable, and was tolerating a regular diet well. Omeprazole 20mg [Hospital1 ] was added to his home regimen, and GI f/u was arranged. . # Hypotension. SBP down to the 70s on arrival, initially thought to be from vasovagal, improved transiently, but then persistent with reported AMS, not responsive to 1L IVF. Received 2 L IVF and total 4 units pRBC. UGIB treatment per above. Resolved by discharge. # Anemia, microcytic. [Month (only) 116] be from GI bleed per above. Iron studies were checked and were normal, as were B12 and folate. Peripheral smear w/ microcytes. Hemolysis labs negative. Should have repeat CBC / iron labs in outpatient setting, and if still microcyctic consider a hemoglobin electropheresis. . # Sinus tachycardia and diffuse TWI. Most likely result of demand given acute blood loss. Asymptomatic with negative CE x 4 . # Code status: full . ============================== TRANSITIONAL ISSUES # microcytic anemia: iron studies normal. Consider repeat CBC and iron studies in outpatient setting, consider hemoglobin electropheresis if iron studies remain normal # f/u pending H pylori serology, treat if positive # f/u w/ gastroenterology for further PUD care Medications on Admission: - Tylenol - Excedrin Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day: Take 30 minutes before you eat breakfast and dinner. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for headache. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - duodenal ulcer - hypotension - anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Last Name (Titles) 76112] You were admitted to [Hospital1 69] because of low blood pressure and dark stool You received 4 units of blood. You had an upper endoscopy, a camera that goes into your esophagus, stomach, and part of the small intestine. Your low blood pressure and dark stool are due to bleeding from an ulcer in your small intestine (duodenum). It is possible that you have been bleeding slowly for some time based on your anemia. You were started on a new medication to decrease the acid secretion from your stomach. One of your lab test is still not back yet. This is to check if you have an infection that caused the ulcer. You should avoid chocolate, peppermint, alcohol, caffeine, onions, and aspirin. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. It will be very important for you to see your doctors [First Name (Titles) 3] [Name5 (PTitle) 57228] below. You should see your primary care doctor and have repeat test to check for any more blood loss. You should see the gastroenterologist for follow up of the ulcer. Please note the following changes in your medicine. - Stop Excedrin. This can make the ulcer worse. - Start omeprazole 40 mg, 1 tab, by mouth, twice a day. This is to reduce the acid. Take 30 minutes before breakfast and dinner. Followup Instructions: Name: Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 110661] (works with Dr [Last Name (STitle) 6984] Location: [Hospital6 ] Address: [Location (un) ]. [Location (un) ] STE 5C, [Location (un) ],[Numeric Identifier 5138] Phone: [Telephone/Fax (1) 11463] Appt: [4-14] at 10:45am Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [2162-4-20] at 3:00 PM With: [Name6 (MD) 11170] [Last Name (NamePattern4) 11171], 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 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "532.40", "276.52", "E935.9", "427.89", "285.1" ]	icd9cm	[ [ [] ] ]	[ "44.43" ]	icd9pcs	[ [ [] ] ]	8559, 8565	6136, 8153	315, 394	8668, 8668	4126, 6113	10174, 10996	2355, 2459		8225, 8536		8586, 8586		8179, 8202			8819, 10151								2474, 4107																						271, 277														422, 2135						8605, 8647		8683, 8795					2157, 2169	2185, 2339
30,677	120,749	19435	Discharge summary	report	Admission Date: [2106-10-21] Discharge Date: [2106-11-25] Date of Birth: [2041-6-13] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 148] Chief Complaint: Abdominal pain Recurrent Pancreatitis Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Pancreatic pseudocyst gastrostomy. 3. Jejunal tube placement. 4. External drainage of pancreatic pseudocyst. 5. Repair of fascial wound dehiscence. 6. Mesh interposition graft using SurgiSis mesh. History of Present Illness: This is a 65 year old male who was admitted here in [Month (only) ] for ETOH pancreatitis. He returns now with recurrent pancreatitis Past Medical History: ETOH pancreatitis [9-24] C.diff [9-24] Hepatitis B (dx [2081]), hyperlipidemia, cellulitis after fly bite ([7-24] tx with penicillin) Social History: lives with domestic partner in [Name (NI) 86] and on [Hospital3 ]; currently self employed as interior designer; frequent Etoh on weekends; former 15 p-y smoker (quit [2069]) Family History: mother died of ?pancreatic cancer, brother with heart valve dz/renal calculi Physical Exam: AVSS NCAT, NAD, talking, A&Ox3 EOM full, anicteric. Neck supple Chest clear Heart regular, no MRG Abdomen soft, distended, tender to deep palpation, tympanitic to percussion with hyperactive BS, no rebound or guarding LE bilateral 1+ edema to halfway up shins, 2+DP pulses bilaterally CN2-12 intact, 5/5 strength of UE/LE Pertinent Results: [2106-10-21] 03:10PM BLOOD WBC-12.8* RBC-4.24* Hgb-13.7* Hct-39.3* MCV-93 MCH-32.3* MCHC-34.9 RDW-14.0 Plt Ct-530* [2106-10-26] 06:53AM BLOOD WBC-9.3 RBC-3.56* Hgb-11.2* Hct-32.6* MCV-92 MCH-31.5 MCHC-34.4 RDW-13.9 Plt Ct-361 [2106-10-21] 03:10PM BLOOD Glucose-129* UreaN-16 Creat-1.3* Na-135 K-6.2* Cl-98 HCO3-30 AnGap-13 [2106-10-23] 07:30AM BLOOD Glucose-76 UreaN-12 Creat-1.1 Na-137 K-4.3 Cl-100 HCO3-26 AnGap-15 [2106-10-26] 06:53AM BLOOD Glucose-130* UreaN-7 Creat-0.8 Na-138 K-3.5 Cl-101 HCO3-30 AnGap-11 [2106-10-21] 03:10PM BLOOD ALT-87* AST-113* AlkPhos-525* Amylase-659* TotBili-1.1 DirBili-0.1 IndBili-1.0 [2106-10-23] 07:30AM BLOOD ALT-34 AST-30 AlkPhos-257* Amylase-308* TotBili-0.7 [2106-10-26] 06:53AM BLOOD ALT-17 AST-19 AlkPhos-181* Amylase-238* TotBili-0.5 [2106-10-21] 03:10PM BLOOD Lipase-581* [2106-10-23] 07:30AM BLOOD Lipase-129* [2106-10-26] 06:53AM BLOOD Lipase-157* [2106-10-22] 10:45AM BLOOD Albumin-2.7* Calcium-8.4 Phos-4.1 Mg-1.7 Cholest-116 [2106-10-26] 06:53AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.7 [2106-10-22] 10:45AM BLOOD Triglyc-112 [2106-11-12] 02:05AM BLOOD WBC-17.0* RBC-3.25* Hgb-9.8* Hct-29.8* MCV-92 MCH-30.1 MCHC-32.9 RDW-15.0 Plt Ct-492* [2106-11-16] 04:59AM BLOOD WBC-19.4* RBC-3.53# Hgb-10.4# Hct-32.8# MCV-93 MCH-29.4 MCHC-31.7 RDW-15.0 Plt Ct-742# [2106-11-24] 05:00AM BLOOD WBC-10.4 RBC-2.85* Hgb-8.2* Hct-25.4* MCV-89 MCH-28.8 MCHC-32.3 RDW-15.1 Plt Ct-614* [2106-11-24] 05:00AM BLOOD Glucose-96 UreaN-10 Creat-0.8 Na-141 K-3.2* Cl-101 HCO3-33* AnGap-10 [2106-11-25] 05:05AM BLOOD K-3.8 [2106-10-26] 06:53AM BLOOD ALT-17 AST-19 AlkPhos-181* Amylase-238* TotBili-0.5 [2106-10-28] 05:40AM BLOOD ALT-16 AST-24 AlkPhos-235* Amylase-246* TotBili-0.4 [2106-11-15] 04:40AM BLOOD ALT-16 AST-24 AlkPhos-193* Amylase-73 TotBili-0.4 [2106-11-22] 06:30AM BLOOD ALT-14 AST-26 AlkPhos-152* Amylase-40 TotBili-0.4 [2106-10-23] 07:30AM BLOOD Lipase-129* [2106-10-28] 05:40AM BLOOD Lipase-138* [2106-11-10] 12:55PM BLOOD Lipase-69* [2106-11-22] 06:30AM BLOOD Lipase-26 [2106-11-24] 05:00AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.8 [2106-11-19] 07:15AM BLOOD Albumin-2.0* Calcium-7.5* Phos-3.2 Mg-1.7 Iron-16* [2106-11-19] 07:15AM BLOOD calTIBC-91* Ferritn-709* TRF-70* [2106-11-23] 06:10AM BLOOD calTIBC-87* Ferritn-782* TRF-67* [2106-11-19] 07:15AM BLOOD Triglyc-189* [2106-11-23] 06:10AM BLOOD Triglyc-179* . CT ABDOMEN W/CONTRAST [2106-10-21] 6:24 PM IMPRESSION: Large pancreatic pseudocyst replacing the head, neck, and body of the pancreas, with smaller pseudocysts about the tail of the pancreas. No ongoing pancreas necrosis. Pseudocyst compresses the splenic vein, SMV, common bile duct, and duodenum, but there is no thrombosis, aneurysm or obstruction. . CT PELVIS W/CONTRAST [2106-11-8] 12:49 PM IMPRESSION: 1. Interval increase in size of both previously noted dominant pseudocysts. 2. The pancreatic pseudocyst surrounds and encases the gastroduodenal artery. Attention to this area should be paid during subsequent surgical procedures. 3. Interval increase in amount of parapancreatic fluid/inflammatory changes. 4. Interval increase in intrahepatic and extrahepatic biliary dilatation. 5. Interval increase in size of the left pleural effusion. 6. New small pericardial effusion. . CT ABDOMEN W/CONTRAST [2106-11-16] 3:16 PM IMPRESSION: 1. Status post cyst-gastrostomy with marked improvement in previously noted large fluid collection within the head of the pancreas. Compared to prior exam, there is slightly increased abdominal and pelvic ascites. 2. Extensive peripancreatic stranding extending into the mesentery inferiorly consistent with pancreatitis. 3. Resolution of intrahepatic biliary dilatation likely related to decompression of large pseudocyst within the head of the pancreas. 4. Small stable bilateral pleural effusions, left greater than right. . Brief Hospital Course: This is a 65 year old male who presented with recurrent pancreatitis. His Amylase and Lipase were elevated to 659 and 581. Pancreatitis: He was NPO with IVF. He was severely dehydrated on admission and received aggressive IVF resuscitation. We monitored his labs, watching his Amylase and Lipase trend down. His abdominal pain began to improve. He was then allowed clear fluids on HD 5, He had a slight bump in his Amylase/Lipase. On [10-27], he was ordered for a PICC and TPN and was made NPO. He continued on TPN and we monitored his Amylase, Lipase and Alk Phos. AlkPhos Amylase TotBili Lipase [2106-10-30] 09:32AM 300* 271* 0.7 144* [2106-10-29] 09:32AM 275* 271* 0.5 164* [2106-10-28] 05:40AM 235* 246* 0.4 138* [2106-10-27] 06:38AM 200* 255* 0.4 146* [2106-10-26] 06:53AM 181* 238* 0.5 157* [2106-10-25] 06:25AM 188* 203* 0.5 100* Due to insurance and disposition issues, he remained in house on TPN. On HD 19, [2106-11-8], his WBC increased to 16K and then 18K the next day. He also complained of increased pain. We obtained a CT and this showed interval increase in size of both previously noted dominant pseudocysts, an interval increase in amount of parapancreatic fluid/inflammatory changes. He also required IV fluid bolus x 3 for hypotension and low urinary output. He was schedule to go to the OR on Thursday [11-11] . C.diff: He contracted C.diff during his previous hospitalization and was taking antibiotics. He continued on antibiotics while here. We rechecked his stool and he continued to be positive for C.diff. His antibiotics continued. Urinary Tract infection: He complained or urinary frequency. A urine culture on [11-8] revealed GNR, ENTEROCOCCUS SP. He was started on Vancomycin and Unasyn. His PICC line was also removed for potential line infection. = = = = = = = = = = = = = = = = = = ================================================================ He went to the OR on [2106-11-11] for s/p cyst-gastrostomy, J-tube. He stayed in the ICU for monitoring due to fluid shifts. He did well post-operatively and was transferred to the floor. He continued with IVF, NGT and we started J-tube feedings. The NGT was removed on [11-15], POD 4. His diet was advanced to clears on POD 5. We were able to remove the superior drain on POD 6, the remaining drain had an Amylase of 118. His wound was slightly opened and packed with W->D dressing. A swab showed [2106-11-18] ENTEROBACTER AEROGENES, CIPROFLOXACIN---------<=0.25 S. He was started on Cipro and will complete his course at rehab. On POD 8, while sitting in the chair, he coughed hard and felt something "[Doctor Last Name ]" and starting draining fluid from his abdomen. He had a fascial dehiscence and went to the OR on [2102-11-19] for: 1. Repair of fascial wound dehiscence. 2. Mesh interposition graft using SurgiSis mesh. He had 2 JP drains in place and these were to wall suction. On discharge the drains were to bulb suction. Continue with Abdominal Binder at all times. His previous drain, that was placed at the original surgery, was removed on POD 12. This had an Amylase of 41. His diet was advanced and he was also on tubefeedings at this time to supplement his diet. His tubedfeedings were stopped at time of discharge. C.Diff: His last 3 stool samples were negative for C.diff. He reported some loose stool, however he was also receiving tubefeedings during this time. Medications on Admission: lipitor 20', protonix 40' Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 doses. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Recurrent pancreatitis and large peri-panreatic fluid collection (Pancreatic pseudocyst) 2. Necrotizing pancreatitis. 3. Biliary obstruction. 4. Malnutrition 5. Fascial wound dehiscence Post-op edema Post-op hypokalemia Post-op Urinary tract infection +C.diff Discharge Condition: Good Diet: Regular Continue with JP drain care to bulb suction Continue with Abdominal binder 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 vomitting, 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 skin, or the whites of your eyes become yellow. * 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 amubulate several times per day. Followup Instructions: [Known firstname ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 1231]. Please follow-up in 2 weeks. Call to schedule your appointment. Completed by:[2106-11-25]	[ "276.8", "008.45", "599.0", "263.9", "997.5", "576.2", "577.0", "998.31", "577.2" ]	icd9cm	[ [ [] ] ]	[ "99.15", "52.09", "38.93", "96.6", "52.4", "46.39", "54.61" ]	icd9pcs	[ [ [] ] ]	9731, 9810	5570, 9166	352, 581	10117, 10213	1580, 5547	11302, 11497	1143, 1222		9242, 9708		9831, 10096		9192, 9219			10237, 11279								1237, 1561																						275, 314														609, 748													770, 922	938, 1127
52,186	156,402	17775	Discharge summary	report	Admission Date: [2130-11-14] Discharge Date: [2130-11-19] Date of Birth: [2069-4-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea on exertion, fatigue, weakness Major Surgical or Invasive Procedure: [2130-11-14] Aortic Valve Replacement(21mm Pericardial) and Two Vessel Coronary Artery Bypass Grafting(SVG to PDA, SVG to Ramus) History of Present Illness: Mr. [Known lastname ] is a 61 year old male with known aortic stenosis. He has had recent development of congestive heart failure. Serial ECHOs displayed worsening aortic stenosis and mitral regurgitation. His most recent ECHO is from [10-9] which revealed severe AS with [First Name8 (NamePattern2) ] [Location (un) 109] of 0.5cm2 and mean gradient of 51mmHg. There was moderate AI, moderate MR, and mild TR. His LVEF was estimated at 60%. In [2130-3-3], he underwent cardiac catheterization which revealed severe two vessel coronary artery disease. He underwent successful PTCA of the RCA at that time but the circumflex lesion PTCA was unsuccessful. The LAD had minimal disease at that time. Given his worsening symptoms, and the severity of his aortic stenosis, he was referred for cardiac surgical intervention. Past Medical History: Chronic Diastolic Congestive Heart Failure Coronary Disease, History of MI, Prior PTCA Aortic Stenosis, Mitral Regurgitation Hypertension Dyslipidemia Chronic Obstructive Lung Disease History of SVT/PAF - prior Ablation Hodgkins Disease - s/p Chemotherapy and Mantle Radiation Hypothyroidism Splenectomy Vein Ligation Social History: Social history is significant for the remote tobacco use (in college). Admits to [3-5] scotch drinks per night. Married, lives with wife. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Discharge exam: Vitals- General- HEENT- Neck- Chest- Heart- Abdomen- Ext- Neuro- Pulses- Incisions- Pertinent Results: [2130-11-14] Intraop TEE: Pre Bypass: The left atrium and right atrium are normal in cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. The mitral annulus, left atrium and left ventricle is normal in size. There is no prolapse or flail segments seen in the mitral valve. There is no pericardial effusion. Post Bypass: Left and right ventricular function is preserved. The aorta is intact. An aortic valve prothesis is in good position and has a mean gradient of 7 mmHg. There is trivial aortic regurgitation. The is mild mitral regurgitation. The remainder of the exam is unchanged. Brief Hospital Course: Mr. [Known lastname ] was admitted and underwent an aortic valve replacment and coronary artery bypass grafting surgery by Dr. [First Name (STitle) ]. Please see operative note for surgical details. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He required several units of PRBC's to maintain hematocrit near 30%. On postoperative day two, 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. Chest tubes and pacing wires were discontinued without incident. The patient developed atrial fibrillation (of which he has a history). He was treated with amiodarone, beta blocker, and anticoagulation. By the time of discharge, the wound was healing, the patient was ambulating with assistance and pain was controlled with oral analgesics. He was discharged in good condition to rehab on POD 5. Medications on Admission: Amiodarone 200 qd, toprol 100 qd, Lasix 20 qd, Levothyroxine 75 mcg qd, Advair, Simvastatin 20 qd, Aspirin 325 qd, Temazepam 15 qd, Albuterol MDI prn, KCL, MVI Discharge Medications: 1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: provider to dose daily for goal INR 2-2.5. 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for 2 days. ML(s) 13. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: Coronary Disease, Aortic Stenosis - s/p AVR and CABG Chronic Diastolic Congestive Heart Failure Mitral Regurgitation History of MI Hypertension Dyslipidemia Chronic Obstructive Lung Disease History of SVT/PAF - s/p Ablation Hodgkins Disease - s/p Chemotherapy and Mantle Radiation Discharge Condition: Good Discharge Instructions: No driving for one month. No lifting more than 10 lbs for 10 weeks from surgery date. Shower daily, no baths. Wash incisions with soap and water only. Do not apply creams, lotions or ointments to any surgical incision. Call cardiac surgeon if there is any concern for wound infection. Followup Instructions: Dr. [First Name (STitle) ] in [5-6] weeks, call for appt Dr. [First Name (STitle) ] in [3-5] weeks, call for appt Dr. [Last Name (STitle) 1911] in [3-5] weeks, call for appt [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2130-11-19]	[ "424.1", "401.9", "412", "424.0", "427.31", "V10.72", "414.01", "428.0", "428.22", "491.22", "V45.82", "272.4" ]	icd9cm	[ [ [] ] ]	[ "36.12", "35.21", "39.61" ]	icd9pcs	[ [ [] ] ]	5953, 6039	3148, 4236	361, 496	6364, 6371	2100, 3125	6704, 7025	1880, 1962		4446, 5930		6060, 6343		4262, 4423			6395, 6681								1977, 1977					1993, 2081																	283, 323														524, 1362													1384, 1704	1720, 1864
32,605	137,103	34626	Discharge summary	report	Admission Date: [2134-10-19] Discharge Date: [2134-11-3] Date of Birth: [2083-9-27] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Aztreonam / Meropenem Attending:[First Name3 (LF) 3556] Chief Complaint: SOB Major Surgical or Invasive Procedure: Intbation Mechanical Ventilation Tracheostomy History of Present Illness: Pt is a 51 yo M with PMH of CHF and hypercarbic respiratory failure requiring intubation who presents with several episodes of SOB today. Pt called EMS, though thought SOB secondary to anxiety. Denied CP, abdominal pain, no orthopnea or PND. Does admit to worsening total body swelling/weight gain. . In the ED, initial vs were: T98.7 P87 BP150/83 R15 O2 sat93 RA. On exam poor air movement and decreased breath sounds at bases. EKG with no changes. CXR with no acute changes wiht ? pulmonary edema. Patient was given lasix 20mg IV x 1. On repeat evaluation pt was somnolent, difficult to arouse, awoke confused though AAO x 3 when arrived. ABG with CO2 retention. Pt was placed on CPAP. Initially he improved, though not quite oriented. On repeat evaluation, ABG without much improvement. Decreased FIO2, RR in 30's. D-dimer sent was borderline positive. Pt was sent for CTA PE and CT head. CT head notable for diffuse white matter disease. Was able to undergo CTA on 2L alone without CPAP. . In the MICU, pt is on 2L NC. He was feeling well on arrival and requesting food. . 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: Achondroplasia cervical decompression at least three lumbar decompressions,laminectomies and spinal fusion Social History: Lives with wife in [Name (NI) ]. No tobacco, ETOH or illicits. Does not work. Ambulates with walker from bed to bathroom. Family History: NC Physical Exam: Vitals: T: BP:152/71 P:88 R: 18 O2: 87% L NC General: Sleepy but answers questions appropriately HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diminished at bases bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: 3+ pitting edema bilaterally SKIN: intertriginal erythema in L groin; buttocks blanching erythema Pertinent Results: ADMISSION LABS ABG 6:30pm: pH 7.26 pCO2 84 pO2 87 HCO3 39 BaseXS 7 ABG 7:50pm: 7.31 pCO2 74 pO2 58 HCO3 39 BaseXS 6 proBNP: 165 D-Dimer: 512 LABORATORY DATA: The patient's CBC has been relatively stable throughout the admission, with WBC ranging from 5.1 to 11.4, Hgb ranging from 12.8-14.0, and Plt ranging from 162-332. At discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV Plt Ct [2134-11-3] 04:55AM 6.3 4.26* 12.3* 37.0* 87 262 INR 3.0 at discharge RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [2134-11-3] 04:55AM 119 33 1.2 138 4.1 90 40 <-Discharge [2134-10-31] 04:26AM 146 21 0.8 140 4.3 96 34 [2134-10-29] 03:09AM 111 9 0.6 141 3.4 99 33 [2134-10-19] 01:45PM 124 16 0.5 141 4.4 101 34 <-Admission The patient's creatinine has slowly increased from 0.5 to 1.2 in the setting of diuretics, as well as start of gentamicin. Most Recent ABG: BLOOD GASES pO2 pCO2 pH calTCO2 Base XS [2134-11-2] 10:45PM 64 67 7.42 45 14 DRUG MONITORING LEVELS ANTIBIOTICS Genta Vanco [2134-11-3] 04:55AM 2.3 [2134-11-3] 04:55AM 2.2 [2134-11-2] 07:36AM 23.9 [2134-10-31] 11:49PM 1.1 [2134-10-29] 02:58PM 23.8 [2134-10-25] 06:11AM 20.4 [2134-10-24] 06:05AM 10.6 MICROBIOLOGY DATA [2134-10-21] Sputum positive for Staph aureus (MSSA) [2134-10-26] BLOOD CULTURE from arterial line, positive for coag neg staph in [3-8] bottles but 0/2 bottles drawn peripherally [2134-10-27] 6:13 pm BRONCHOALVEOLAR LAVAGE: neg gram stain. no growth, no fungus, and no Acid Fast Bacteria. [2134-10-28] BLOOD CULTURE (from PICC) STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S [2134-11-2] PICC TIP-IV WOUND CULTURE- no significant growth [2134-11-2] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2134-11-2] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2134-11-1] SINUS ASPIRATE: Gram stain GPC, cx no sig growth [2134-11-1] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2134-10-31] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2134-10-31] URINE URINE CULTURE-FINAL NO GROWTH. [2134-10-30] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2134-10-30] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2134-10-29] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2134-10-29] SPUTUM GRAM STAIN-GRAM NEGATIVE ROD(S) CULTURE-FINAL {YEAST} INPATIENT [2134-10-29] BLOOD CULTURE Blood Culture, Routine-PENDING CXR [10-19]: Markedly limited study. There is suggestion of volume overload. Slightly more confluent areas are likely due to edema; however, early developing infiltrate cannot be excluded. Recommend repeat radiography following appropriate diuresis and clinical correlation. CTA CHEST [10-19] 1. Very limited study, without evidence for large central pulmonary embolism. 2. Apparent narrowing of the left lower lobe bronchus is equivocal, however brochomalacia cannot be excluded. 3. 4-mm right middle lobe nodular density can be re-evaluated with CT in one year. If there is history of malignancy, however, earlier follow-up should be considered. CT HEAD [10-19] IMPRESSION: 1. Limited exam shows no acute intracranial process. Appearance of the brain with ventriculomegaly out of proportion to cerebral sulci and hypodensity in the subcortical and periventricular white matter is unchanged from [2133-8-11]. Possibility of normal pressure hydrocephalus cannot be excluded. To correlate clinically. 2. Scattered paranasal sinus mucosal disease. 3. Small foramen magnum, a finding which is compatible with the patient's known achondroplasia. ECHOCARDIOGRAM [10-20] The left ventricle is not well seen. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve is not well seen. The mitral valve leaflets are not well seen. IMPRESSION: Severely limited study due to patient's body habitus. The right ventricle is probably dilated and hypokinetic with pressure/volume overload. LV systolic function and valvular function cannot be adequately assessed. CT CHEST [10-30] IMPRESSION: Increased patchy opacities in the left upper and left lower lobes since the CT on [10-19], suggestive of pneumonia. No loculated pleural fluid, as questioned. CT SINUS [10-31] IMPRESSION: 1. Marked worsening of pansinusitis with polypoidal mucosal thickening in a multiseptated right maxillary sinus and near complete opacification of a multipartite sphenoid sinus. 2. Unchanged ventricular dilation and extensive subcortical and periventricular white matter hypoattenuation, better described on prior dedicated CT brain studies. The study is somewhat limited due to obliquity of patient positioning within the scanner. ADDENDUM :There is moderate soft tissue thickening around the partially imaged oropharyngeal soft tissues; part of this could be due to enlarged lymphoid tissue along the Waldeyer ring. ATTENDING COMMENTS: The upper spinal findings could relate to past laminectomies to treat spinal stenosis, associated with achondroplasia. Please correlate with prior history. Also, both the sinus pathology and nasopharyngeal soft tissue thickening can relate, at least in part, to chronic intubation. CXR [11-1] FINDINGS: Tracheostomy tube remains in standard position. Cardiac silhouette remains enlarged. New pulmonary vascular engorgement with adjacent perihilar haziness attributed to mild fluid overload. Worsening left retrocardiac opacity likely due to atelectasis given appearance on earlier radiographs and CT. Increasing patchy opacity at right lung base could potentially represent an area of developing pneumonia, and followup radiographs may be helpful in this regard. Brief Hospital Course: MICU COURSE: ============ 51 y.o. M with PMH of CHF, OSA, OHS presents with SOB and hypercarbic respiratory failure. # Hypercarbic Respiratory Failure: This was felt to be multifactorial with contributors being obstructive sleep apnea and obesity hypoventilation syndrome given body habitus, though the patient was never formally evaluated. Serum and urine tox screens were negative. The patient was initially on BiPap, but briefly became unresponsive and somnolent, so he was intubated. Later that same evening, the patient was noted to desat after being moved. CXR showed collapsed left lung. He was placed on FiO2 of 100% from 60%. Bronchoscopy showed a mucous plug which was removed from L mainstem. Due to anatomy, there was some difficulty in retracting the bronchoscope. The patient then had ET tube removed and it was replaced under fiberoptic guidance. He was maintained on the ventilator and then tracheostomy was performed as he was unable to be weaned from the ventilator. This was performed by CT surgery given his anatomy successfully. The patient was then transitioned to trach collar and was on this for 24 hours prior to transfer to rehab facility. He was actively diuresed to treat pulmonary vascular congestion. Due to his restrictive body habitus and sleep apnea, a sleep consultation was obtained. He becomes mildly hypoxic at night with PaO2 of 64, and sleep recommended that he go on nocturnal bipap via trach with settings of [11-8]. He will need full pulmonary function testing at his follow-up sleep study. # Healthcare Associated Pneumonia: Given the patient's inability to wean, he was treated for pneumonia with vancomycin, driven by methicilin sensitive staph aureus found on sputum culture. He was treated for a two week course, ending on [2134-11-4]. #. Ventilator Associated Pnuemonia: During his hospitalization, the patient was treated for ventilator associated pneumonia with gram negative rods found in his sputum. Given his multiple allergies, he was treated with gentamicin for an eight day course. He will continue to receive ciprofloxacin and gentamicin at rehab ending [2134-11-7]. # Vascular Access and Positive Blood Cultures: The patient had a PICC line during the admission. He had a blood culture from an old arterial line that was removed that grew coag neg staph, and later had a PICC culture that also grew coag neg staph. The PICC was removed. No peripheral cultures grew, and this was felt to likely be a contaminant. Surveillance blood cultures after completion of vancomycin (for pneumonia, ending [2134-11-4]) could be obtained. # Chronic Diastolic Congestive Heart Failure: The patient was diuresed during his hospital stay and was net negative 2.5 liters during length of stay. #. Sinusitis: The patient continued to spike fevers in spite of treating his VAP. Sinus CT was performed given that the patient had NGT placed for a moderate duration of time. CT showed sinusitis. ENT was consulted. Culture was performed. Afrin and nasal saline were started. #. Altered Mental Status: Likely secondary to hypercarbic respiratory failure. Tox screens negative. Head CT negative for etiology of altered mental status. After respiratory status improved, pt's mental status returned to baseline. #. BPH: Continued Terazosin. Code: Full Communication: Patient and Wife [Name (NI) ] [Numeric Identifier 79436] (cell) Disposition: Transfer to Rehab Facility REHAB TO DO's: -------------- [ ] Arrange nocturnal bipap 10/5 through trach [ ] Arrange ENT follow-up [ ] Antibiotics as above. Would resend blood and urine cultures for fever. Medications on Admission: Docusate 100mg [Hospital1 ] Miconazole 2% powder [Hospital1 ] Senna PO qHS Doxazosin 1mg qHS Atenolol 25 PO daily Spironolactone 25 PO bid Discharge Medications: 1. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 4-10 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritus. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for congestion. 13. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal QHS (once a day (at bedtime)). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for HR<60 SBP<100. Tablet(s) 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: last day on [2134-11-7]. 17. Vancomycin 500 mg Recon Soln Sig: 1000 (1000) mg Intravenous Q 12H (Every 12 Hours) for 1 days: last day [2134-11-4]. 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Gentamicin 40 mg/mL Solution Sig: Four Hundred (400) mg Injection q 36 hours for 4 days: last day [2134-11-7]. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: 1. Respiratory Failure 2. Obstructive Sleep Apnea 3. Obesity Hypoventilation Syndrome 4. Ventilator Associated Pneumonia 5. Sinusitis Discharge Condition: Stable. On Trach Collar. Tolerating po's. Discharge Instructions: You were admitted to the Intensive Care Unit with shortness of breath. You were intubated and on placed on mechanical ventilation. Because you had trouble weaning off the ventilator, you had a tracheostomy performed by the surgeons without any complications. You were off the ventilator for 24 hours prior to discharge. You were also tolerating a regular diet. Please continue to take all your medications as prescribed. Your current medication list is being communicated to [Hospital1 79437]. Upon discharge, please review your medication list for any changes to your usual home medications. Please keep all your follow up appointments. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever > 101, chest pain, shortnes of breath, abdominal pain, intractable nausea/vomiting, bright red blood per rectum, or any other concerning symptoms. Followup Instructions: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2134-11-16] 11:10 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2134-11-16] 11:30 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 3688] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2134-11-16] 11:30 [2134-11-19] 02:15p [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 275] SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] [Hospital 191] MEDICAL UNIT [2134-11-30] 01:00p SLEEP [Doctor Last Name ],[Hospital1 ] SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] SLEEP UNIT NEUROLOGY (SB) **Pt should f/u with Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] in [2-5] months for reassessment and possible repeat CT scan. Please call ([Telephone/Fax (1) 79438] to make an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560] Completed by:[2134-11-3**]	[ "327.23", "518.81", "584.9", "600.00", "428.32", "041.85", "278.8", "997.31", "473.9", "428.0" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.04", "33.24", "38.93", "31.1", "96.6" ]	icd9pcs	[ [ [] ] ]	15006, 15077	9057, 12115	318, 365	15274, 15319	2725, 3048	16258, 17470	2157, 2161		12884, 14983		15098, 15098		12713, 12861			15343, 16235								2176, 2706													3062, 9034									275, 280							1488, 1868							393, 1470						15117, 15253		12130, 12687					1890, 1998	2014, 2141
70,100	122,964	42740	Discharge summary	report	Admission Date: [2151-2-2] Discharge Date: [2151-2-3] Date of Birth: [2115-4-3] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 338] Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: None. History of Present Illness: 35 yo F with a history of substance abuse presenting s/p cardiac arrest in the setting of likely heroin overdose. The patient was found at 18:10 by her mother at home down and pulseless in the bathroom with a needle present at the site. EMS was called (unclear how much time elapsed prior to arrival) and she was found to be in PEA arrest. She received 45 minutes of ACLS including 3 rounds of epinephrine, amiodarone, and bicarb before converting to VF, receiving multiple shocks subsequently and having ROSC. She was taken to an OSH, arriving by 19:30, where she was started on a heparin gtt, dopamine gtt at 15-20 mcg, and levophed at 4 mcg. She was also given rectal aspirin and started on a bicarb gtt. Her pH there was 6.8 and she was noted to be anuric. A R triple lumen femoral line and L IO line were placed and she was started on a cooling protocol w/ ice packs in the arms and groin, transported to [Hospital1 18] for further management. HR was 113 and SBP was around 90 prior to xfer. . In [Hospital1 18] ED, initial VS were notable for temperature of 31 degrees. The patient was noted to have fixed and dilated pupils and was unresponsive. Dopamine and levophed gtts were continued. Labs were notable for arterial pH of 7.14, lactate of 12.4, troponin of 17.36, creatinine of 1.7. CXR was notable for multiple rib fractures. A sterile left femoral A line placed and patient was seen by cardiology who felt that a cardiac etiology was not the primary process- heparin gtt was d/c-ed. She was seen by the post arrest team who recommended rewarming to 33 degrees and initiating artic sun protocol. She was pan scanned prior to transfer to the MICU. Transfer VS were: 111 83/51 MAP63 o2 SAT 95% On AC TV500, FIO295, 24, PEEP5. . On arrival to the MICU, the patient was intubated, sedated and unresponsive. . Review of systems: Unable to obtain [1-14] mental status. Past Medical History: s/p gastric bypass surgery h/o heroin abuse Diabetes mellitus Hepatitis C Social History: H/o recent incarceration, released on [2150-12-16], and heroin abuse. Has a fiance with whom she has a couple of children. Family History: Non contributory. Physical Exam: VS: temperature 31 degrees General: intubated, unresponsive (not on sedation) HEENT: pupils fixed and dilated; no gag response, no cough Neck: supple, JVP not elevated CV: Regular rate and rhythm, Lungs: coarse bs/ b/l Abdomen: soft, non-tender, mildly distended GU: Foley in place Ext: warm, no edema Neuro: unresponsive, does not withdraw to nailbed pressure, no gag or corneal reflexes. Pertinent Results: [2151-2-2] 10:50PM WBC-14.7* RBC-3.97* HGB-11.3* HCT-35.8* MCV-90 MCH-28.6 MCHC-31.7 RDW-12.7 [2151-2-2] 10:50PM PLT COUNT-260 [2151-2-2] 10:50PM PT-16.6* PTT-150* INR(PT)-1.6* [2151-2-2] 10:50PM FIBRINOGE-141* [2151-2-2] 10:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2151-2-2] 10:50PM CK-MB-GREATER TH [2151-2-2] 10:50PM cTropnT-17.36* [2151-2-2] 10:50PM LIPASE-56 [2151-2-2] 11:00PM GLUCOSE-457* LACTATE-12.4* NA+-140 K+-4.4 CL--103 TCO2-11* [2151-2-2] 11:37PM LACTATE-13.5* [2151-2-2] 11:37PM TYPE-ART RATES-29/24 TIDAL VOL-500 PEEP-5 O2-100 PO2-91 PCO2-37 PH-7.14* TOTAL CO2-13* BASE XS--15 AADO2-592 REQ O2-96 -ASSIST/CON INTUBATED-INTUBATED [2-2] CT Torso: 1. Multiple bilateral rib fractures of mixed chronicity, the acute injuries likely related to recent prolonged compressive resuscitation. 2. Left upper lobe predominant consolidation, likely a combination of post-resuscitative contusion and aspiration. 3. Status post gastric bypass without evidence of obstruction. 4. Hepato-steatosis. [2-2] CT Head: There is diffuse severe cerebral edema as evidenced by loss of [Doctor Last Name 352]-white matter differentiation and focal effacement. The frontal horns of the lateral ventricles are slit-like. Suprasellar and basilar cisterns are effaced, consistent with downward transtentorial herniation. The tonsils appear low lying with crowding of the foramen magnum. However, there is no definite current evidence to suggest tonsillar herniation. Patient is status post intubation, with aerosolized secretions in the [Last Name (un) ]- and oro-pharynx. Small amount of mucus is seen in the sphenoid sinus. Paranasal sinuses and mastoid air cells are otherwise well aerated. There is no skull base fracture. Globes and soft tissues are within normal limits. IMPRESSION: Findings consistent with severe cerebral edema with downward transtentorial herniation without current evidence of tonsillar herniation. Brief Hospital Course: 35 yo F with a history of heroin abuse presents s/p PEA arrest. #) S/p PEA Arrest: Likely secondary to heroin overdose/hypoxia given history. Unclear if tox screen was done at OSH. Patient was initially started on cooling protocol per post arrest team and on arrival in the MICU dropped her systolics to the 60s with improvement to the 80s on five maxed pressors (norepinephrine, dopamine, vasopressin, phenylephrine, and epinephrine). Despite ongoing resucitative efforts, her lactate continued to rise to 14 and pH was 7.11. Soon after escalation of pressors, wet read of CT head was obtained which showed diffuse cerebral edema with evidence of downward transtentorial herniation and foramen magnum crowding. Given this finding in the setting of fixed, dilated pupils, the absence of brainstem reflexes including gag, cough, and corneal reflexes, and no spontaneous respirations on the ventilator ongoing efforts at resuscitation were deemed futile based on her exam and CT scan findings of brain death and severe anoxic encephalopathy. Her family was notified and consented to withdrawal of care after reheating the patient. The patient passed away early on the morning of [2-3] - the family and medical examiner were notified and an autopsy is planned. Medications on Admission: alprazolam 1 mg amlodipine 5 mg daily HCTZ 25 mg daily lisinopril 40 mg daily ativan 2 mg daily upto QiD metformin 500 mg PO BID metoprolol succinate 100 mg PO daily oxycodone 30 mg PO BID oxycontin 80 mg PO QID risperdal 0.25 mg PO BID insulin Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Discharge Condition: Expired Discharge Instructions: None. Followup Instructions: None. Completed by:[2151-2-9]	[ "E980.0", "511.89", "276.4", "348.1", "401.9", "304.71", "348.82", "250.00", "V49.86", "965.01", "V12.53" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	6574, 6583	4986, 6250	301, 308	6641, 6650	2925, 4044	6704, 6739	2481, 2500		6545, 6551		6604, 6620		6276, 6522			6674, 6681								2515, 2906																		2180, 2224				243, 263														336, 2161		4053, 4963											2246, 2321	2337, 2465
28,847	195,559	31961	Discharge summary	report	Admission Date: [2196-9-1] Discharge Date: [2196-9-4] Date of Birth: [2133-6-9] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 281] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Rigid Bronchoscopy with balloon dilatation Y stent placement in Right mainstem bronchus stent placement in Right bronchus intermedius History of Present Illness: Ms [Known lastname 74905] is a 63 yo F and has a history of metastatic uterine carcinoma with lung lesions causing compression of the RLL bronchi. She presents with a central airway obstruction and respiratory failure. Past Medical History: Uterine Ca COPD Osteoporosis s/p TAH/BSO [8-/2194] Social History: Lives with husband [Name (NI) ] 40 pack-year smoking history, quit Occasional EtOH No h/o asbestos exposure Family History: Father- [Name (NI) ] Ca Physical Exam: On discharge 98.4F 89 149/73 18 98% on 100% face tent NAD, breathing comfortably with face tent Able to converse with mild SOB RRR decreased breath sounds in RLL soft NT/ND LE- warm, no edema Pertinent Results: [2196-9-4] 04:00AM BLOOD WBC-7.7 RBC-3.24* Hgb-10.5* Hct-31.5* MCV-97 MCH-32.3* MCHC-33.3 RDW-20.6* Plt Ct-256 [2196-9-3] 03:44AM BLOOD WBC-7.5 RBC-3.39* Hgb-10.7* Hct-32.3* MCV-95 MCH-31.5 MCHC-33.1 RDW-21.3* Plt Ct-241 [2196-9-3] 03:44AM BLOOD PT-13.3* PTT-30.6 INR(PT)-1.2* [2196-9-4] 04:00AM BLOOD Glucose-94 UreaN-14 Creat-0.4 Na-142 K-3.6 Cl-95* HCO3-43* AnGap-8 [2196-9-3] 03:44AM BLOOD Glucose-140* UreaN-15 Creat-0.6 Na-137 K-4.1 Cl-97 HCO3-34* AnGap-10 [2196-9-2] 04:49PM BLOOD Type-ART pO2-79* pCO2-59* pH-7.40 calTCO2-38* Base XS-8 . . PORTABLE CHEST, [2196-9-3] COMPARISON: [2196-9-2]. INDICATION: Lung [Hospital3 ] distress. Endotracheal tube, tracheobronchial stent and vascular catheter are unchanged in position. Large right lung mass measuring approximately 10 cm is unchanged, as well as an area of predominantly discoid atelectasis at the right lung base. Upper lobe predominant emphysema is present. Left lung is grossly clear Brief Hospital Course: Pt was transferred from [Hospital6 12112] intubated for evaluation. She was apparently having increased SOB and cough for 2 weeks prior to presentation. On evaluation at [Last Name (un) 4199] she was in respiratory distress and was intubated. At [Hospital1 18] she was taken for bronch and showed: The left mainstem, left upper lobe and left lower lobe segmental bronchi appeared normal. The right mainstem bronchus showed evidence of extrinsic compression, especially in the distal aspect. The bronchus intermedius appeared to be compressed from an extrinsic mass to the level of the right middle lobe. The right lower lobe bronchi are completely obscured with tumor. The bronchoscope could be advanced into the right upper lobe with patent segmental bronchi, however, the takeoffs to the right upper lobe appeared to be compressed extrinsically. Using the balloon dilation, the right mainstem was dilated to 13 mm in diameter. Following this, tracheal bronchial (Y) stent was prepared with the following dimensions. The diameter of the tracheal limb 16 mm, diameter of the right and left mainstem bronchial limbs 13 mm, length of the tracheal limb 4 cm, length of the left mainstem limb 2 cm, length of the right mainstem limb 1.5 cm. The stent was deployed in the trachea in the usual manner and was manipulated into place. Following this, an Ultraflex uncovered metallic stent (10 mm x 2 cm) was advanced into the bronchus intermedius and deployed. Using a balloon, the stent was dilated to 10 mm in diameter. The bronchoscope was then advanced into the stent and appeared to be patent distally. The right middle lobe orifice could be easily visualized. The right upper lobe orifice remained unobstructed by the metallic or the silicon stents. She was extubated and brought out of the OR and brought back to the ICU. She had some respiratory distress and required re-intubation. On [9-3] she was extubated and did well. She has been stable and plans have been made for the patient to be transferred back to [Last Name (un) 4199]. Medications on Admission: Combivent, Solumedrol, Avelox, Procrit Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day) as needed for DVT prophylaxis. 2. Lidocaine (PF) 10 mg/mL (1 %) Solution Sig: One (1) ML Injection Q2-3H (every 2-3 hours) as needed for cough. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day) as needed for copd. 5. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for HTN. 6. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day) as needed for stent maintenance. 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Levofloxacin 750 mg IV ONCE DAILY 11. Codeine Phosphate 15 mg IV Q4H:PRN cough 12. MethylPREDNISolone Sodium Succ 80 mg IV Q8H copd Discharge Disposition: Extended Care Discharge Diagnosis: Right mainstem bronchial compression Discharge Condition: stable Discharge Instructions: Call Dr.[Name (NI) 5070] office [Telephone/Fax (1) 74906] if you experience: Fever > 101 or chills,Increased shortness of breath, cough or sputum production, Chest pain, nausea, vomiting, or nightsweats Please take all medications as prescribed No driving while taking narcotics Take stool softners while taking narcotics. i.e. colace, senna Please take all medications as prescribed No driving while taking narcotics Take stool softners while taking narcotics. i.e. colace, senna Followup Instructions: Call Dr.[Name (NI) 5070] office ([Telephone/Fax (1) 74906]for a followup appointment only if you experience complications with the bronchial stent [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 286]	[ "733.00", "E912", "785.0", "V15.82", "518.84", "276.2", "V10.42", "V16.1", "934.8", "491.21", "519.8", "518.0", "197.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "31.99", "96.04", "96.56", "96.71", "96.05", "33.91" ]	icd9pcs	[ [ [] ] ]	5494, 5509	2212, 4277	325, 461	5590, 5599	1201, 2189	6138, 6388	937, 966		4366, 5471		5530, 5569		4303, 4343			5623, 6115								981, 1182																						278, 287														489, 714													736, 792	808, 921
9,077	132,378	20348	Discharge summary	report	Admission Date: [2115-4-20] Discharge Date: [2115-4-21] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: Briefly, the patient is a 40- year-old gentleman with a history of mental retardation who fell from bed and called for help. His sister found him unresponsive and called Emergency Medical Service. Emergency Medical Service found that he had fixed and dilated pupils with no gag. He was intubated and transferred to an outside hospital, and he was found to be posturing at the outside hospital. PAST MEDICAL HISTORY: 1. Hypertension. 2. Mental retardation. 3. Seizure disorder. MEDICATIONS ON ADMISSION: His only medication is Gabitril. PHYSICAL EXAMINATION ON PRESENTATION: The patient was afebrile and tachycardic at 116 with a blood pressure was 108/61. His other vital signs were stable. He was unresponsive with no corneal reflexes. His pupils were 8 mm and fixed with no oculocalorie response. His lungs were clear. His heart was tachycardic with no murmurs. His abdomen was soft and nontender. His extremities were warm and well perfused. PERTINENT LABORATORY VALUES ON PRESENTATION: His laboratories were all within normal limits except for a blood urea nitrogen of 15 and a creatinine of 1.6. His urinalysis was negative. His urine toxicology screen was negative. His amylase was normal. PERTINENT RADIOLOGY-IMAGING: A computed tomography scan was done which showed a significant right thalamic bleed. SUMMARY OF HOSPITAL COURSE: He was admitted to the Intensive Care Unit. The family was contact[Name (NI) ] and were brought in. Neurosurgery was consulted, and it was felt that there was nothing that could be done for him from a neurological standpoint. A family meeting was held, and it was decided on hospital day two that the patient would have his support withdrawn. The patient died at 7:46 p.m. on [2115-4-21]. The Intensive Care Unit attending was present during the pronouncement. The patient was pronounced dead on [2115-4-21], at 7:46 p.m. and the family was notified. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 13037] Dictated By:[Doctor Last Name 11225] MEDQUIST36 D: [2115-7-5] 15:25:03 T: [2115-7-7] 18:52:56 Job#: [Job Number 54576]	[ "458.29", "E884.4", "348.8", "401.9", "348.4", "319", "431", "331.4" ]	icd9cm	[ [ [] ] ]	[ "38.93", "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]													665, 1489																				1518, 2346																											155, 553													575, 638
2,667	131,592	51070	Discharge summary	report	Admission Date: [2125-11-15] Discharge Date: [2125-11-17] Date of Birth: [2064-11-7] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Atorvastatin / Nsaids / Haloperidol / Dextromethorphan / Egg Attending:[First Name3 (LF) 5810] Chief Complaint: Vomiting, high blood sugars Major Surgical or Invasive Procedure: None History of Present Illness: 59 yo F w/ PMH of ESRD s/p living-related kidney transplant [2107] and DMI w/ failed pancreas transplant [2120], gastritis and esophagitis, who presents with hyperglycemia and vomiting. Patient states that she's had high blood sugars for 2-3 weeks, in the 600s. She started non bilious, non bloody vomiting two days prior to admission, two to three times per day. Patient presented to an OSH one week ago with vomiting. At that time, no further work up was pursued. She went to [Company 191] today complaining of high blood sugars and vomiting. At that time, she vomited once in the exam room, and was found to have ketonuria. She was sent to the ED for further evaluation. In the ED, initial VS: T 96.7 BP 199/107 HR 108 RR 20 98% on RA. She was reportedly afebrile. Labs remarkable for glucose of 1157, K of 6.1, anion gap of 23, and ketonuria. She was given IV normal saline, and started on an insulin gtt @ 5.5u/hr. Vitals on transfer were BP 166/69 HR 103 RR 20 O2 98% on RA Currently, she denies chest pain, shortness of breath, abdominal pain. Denies change in dietary habits. Unable to see [Name8 (MD) ] MD over few weeks. No fevers, chills, diarrhea, dysuria, or cough. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. DM type 1 c/b recurrent hypoglycemia, gastroparesis, and retinopathy, s/p failed pancreas transplant 2. ESRD now w/ functional renal transplant, [2107], baseline Cr 1.5 3. HTN 4. DM retinopathy 5. s/p vitrectomy 6. depression 7. anterior tibia fx [2115] 8. Inherited Tic disorder 9. Gastritis, esophagitis -admission [2125-3-11] Social History: Raised in [Location (un) 1475] with two siblings. Has advanced practice nursing degree and works part-time as a psychotherapist and teaches nursing part-time. Has one adult daughter with stage IV ovarian cancer. Has one adult son who was recently in prison. Family History: - Mother with depression - son with hx of alcohol and marijuana abuse - paternal cousin and his two sons completed suicide - Tic disorder in aunt and grandmother. Physical Exam: GENERAL: Sleepy, arousable to voice. HEENT: NCAT. EOMI. PERRL. Neck supple. Oropharynx clear. CARDIAC: RRR. No murmurs. LUNG: CTAB. No wheezes or crackles. ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding. EXT: WWP. No LE edema. NEURO: A+Ox3. Sleepy, though arousable to voice and able to relate history. No focal neurologic deficits. DERM: No rashes noted. Pertinent Results: LABS: . MICROBIOLOGY: None . STUDIES: EKG: NSR @ 101 bpm. Nl axis. TWI in lead III (seen on prior). . CXR: No acute cardiopulmonary abnormality. [2125-11-15] 12:25PM BLOOD WBC-5.8# RBC-3.61* Hgb-11.6* Hct-39.6 MCV-110# MCH-32.1 MCHC-29.2* RDW-14.0 Plt Ct-203 [2125-11-15] 12:25PM BLOOD Neuts-93.1* Lymphs-4.9* Monos-1.3* Eos-0.5 Baso-0.2 [2125-11-16] 04:38AM BLOOD PT-11.9 PTT-18.1* INR(PT)-1.0 [2125-11-15] 12:25PM BLOOD Glucose-1157* UreaN-36* Creat-1.9* Na-122* K-6.1* Cl-82* HCO3-17* AnGap-29* [2125-11-15] 03:45PM BLOOD Glucose-848* UreaN-36* Creat-1.8* Na-131* K-4.2 Cl-93* HCO3-19* AnGap-23* [2125-11-15] 08:00PM BLOOD Glucose-280* UreaN-30* Creat-1.5* Na-140 K-4.2 Cl-106 HCO3-24 AnGap-14 [2125-11-16] 12:14AM BLOOD Glucose-133* UreaN-26* Creat-1.2* Na-143 K-4.9 Cl-111* HCO3-21* AnGap-16 [2125-11-16] 04:38AM BLOOD Glucose-356* UreaN-22* Creat-1.2* Na-140 K-5.1 Cl-108 HCO3-19* AnGap-18 [2125-11-17] 06:35AM BLOOD Glucose-108* UreaN-13 Creat-1.0 Na-139 K-3.8 Cl-105 HCO3-24 AnGap-14 [2125-11-15] 12:25PM BLOOD ALT-97* AST-53* AlkPhos-145* TotBili-1.0 [2125-11-16] 04:38AM BLOOD ALT-72* AST-42* LD(LDH)-215 CK(CPK)-91 AlkPhos-109 TotBili-0.6 [2125-11-17] 06:35AM BLOOD ALT-128* AST-295* LD(LDH)-311* AlkPhos-120* TotBili-0.5 [2125-11-16] 04:38AM BLOOD Lipase-18 [2125-11-16] 04:38AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.7 [2125-11-17] 06:35AM BLOOD VitB12-[2029]* Folate-15.7 [2125-11-16] 12:14AM BLOOD Cyclspr-38* Brief Hospital Course: Ms. [Known lastname 24397] is a 59 year old woman with type I diabetes and ESRD s/p living-related kidney transplant in [2107]. She presented to the emergency department with diabetic ketoacidosis. . 1. DKA: Initial glucose in ED of 1157 with an anion gap of 23. Patient was initially admitted into the MICU for treatment of DKA. Glucose levels quickly corrected to 200 range and the anion gap normalized. She was transitioned to Lantus and sliding scale regimen. She was monitored in the ICU overnight and was transferred to the medical floor the following afternoon. [Last Name (un) ] was consulted for assitance with her insulin levels and recommended a regimen of 20 units of Lantus every morning. The precipitant of DKA was unknown. Patient had no evidence of infections or acute coronary syndrome. 2. ESRD s/p renal transplant in [2107]. On admission, Cr 1.9, likely secondary to intravascular depletion in the setting of DKA. On discharge, creatinine was 1.0. Patient was followed by the transplant service. There was no change in her immune suppression regimen. 3. Hypertension: Antihypertensives were held initially held upon admission. They were restarted prior to discharge. Patient had slightly elevated blood pressure on the day of discharge. She was going to follow up at the post discharge clinic on [11-20]. . 4. Gastritis and esophagitis: Continued on omeprazole per outpatient regimen. . 5. Mild transaminitis: Patient had mildly elevated liver enzymes on admission. They were initially thought to be due to her DKA. Hepatitis studies were pending on the day of discharge. She was instructed to arrive at her clinic appointment early to have the liver studies repeated. . 6. Code status: Patient was a full code. . 7. Prophylaxis: Patient received subcutaneous heparin. Medications on Admission: 1. Prednisone 3 mg po qod 2. Omeprazole 40 mg po bid 3. Methyldopa 500 mg po q12h 4. Acetaminophen 325 mg po q6h PRN pain, fever 5. Cyclosporine 75mg po bid 6. Insulin pump 7. Azathioprine 50 mg po daily 8. Captopril 50 mg po bid 9. Clonazepam 0.5mg po tid Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. Methyldopa 500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 5. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Captopril 50 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day: See attached sliding scale. 8. Humalog 100 unit/mL Solution Sig: sliding scale dosing Subcutaneous four times a day. 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Outpatient Lab Work Please draw a panel 7 (electrolytes and kidney function), LFTs (ALT, AST, Alk phos, LDH, Tbili), and a CBC. Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic ketoacidosis Acute renal failure Secondary: Transaminitis History of end-stage renal disease status post a renal transplant Hypertension Depression Discharge Condition: Stable, blood pressure somewhat elevated with SBPs in the 160's. Blood sugars were under good control. Discharge Instructions: You were admitted to the hospital due to elevated blood glucose levels which led to diabetic ketoacidosis. You were admitted to the Intensive Care Unit were you were treated for your elevated blood sugars with good response. The diabetes doctors [Name5 (PTitle) 6349] your [Name5 (PTitle) ] insulin regimen and made some changes. Medication changes: 1. You should take lantus 20 units daily. 2. Your sliding scale was modified: Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 71-80 mg/dL 0 Units 0 Units 0 Units 0 Units 81-120 mg/dL 3 Units 3 Units 3 Units 0 Units 121-160 mg/dL 4 Units 4 Units 4 Units 0 Units 161-200 mg/dL 5 Units 5 Units 5 Units 0 Units 201-240 mg/dL 6 Units 6 Units 6 Units 2 Units 241-280 mg/dL 7 Units 7 Units 7 Units 3 Units 281-320 mg/dL 8 Units 8 Units 8 Units 4 Units 321-360 mg/dL 9 Units 9 Units 9 Units 5 Units 361-400 mg/dL 10 Units 10 Units 10 Units 6 Units You were also found to have somewhat elevated liver enzymes. It is unclear what is causing this elevation. You will need to have these levels followed as an outpatient. You blood pressure was also found to be somewhat elevated. However, no changes were made to your blood pressure medications. You should have your blood pressure rechecked as an outpatient at your follow up visit. Call your primary doctor, or go to the emergency room if you experience persistently elevated blood sugars which you are unable to control, confusion, chest pain, shortness of breath, severe abdominal pain, or other symptoms concerning to you. Followup Instructions: Initially an appointment had been scheduled in the [Hospital 1944] clinic with labs, but this had to be modified given that the patient's primary care doctor is not in the [Company 191] practice. This was discussed with the patient by telephone on [2125-11-19] and she will contact her PCP this morning to arrange for labs and follow-up later this week. She was feeling well at the time of the phone call. You will also need to follow up with your primary doctor within the next two weeks as well as your diabetes doctor.	[ "250.13", "362.01", "530.81", "535.50", "584.9", "996.86", "585.9", "E878.0", "250.53", "403.90", "996.81", "276.50", "250.63", "536.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7649, 7655	4626, 6440	391, 397	7866, 7972	3105, 4603	9952, 10490	2531, 2695		6747, 7626		7676, 7845		6466, 6724			7996, 8337								2710, 3086																			8357, 9929			321, 353														425, 1866													1888, 2234	2250, 2515
10,515	107,232	48308	Discharge summary	report	Admission Date: [2162-8-9] Discharge Date: [2162-8-13] Date of Birth: [2110-9-29] Sex: F Service: MEDICINE Allergies: Heparin (Porcine) / Erythromycin Base Attending:[First Name3 (LF) 12084] Chief Complaint: fever to 103.0 at home, RLE pain, and chills. Major Surgical or Invasive Procedure: none History of Present Illness: [Known firstname ] [Known lastname 101760] is a 51-year-old woman with history of ESRD s/p renal transplant [2151], PVD, CAD who presented to the Emergency Department this morning with complaints of fever to 103.0 at home, RLE pain, and chills. Reports she was in her USOH until 5 Am this morning - had to urinate, but due to limited mobility from osteoarthritis, used a bedpain with assistance from husband. [Name (NI) 4906] noted patient to be extremely warm and took patient's temperature, found it to be 103.0. Patient also began to complain of right foot pain, swelling, and redness, which she had not experienced prior to this morning (may have had some heel pain 2 days PTA, but unclear if this is new or old). Reports chronic LE issues secodnary to [Name (NI) 1106] insufficiency, but pain and erythema are new. Patient also reports growth on Left 4th digit that was being managed as outpatient. Was productive of pus ~ 1 week ago, which was swabbed and drained by PCP [Last Name (NamePattern4) ] [8-6]. Wound swab grew coagulase positive staph and Enterobacter cloacae. No further pus drainage, differential according to OMR note was blister drainage vs. gout vs. local pus collection. She denied any subsequent pus drainage from the finger. . On review, patient denied chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea, constipation, or diaphoresis. Skin changes as per HPI. . In the ED, initial VS were T 102.8; HR 52; BP 93/32; RR 18; O2 94% RA. Patient received doppler of RLE which did not reveal DVT. BP was recorded as upper 80s systolic. Lactate was 1.7, she was started on Vancomycin and Ceftazidime for presumed sepsis from RLE. CXR without infiltrate. Patient refused central line as she did not think it was warranted. She was admitted to the MICU for further care. . Of note, patient reports that her Allopurinol was recently increased to 100 [Hospital1 ] due to her gout issues. Past Medical History: # SLE # End stage renal disease s/p transplant [2158] now with chronic allograft nephropathy # Dilated cardiomyopathy, EF 35% # Peripheral [Year (4 digits) 1106] disease, s/p right first toe amputation, s/p # Bilateral femoral popliteal bypass. # Osteoarthritis, s/p left total hip replacement. # s/p multiple AV fistula revisions # s/p colectomy with end ileostomy secondary to perforated ischemic transverse colon # Coronary artery disease, s/p perioperative myocardial infarction # History of MRSA wound infection # Positive Hepatitis C # Hemachromatosis from mult transfusions # Anemia of Chronic Inflammation # Hyperparathyroidism s/p parathyroidectomy 10 yrs ago # Avascular necrosis of hips Social History: Denies tobacco, Etoh, drugs. On disability. Family History: No history of CAD or malignancy. + h/o DM in her mother. Physical Exam: VS: T 97.8; BP 101/78; HR 76; RR 14; O2 98% 1.5L NC GEN: Lovely middle-aged woman in NAD HEENT: PERRL. EOMI. Wears glasses. MMM. Op clear CV: III/VI systolic murmur LUSB LUNGS: CTA B/L ABD: colostomy bag on RLQ without erythema or drainage. soft. well-healed prior surgical scars. NT/ND. EXT: RLE with dolor, calor, rubor. Non-palpable pulses. 1st digit s/p amputation. Exquisitely tender to touch. No crepitus. LLE with swelling. Non-tender, warm. Hand: 4th digit on left hand with crusted lesion on distal aspect of palmar side - no pus, erythema, or other signs of active infection NEURO: AO x 3. No asterixis. No focal deficits except decreased LE ROM [2-19] pain. Pertinent Results: [2162-8-9] 11:10PM URINE HOURS-RANDOM UREA N-527 CREAT-158 SODIUM-21 [2162-8-9] 11:10PM URINE OSMOLAL-250 [2162-8-9] 11:10PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2162-8-9] 11:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2162-8-9] 11:10PM URINE RBC-[3-22]* WBC-[6-27]* BACTERIA-MOD YEAST-NONE EPI-0-2 RENAL EPI-0-2 [2162-8-9] 11:10PM URINE HYALINE-0-2 [2162-8-9] 12:18PM TYPE-[Last Name (un) ] COMMENTS-GREEN [2162-8-9] 12:18PM LACTATE-1.5 [2162-8-9] 11:55AM WBC-12.0# RBC-3.65 HGB-10.2* HCT-30.8* MCV-85 MCH-28.1 MCHC-33.2 RDW-15.5 [2162-8-9] 11:55AM NEUTS-87* BANDS-1 LYMPHS-6* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2162-8-9] 11:55AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2162-8-9] 11:55AM PLT SMR-LOW PLT COUNT-148* . RLE duplex ([2162-8-9]): IMPRESSION: No evidence of DVT involving the right lower extremity. . RIGHT FOOT, THREE VIEWS. ([2162-8-9]): The patient is status post amputation of the first ray at the base of the first proximal phalanx. The amputation borders are relatively well corticated. On today's exam, there is more pronounced focal osteopenia along the plantar medial aspect of the distal 1st metatarsal -- if this corresponds to a site of ulceration, then this could represent early osteomyelitis. No cortical interruption or periosteal new bone formation is identified at this site or elsewhere in the foot. There is diffuse osteopenia and dense [Month/Day/Year 1106] calcification. There is some increased density in the middle phalanx of the second digit, unchanged compared with [2162-3-18]. No acute fracture and no dislocation is identified. . AP Chest ([2162-8-9]): FINDINGS: Portable AP view of the chest is obtained and compared with prior study from [2162-3-18]. The heart is enlarged. Linear right basilar atelectasis is noted. No large pleural effusions are present. There is no evidence of CHF. The mediastinal contour is unremarkable. Aortic knob calcification is present. There is no pneumothorax. Osteopenia is noted in the visualized osseous structures. IMPRESSION: Cardiomegaly, with right basilar atelectasis. No CHF. . LEFT FOURTH FINGER PERFORMED ON [8-10]: AP, lateral and oblique films were obtained. As seen on the study from [2158-5-10], there are extremely extensive [Year (4 digits) 1106] calcifications and demineralization of the bony structures. Amorphous soft tissue calcifications are seen at the level of the middle and distal phalanges. There is distal soft tissue thinning. The findings are consistent with the history of SLE. No finding is seen that suggests osteomyelitis. IMPRESSION: As seen on the study from [2158-5-10], there is profound osteopenia with extensive [Month/Day/Year 1106] calcifications. There are more extensive amorphous fourth finger soft tissue calcifications than on the prior study. . AP chest ([2162-8-10]): FINDINGS: AP single view of the chest obtained with patient in sitting upright position is analyzed in direct comparison with a similar preceding study of [2162-8-9]. Marked cardiomegaly including evidence of left atrial enlargement is present as before. There is some upper zone redistribution pattern, but no conclusive evidence for interstitial or alveolar edema is noted. Linear atelectasis exists bilaterally but the lateral pleural sinuses remain free. No pneumothorax is present. When direct comparison of the lung fields is made with the previous examination, there is slightly more increased perivascular haze and also the heart size appears to have increased slightly. No new discrete parenchymal infiltrates are identified. IMPRESSION: Further progression of cardiomegaly and now some mild congestion. No evidence of pulmonary edema as yet. . Brief Hospital Course: In the MICU pt abx regiment was changed to vanc and meropenem due to the hx of (MSSA and) enterobacter. Was also followed by the renal service due to ARF with a creatinine bump to 2.4, was managed with gentle fluid rehydration with return of systolic bp into 130s. Had cotrosyn stim test to test for adrenal insufficiency as a cause of hypotension; was normal. Hypotension possibly related to patient being on BB with worsening renal failure but may also have been due to sepsis although blood culutures did not grow out positive. Also, lactate was normal making ischemia due unlikely as a cause. Pt swelling, pain and redness with great improvement; pt was therefore transferred to the floor on CC7. . Pt continued to improve on the floor; her renal function quickly returned to [Location 4222] with a creatinine of 1.8; she remained afebrile for the remainder of the stay. A source of infection was never clearly identified. Bladder and respiratory infections were thought very unlikely given normal studies. Pt had no GI sx's. ID thought source of fever was most likely the L 4th finger with a gout lesion that was superinfected. Since cultures of this had grown out enterobacter and MSSA (although a hx of MRSA) vanc and meropenem was continued. Cellulitis of the R leg was thought possible although less likely as a cause of fever. Later in the stay pt was refusing PICC placement and was demanding to go home. Pt had expressed discontent with numerous thing during the hospitalization up to this point, one of them being the experience with the plastic surgery team during their visit (recommended soaking the finger qid for 15 minutes in warm water and taking off ring). Despite numerous conversations with the intern, the resident, the attending, the transplent team, the entire ID team, pt clearly stated she would leave that day and do so without a PICC. . The following is a summary of the contants of the conversation held with patient prior to discharge: We have decreased your gabapentin dose to 300 daily, decreased your cellcept to 500 twice a day (since so far out and ID thought this may help with fighting infection). We have also changed your calcitriol to 0.5 mcg twice a day, your Sodium bicarbonate to 650mg three times a day, and decreased your metoprolol to 12.5 mg twice a day.We have recommended that you have a PICC line placed for IV antibiotics, however you have refused. Instead, we have developed an alternative plan as below. You should also start taking your linezolid on the evening of sunday [8-15] until you are out of pills. Start your ciprofloxacin tonight and continue until you are out of pills. You need to understand that this is not the optimal therapy as you may not absorb the linezolid as well as an IV antibiotic. In addition, linezolid can cause decreaased platelets, for which you are already at high risk. You will need to have MWF blood counts to monitor your platelets with your VNA until one week after you finish your linezolid dosing. They will send the results to Dr. [Last Name (STitle) ] for review. We also strongly recommend that you schedule an MRI for your finger to make sure there is no osteomyelitis as well as an echocardiagram to make sure you do not have endocarditis. Please schedule these tests on Monday. . When patient left on [8-13] she was urinating on own, was off supplemental oxygen, afebrile and eating and drinking on her own. Medications on Admission: 1. Allopurinol 100mg PO BID (recently increased) 2. Cellcept 1g PO BID 3. Prednisone 10mg PO qd 4. Protonix 40mg PO qd 5. Calcitriol 0.25mcg PO TID 6. NaHCO3 [2105] [Hospital1 ] 7. Metoprolol 25 PO BID 8. Cyclosporine 25mg PO BID 9. Folic Acid 4mg PO qd 10. Bactrim 1 pill 3x/week 11. Fentanyl Patch 50mcg/hr q72h 12. Neurontin 600 PO TID 13. MVI s iron qd Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 6. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:0 8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:0 10. Folic Acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Disp:30 Capsule(s) Refills:0 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) units Injection QMOWEFR (Monday -Wednesday-Friday). 16. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:0 17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 18. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 19. Outpatient Lab Work CBC qMWF. Call results to Dr. [Last Name (STitle) ] [Telephone/Fax (1) 250] Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: RLE cellulitis Acute Renal Failure Gout s/p transplant Discharge Condition: stable Discharge Instructions: Please seek medical attention IMMEDIATELY should you develop fevers, chills, confusion, dizziness, increased leg pain, shortness of breath or any other concerning symptoms. We have decreased your gabapentin dose to 300 daily, decreased your cellcept to 500 twice a day. We have also changed your calcitriol to 0.5 mcg twice a day, your Soudium bicarbonate to 650mg three times a day, and decreased your metoprolol to 12.5 mg twice a day. We have recommended that you have a PICC line placed for IV antibiotics, however you have refused. Instead, we have developed an alternative plan as below. You should also start taking your linezolid on the evening of sunday [8-15] until you are out of pills. Start your ciprofloxacin tonight and continue until you are out of pills. You need to understand that this is not the optimal therapy as you may not absorb the linezolid as well as an IV antibiotic. In addition, linezolid can cause decreaased platelets, for which you are already at high risk. You will need to have MWF blood counts to monitor your platelets with your VNA until one week after you finish your linezolid dosing. They will send the results to Dr. [Last Name (STitle) ] for review. Followup Instructions: Please call [Telephone/Fax (1) 250] tommorrow morning to arrange for an appoinitment with Dr. [Last Name (STitle) ]. She should follow your CBCs checked by your VNA as well as to follow up your ECHO and MRI results. . Please make appointments to obtain an ECHO and and MRI performed by early next week. We have provided you with information on how to arrange these Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2162-9-14] 3:00 Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7145] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[2162-9-15] 12:30 Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7145] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[2162-12-29] 2:30	[ "425.4", "E878.0", "038.9", "707.05", "274.9", "584.9", "V43.64", "710.0", "995.92", "443.9", "285.21", "070.54", "682.6", "996.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13678, 13722	7906, 11342	344, 350	13821, 13830	3913, 7883	15088, 16008	3146, 3204		11758, 13655		13743, 13800		11368, 11735			13854, 15065								3219, 3894																						259, 306														378, 2340													2362, 3069	3085, 3130
55,973	164,256	4025	Discharge summary	report	Admission Date: [2181-7-31] Discharge Date: [2181-8-9] Date of Birth: [2120-10-31] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy, Lentals, Beans Attending:[First Name3 (LF) 3624] Chief Complaint: Weakness, dyspnea Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 60 yo F w/ h/o renal and pancreatic transplants, DM type 1, diastolic CHF, and CAD who presents with weakness and dyspnea. Of note, patient was discharged from [Hospital1 18] yesterday after 3 day admission for SOB, chest pain, which was attributed to CHF exacerbation. She was diuresed three liters and discharged home on fluid restriction and dietary modification as well as home dose of lasix. At home, patient reported feeling weak and tired- sleeping a lot. Was febrile to over 101 and started shaking at home. Also noticed dysuria and malodorous urine. No frequency or urgency. Developed some SOB w/ fevers. Called friend who on seeing her suggested [Name (NI) ] visit. . In the ED, initial vs were: T102.4 P84 BP136/66 R14 O2 sat 95% RA. Patient was given 1 g tylenol, 1 g meropenam, and 300 cc fluid bolus as she appeared clinically dry; IVF were stopped at that point as she complained of worsened dyspnea. She maintained sats in the high 90s on room air, but given tachypnea was admitted to the ICU for monitoring. VS on transfer were HR110 120/70 RR25 O2 sat 97 3L. . In the ICU, patient reported mild nausea, fever, and mild dyspnea. Denied CP, cough, vomiting, hematemesis, abdominal pain, flank pain, diarrhea, melena, or BRBPR. No headaches, myalgias or arthralgias. . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure, palpitations. Denies vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies urinary frequency or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: #CHF; diastolic dysfunction with preserved EF # s/p renal transplant ([2157]) -- c/b chronic rejection -- second renal transplant ([2160]) # s/p pancreas transplant -- with allograft pancreatectomy ([5-/2174]) -- redo pancreas transplant ([6-/2175]) -- admission for acute rejection ([7-/2180]), resolved with increased immunosupression # Diabetes mellitus type I -- c/b neuropathy, retinopathy, dysautonomia -- no longer requires regular insulin after the pancreas transplant, but has been given SS while on high-dose prednisone in house # Autonomic neuropathy # Sleep disordered breathing -- Unable to tolerate CPAP; uses oxygen 2L NC at night # Osteoporosis # Hypothyroidism # Pernicious anemia # Cataracts # Glaucoma # Anemia of CKD, on Aranesp in the past # R foot fracture c/b RLE DVT # Chronic LLE edema # Recurrent E. coli pyelonephritis # s/p anal polypectomy ([5-/2176]) # s/p bilateral trigger finger surgery ([8-/2178]) # s/p left [Year (4 digits) 6024] ([8-/2179]) Social History: Child psychiatrist, on disability. Lives alone in [Hospital1 8]. Has a PCA 8h/day. Ambulatory with a prosthesis. Denies alcohol, tobacco, or illicit drug use. Family History: Father with MI at 57 No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Physical Exam on Admission: Vitals: T: BP: P: RR: SpO2: General: Alert, oriented, fatigued but interactive, shivering HEENT: exopthalmos, sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bibasilar crackles, R>L, no wheezes, ronchi CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly; well healed midline incision Back: no flank tenderness GU: no foley [Hospital1 ]: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge: Vitals: Tm 98 Tc 96.2 HR: 58 BP: 125/69 RR: 18 SpO2: 100% I/O: 1640/2200 + 2 BM General: Alert, oriented, pleasant HEENT: exopthalmos, sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, ronchi CV: RRR normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly; well healed midline incision GU: no foley [Hospital1 ]: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, R arm with picc has bruise but no palpable hematoma Pertinent Results: Labs on Admission: [2181-7-30] 06:10AM WBC-2.0* RBC-3.17* HGB-9.0* HCT-28.1* MCV-89 MCH-28.2 MCHC-31.9 RDW-15.1 [2181-7-30] 06:10AM PT-11.2 PTT-24.9 INR(PT)-0.9 [2181-7-31] 10:06PM LACTATE-1.0 [2181-7-31] 09:00PM GLUCOSE-106* UREA N-75* CREAT-2.0* SODIUM-134 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-22 ANION GAP-17 [2181-7-31] 09:00PM ALT(SGPT)-6 AST(SGOT)-20 ALK PHOS-61 TOT BILI-0.3 [2181-7-31] 09:00PM LIPASE-27 [2181-7-31] 09:00PM cTropnT-<0.01 [2181-7-31] 09:00PM ALBUMIN-3.8 MAGNESIUM-2.2 [2181-7-31] 09:00PM WBC-5.2# RBC-3.38* HGB-9.7* HCT-29.7* MCV-88 MCH-28.8 MCHC-32.8 RDW-15.4 [2181-7-31] 09:00PM NEUTS-80.8* LYMPHS-13.0* MONOS-4.0 EOS-1.9 BASOS-0.3 [2181-7-31] 09:00PM PLT COUNT-168 [2181-7-31] 09:00PM PT-10.8 PTT-21.0* INR(PT)-0.9 [2181-7-31] 09:00PM URINE COLOR-Straw APPEAR-Hazy SP [Last Name (un) 155]-1.009 [2181-7-31] 09:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [2181-7-31] 09:00PM URINE RBC-2 WBC-133* BACTERIA-MOD YEAST-NONE EPI-<1 [2181-7-31] 09:00PM URINE HYALINE-1* [2181-7-31] 09:00PM URINE WBCCLUMP-FEW [2181-7-30] 06:10AM GLUCOSE-85 UREA N-72* CREAT-2.0* SODIUM-135 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15 [2181-7-30] 06:10AM AMYLASE-91 [2181-7-30] 06:10AM LIPASE-25 [2181-7-30] 06:10AM CALCIUM-9.3 PHOSPHATE-4.4 MAGNESIUM-2.5 [2181-7-30] 06:10AM tacroFK-5.7 rapamycin-9.0 [2181-7-30] 06:10AM WBC-2.0* RBC-3.17* HGB-9.0* HCT-28.1* MCV-89 MCH-28.2 MCHC-31.9 RDW-15.1 [2181-7-30] 06:10AM PLT COUNT-149* [2181-7-30] 06:10AM PT-11.2 PTT-24.9 INR(PT)-0.9 . Chest: [2181-7-31] IMPRESSION: Mild pulmonary edema with small bilateral pleural effusions, similar compared to the prior study. Bibasilar air space opacities likely reflect atelectasis. . 8/ [10-2] RENAL ULTRASOUND: The transplanted kidney measures 11.3 cm. No evidence of hydronephrosis or perinephric fluid collection. The main renal artery and vein are patent with normal waveforms. Resistive indices in the upper, mid and lower poles of the transplant kidney are 0.75, 0.74 and 0.72 respectively, previously ranging from 0.78 to 0.81. The bladder is collapsed about the Foley and could not be well evaluated in this study. IMPRESSION: 1. No perinephric fluid or hydronephrosis. 2. Resistive indices in the upper, mid and lower poles of the transplant kidney range from 0.75 to 0.78. Findings discussed with Dr. [Last Name (STitle) ] at 9 pm on [2181-8-1] via telephone [2181-8-9] 05:34AM BLOOD WBC-2.6* RBC-2.95* Hgb-8.6* Hct-26.4* MCV-89 MCH-29.0 MCHC-32.5 RDW-15.3 Plt Ct-180 [2181-8-8] 06:00AM BLOOD WBC-3.1* RBC-2.87* Hgb-8.4* Hct-25.9* MCV-91 MCH-29.2 MCHC-32.2 RDW-15.8* Plt Ct-203 [2181-8-8] 06:00AM BLOOD Neuts-54.8 Lymphs-27.9 Monos-11.3* Eos-5.8* Baso-0.1 [2181-8-9] 05:34AM BLOOD Glucose-79 UreaN-73* Creat-1.6* Na-137 K-4.6 Cl-104 HCO3-26 AnGap-12 [2181-8-8] 06:00AM BLOOD Glucose-82 UreaN-75* Creat-1.5* Na-138 K-4.3 Cl-105 HCO3-25 AnGap-12 [2181-8-9] 05:34AM BLOOD ALT-5 AST-18 LD(LDH)-170 AlkPhos-55 TotBili-0.2 [2181-8-2] 04:22AM BLOOD CK-MB-15* MB Indx-8.3* cTropnT-1.11* [2181-8-1] 11:05PM BLOOD CK-MB-13* MB Indx-6.9* cTropnT-1.11* [2181-8-9] 05:34AM BLOOD Calcium-10.3 Phos-5.4* Mg-2.4 [2181-8-8] 06:00AM BLOOD Calcium-10.0 Phos-4.9* Mg-2.7* [2181-8-9] 05:34AM BLOOD tacroFK-5.6 [2181-8-8] 06:00AM BLOOD rapmycn-11.2 [2181-8-1] 01:04PM BLOOD Type-ART Temp-37.6 pO2-88 pCO2-35 pH-7.43 calTCO2-24 Base XS-0 Intubat-NOT INTUBA [2181-8-1] 01:04PM BLOOD Lactate-0.9 [2181-7-31] 09:00PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [2181-7-31] 09:00PM URINE RBC-2 WBC-133* Bacteri-MOD Yeast-NONE Epi-<1 [2181-7-31] 09:00PM URINE CastHy-1* . [2181-7-31] 9:00 pm URINE Site: CLEAN CATCH FINAL REPORT [2181-8-5] URINE CULTURE (Final [2181-8-5]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. TETRACYCLINE SENSITIVITY REQUESTED BY DR. [Last Name (STitle) 13125] [Numeric Identifier 17770]. TETRACYCLINE sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMIKACIN-------------- 8 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S . [2181-7-31] 9:00 pm BLOOD CULTURE #2. FINAL REPORT [2181-8-3] Blood Culture, Routine (Final [2181-8-3]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 328-1435P [2181-7-31]. Anaerobic Bottle Gram Stain (Final [2181-8-1]): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [2181-8-1]): GRAM NEGATIVE ROD(S). Brief Hospital Course: Primary Reason for Hospitalization: 60F with PMH pancreatic and renal transplants, DM type II, diastolic CHF, HTN, and hypothyroidism, recently admitted for CHF exacerbation who presents with weakness, fevers, and hypotension suggestive of urosepsis. Active Diagnoses: # Urosepsis: Patient presented with weakness, fevers, hypotension in setting of dirty UA. She has history of urosepsis as recently as [2180-6-22], when was treated for cephalosporin sensitive E. coli with meropenem for 14 days. Given immunosuppression and altered anatomy, patient at higher risk for these infections. She was treated again with meropenam (renally-dosed) and vancomycin for empiric coverage. Urine and blood cultures were sent. For the first few days of hospitalization, she was bolused with IVF for hypotension and her anti-hypertensives were held. Her blood cx grew out E. coli, and she was continued on meropenem for total 14 days (complicated UTI). The plan is to switch to ertepenem when discharged home (once daily IV). An urology consult was obtained for recurrent urosepsis, and outpatient follow-up was deemed ok. Since pancreas is draining through bladder, she may have a stone in the bladder not visualized on renal u/s. Cystoscopy might show something that can be removed. On floor, pt was stable, her mental status was at baseline and did not have any fevers. She was continued on iv antibiotics and renal function improved to baseline. She was discharged on an additional 6 days of ertepenam and will start fosfomycin for ppx. # SOB/Tachypnea: On admission, the patient experienced a subjective feeling of dyspnea not associated with hypoxia. She was satting in high 90s on 1-2L oxygen, which appears to baseline for her, as she uses oxygen at home. Differential diagnosis included ischemic cardiac etiologies, pneumonia (no cough), CHF (CXR similar to prior admission CXR), and anxiety. She was noted to have crackles on lung exam and to have slight pulmonary edema, but likely not much worse than baseline. Her cardiac enzymes were checked and returned elevated (see below). She was continued on supplemental oxygen, and diuresis was initially held given her hypotension and possible sepsis. As her blood pressure improved, she was diuresed. On the floor pt was euvolemic and O2 saturations were normal on room air. At time of discharge, she was taking all home antihypertensives and diuretics. #NSTEMI: On admission, her troponin returned positive at 0.36 (she was discharged the day prior with troponin <0.01), CK 15, MB 10.6. She was noted on her last admission to have a LBBB, she is defined as having a NSTEMI (EKG changes masked), most likely secondary to demand instead of ACS. She was started on a heparin gtt, ASA, statin. Her troponin was trended q8h and stabilized to 1.11 by HD3, so her heparin drip was turned off. On the floor she was stable without chest pain and her tele did not have any events. She was discharged on lisinopril, asa and carvedilol. She will follow up with Cardiologist within next month. #Diastolic CHF: Patient has dilated LV with preserved EF, as well as crackles on lung exam and CXR showing b/l pleural effusions and pulmonary edema similar to prior admission. Her lasix, lisinopril and carvedilol were initially held for hypotension, but when her blood pressure improved by HD3, a lasix drip was started. On HD4, the lasix gtt was discontinued, and she was started on Lasix 60mg IV BID with a goal UOP of 1L/day. ETT was obtained, showing a likely distal LAD lesion, not cardiomyopathy, distal septal akinesis, 3+ MR which may have been associated with volume. Her carvedilol dose was slowly increased back to her home dose as tolerated, and her doxasozin continued to be held. On the floor her pressures and kindney function improved and she was restarted on all home medications. She had an episode of orthostasis, but pressures continued to improve. # [Last Name (un) ]: Patient presented with acute kidney injury, stable from discharge the day prior at 2.0. Baseline creatinine appears to be around 1.6. Her lisinopril was initially held. Sediment muddy brown casts. A renal ultrasound showed no perinephric fluid or hydronephrosis. AT the time of ICU call out, Cr stable at 1.9. At time of discharge her cr was 1.6. She will follow up with Dr [Last Name (STitle) ]. # HTN: On admission, was hypotensive from urosepsis, so carvedilol, doxazosin and lisinopril were held. As her bp improved, she was restarted on carvedilol, first at a lower than home dose and titrate up slowly to home dose of 12.5mg [Hospital1 ]. Doxazosin was restarted. At the time of ICU call out, lisinopril was still held. On the floor her pressures improved and she was discharged on all home medications. # S/p Renal and pancreas transplant: Was seen by renal transplant and her sirolimus, tacrolimus, and prednisone were adjusted. Her sacrolimus was discontinued, tacrolimus dose decreased to 1.5 [Hospital1 ], and started on hydrocortisone 100mg q8h. The hydrocortisone was tapered and she was eventually restarted on prednisone at 5mg daily. On HD3, she was restarted on rapamune 2mg daily and her tacrolimus 1.5 mg [Hospital1 ] was retimed to 0600 and 1800 dosing. Her tacro and [Last Name (un) ] levels were checked daily at 0530 (do NOT order with AM labs). The goal levels for both rapamune and tacrolimus are [8-1] and need to be checked daily. She was also given pancreatic enzyme replacement per home regimen. She was discharged on home tacro and [Last Name (un) ] doses. #History of C. Diff: Per ID, she was started on empiric PO vancomycin 125 Q6H for 1 week following end of meropenem therapy. At time of discharge surveillance cdiff was negative and diarrhea had improved. She will continue PO vanco until [2181-8-21] Chronic Diagnoses: # Hypothyroidism: TSH was in normal range during last hospitalization (0.7 on [7-27]). She was continued on levothyroxine at alternate qOD dosing of 112mcg and 100 mcg. # Glaucoma: She was continued on eye drops and methazolamide per home regimen. Transitional Issues: - pt will need weekly labs on Tuesdays: CBC, chem 10, tacro level, [Last Name (un) ] level - will need aranesp after d/c - needs podiatry for ingrowns - needs PT, prosthesis refit, OT, cards rehab Code Status: Full code Medications on Admission: acyclovir 400 mg PO Q12H doxazosin 2 mg PO QAM doxepin 10 mg PO HS levothyroxine 112 mcg qOD levothyroxine 100 mcg qOD lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, PO TID w/ meals methazolamide 50 mg PO BID prednisone 5 mg PO DAILY simvastatin 20 mg PO DAILY folic acid 1 mg PO DAILY omega-3 fatty acids 1 Capsule PO BID ipratropium bromide 0.02 % Solution 1 INH Q6H PRN Forteo 20 mcg/dose - 600 mcg/2.4 mL Pen Injector Sig: One (1) ML Subcutaneous daily. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS aspirin 81 mg PO DAILY Calcium-Vitamin D Cyclosporine 0.05% dropperette albuterol sulfate 2.5 mg /3 mL (0.083 %) NEB One INH q6hr PRN Lasix 20 mg PO once a day sirolimus 2 mg PO DAILY carvedilol 12.5 mg PO BID tacrolimus 2 mg PO Q12H Home oxygen 1-2L as needed Discharge Medications: 1. fosfomycin tromethamine 3 gram Packet Sig: One (1) packet PO once a week: dissolve in [2-23] ounces of water. Can be taken with or without food. . Initiate after completion of Ertapenem course. . 2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) INH Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 14. 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. 15. ipratropium bromide 0.02 % Solution Sig: One (1) INH Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 16. teriparatide 20 mcg/dose (750 mcg/3 mL) Pen Injector Sig: One (1) ML Subcutaneous daily (). 17. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): administered at 6am. 18. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. tacrolimus 0.5 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 20. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<100. 21. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 22. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 23. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 24. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 25. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 26. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic daily (). 27. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 28. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 29. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO TID with meals. 30. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 31. oxygen 1-2L PRN SOB or sats <91% 32. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 33. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) mL Injection once a month: please give monthly dose day pt arrives at rehab. 34. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 12 days: please continue until [2181-8-21]. 35. Outpatient Lab Work Weekly labs (Tuesdays): Sirolimus (rapamycin) level, tacrolimus level, CBC, Chem 7 . Fax to please fax to Dr. [Last Name (STitle) ] at transplant center: [Telephone/Fax (1) 697] 36. pentamidine 300 mg Recon Soln Sig: One (1) INH Injection once a month. . 37. Ertapenem 1g IV daily until [8-15]. . 38. Outpatient Lab Work Weekly labs (Tuesdays): Sirolimus (rapamycin) level, tacrolimus level, CBC, Chem 7 . Fax to please fax to Dr. [Last Name (STitle) ] at transplant center: [Telephone/Fax (1) 697] Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing medical Care Discharge Diagnosis: Urosepsis NSTEMI CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Dr. [Known lastname 17759], It was a pleasure taking care of you. You were admitted to the hospital for a complicated urinary tract infection that extended into your bloodstream (urosepsis). You had a change in mental status secondary to the infection and needed to be transferred to the ICU. You also had a heart attack. You were treated with heparin for the heart attack. No other new interventions for the heart attack are necessary at this time. Please continue all of your home medications with the following changes: Start Ertapenem for an additional 6 days (last day [2181-8-15]) Start After you finish ertapenem, start Fosfamycin 3gm in 4 Oz of water weekly for UTI prophylaxis. START: vancomycin oral liquid 125mg by mouth every six hours until [2181-8-21]. START: Atorvastatin 80 mg by mouth daily and STOP simvastatin 20 mg by mouth daily CHANGE: Lasix 20mg tab one tablet by mouth daily to lasix 20mg tab one tablet by mouth twice daily . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: PODIATRY When: FRIDAY [2181-8-10] at 1:50 PM 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 Department: RADIOLOGY When: FRIDAY [2181-8-17] at 12:45 PM With: RADIOLOGY [Telephone/Fax (1) 327] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2181-8-24] at 1 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2003], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2181-9-4] at 9:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage You will also be seeing Dr. [Last Name (STitle) ] your Transplant Nephrologist at this visit as well. Department: UROLOGY When: MONDAY [2181-9-10] at 10:30 AM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 164] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629**]	[ "599.0", "995.92", "414.01", "780.50", "584.5", "038.42", "V46.2", "410.71", "428.0", "785.52", "428.32", "E878.0", "276.51", "733.00", "244.9", "996.81", "365.9", "787.91" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	21445, 21524	10300, 10553	413, 430	21589, 21589	4712, 4717	22828, 24597	3343, 3479		17649, 21422		21545, 21568		16695, 17626			21740, 22805								3494, 3508															16442, 16669			1769, 2108				355, 375														458, 1750							4732, 10277	21604, 21716				10571, 16421	2130, 3146	3162, 3327

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.