Split (1)

train · 26.9k rows

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31,651	158,766	11312	Discharge summary	report	Admission Date: [2193-7-29] Discharge Date: [2193-8-14] Date of Birth: [2142-10-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: confusion Major Surgical or Invasive Procedure: cerebral angiogram x 2 Intubation Central line History of Present Illness: 50 M with h/o MVP, who presented [7-29] after 2-3d fever (Tm 103), malaise. On the morning of admission pt's wife noted increased confusion, and thus brought pt to ED. . In [Hospital1 18] [Name (NI) ] pt was initially A&Ox3, but intermittently found to be confused, though otherwise neurologically intact per notes. CT HEAD was obtained which revealed left frontal SAH with multiple foci of ?hemmorhage vs emboli. labs revealed platelets 77, WBC 7.9, Na was 126 with K of 3.1. . pt received 4 units of platelets [3-8] SAH, and was loaded with phenytoin 1g. ID and neurosurgical consult were obtained. for fever, ddx was broad given mental status changes (bacterial, meningitis, parasitic, lyme, RMSF, HSV etc..), pt started on vanco, doxycycline, CTX, acyclovir for concern of bacterial infection vs lyme disease, though he remained febrile to 101 despite tylenol and cooling blankets. . Blood cultures on [7-29] subsequently grew [Month/Year (2) 8974], raising concern for septic emboli. Given his h/o MVP, pt underwent TTE and TEE which were negative for vegetation, but did reveal new flail mitral valve. Cardiothoracic surgery consulted [7-31], with plan for likely outpt valve replacement. . pt underwent MRI [7-29] to further evaluate multiple foci of hemmorhage in head and for concern of mycotic aneurysm, however shortly after study developed respiratory distress, ultimately requiring intubation [7-30]. This was subsequently felt most likely [3-8] aggressive IVF hydration during initial ED presentation (8L IVF per notes). Pt was diuresed, and quickly weaned from vent on [7-31]. Cerebral angiogram performed on [8-2] which was limited by motion, but unremarkable. . On [2193-8-5] he had a cerebral angiogram under general anesthesia. The procedure was complicated by hypotension while intubated, for which he was on neo transiently. He received 1600ml of LR during the case. He was extubated, but in the PACU developed respiratory distress with oxygen sats in the 80's and reintubated. He again had hypotension (while on propofol) to the 80s and was bolused LR and restarted on Neo (at 1-0.75mcg/kg) to maintain an SBP of 90-100's. Pt transferred to MICU. . Patient was extubated in the MICU (neg 3.2L) and breathing on room air prior to transfer back to the floor. Noted to have temperature spike to 102.3. Repeat echocardiogram was done and no change was noted. Patient was sent to abdominal CT for further work-up of fever, which demonstrated ? splenic abscess (final read pending). . Pt triggered at 2:47 am for BP 180/91, HR 140s in setting of fever to 102.3. RR 24, satting 97% 2L. Pt given tylenol 350 mgx1 and 1 L NS. Pt defervesced and HR returned to 90s. Pt reported some shortness of breath. EKG: ST 120s, no st-t changes. Given concern for flash pulmonary edema in setting of fluid/compromised hemodynamics, o/n attg recommended transfer to MICU service for further monitoring. Past Medical History: MVP--Flail mitral valve leaflet Hypertension Obstructive Sleep Apnea History of Kidney Stones Hypercholesterolemia Social History: Married with three grown children. Works in banking and finance. No history of alcohol or drug use. Family History: Notable for hypertension. Father died of esophageal cancer. No known history of blood dyscrasia, aneurysms, stroke. Physical Exam: Temp 98.9 BP 117/70 Pulse 100 Resp 26 O2 sat 98% RA Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, 3/6 SEM at lsb Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3 Skin - No rash Pertinent Results: [2193-7-28] 11:32PM BLOOD WBC-7.9# RBC-4.08* Hgb-13.1* Hct-34.8* MCV-86 MCH-32.1* MCHC-37.6* RDW-12.8 Plt Ct-77# [2193-8-14] 05:43AM BLOOD WBC-5.9 RBC-2.89 Hgb-8.6* Hct-24.5* MCV-85 MCH-29.8 MCHC-35.1* RDW-14.6 Plt Ct-338 [2193-8-14] 08:48AM BLOOD Hct-26.4* [2193-7-28] 11:32PM BLOOD Neuts-88* Bands-3 Lymphs-5* Monos-2 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [2193-7-29] 04:29AM BLOOD PT-12.7 PTT-37.6* INR(PT)-1.1 [2193-7-31] 03:04AM BLOOD Fibrino-494* D-Dimer-2079* [2193-8-12] 06:27AM BLOOD Ret Aut-4.0* [2193-7-28] 11:32PM BLOOD Glucose-123* UreaN-22* Creat-1.3* Na-126* K-2.9* Cl-87* HCO3-30 AnGap-12 [2193-8-14] 05:43AM BLOOD Glucose-94 UreaN-13 Creat-1.0 Na-134 K-3.8 Cl-100 HCO3-27 AnGap-11 [2193-7-28] 11:32PM BLOOD ALT-27 AST-52* AlkPhos-66 TotBili-2.1* [2193-7-29] 06:01AM BLOOD LD(LDH)-228 TotBili-1.4 DirBili-0.7* IndBili-0.7 [2193-8-14] 05:43AM BLOOD ALT-29 AST-26 LD(LDH)-250 AlkPhos-58 TotBili-0.5 [2193-7-31] 03:04AM BLOOD Lipase-58 [2193-7-30] 05:01AM BLOOD proBNP-7778* [2193-7-31] 03:04AM BLOOD CK-MB-NotDone cTropnT-0.06* [2193-7-29] 06:01AM BLOOD Albumin-2.8* Calcium-7.4* Phos-1.7* Mg-2.1 [2193-8-14] 05:43AM BLOOD Albumin-3.1* Calcium-9.0 Phos-3.8 Mg-2.2 [2193-8-7] 03:30AM BLOOD calTIBC-143* VitB12-1404* Folate-5.3 Ferritn-1729* TRF-110* [2193-8-12] 06:27AM BLOOD Hapto-52 [2193-7-29] 06:01AM BLOOD Osmolal-269* [2193-7-28] 11:32PM BLOOD TSH-0.80 [2193-7-31] 05:19AM BLOOD Vanco-7.1* [2193-8-13] 09:52PM BLOOD Vanco-18.7 IMAGING: [2193-8-6]: TTE: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened (posterior leaflet and its supporting structures are markedly thickened). The mitral valve leaflets are myxomatous. The mitral valve leaflets are elongated. There is moderate/severe posterior mitral leaflet prolapse. There is partial posterior mitral leaflet flail. An eccentric jet of (at least) moderate (2+) mitral regurgitation is seen; the severity of mitral regurgitation may be underestimated secondary to the eccentric nature of the regurgitant flow (Coanda effect). No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2193-7-31], the findings are similar. [2193-8-5]: REPEAT CEREBRAL ANGIOGRAM under general anesthesia FINDINGS: There is no evidence of aneurysm, arteriovenous malformation, or other cause for subarachnoid hemorrhage. On delayed images from the bilateral external carotid injections, there are small foci of patchy blush of the bilateral posterior parietal scalp which is nonspecific but likely venous filling. IMPRESSION: No evidence of aneurysm, arteriovenous malformation, or other cause for subarachnoid hemorrhage. [2193-8-2] CEREBRAL angiogram: Severely limited exam due to patient motion, but no gross aneurysms or vascular malformations are identified. A repeat angiogram with anesthesia may be considered if clinically warranted. . [2193-8-1] TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No ASD or PFO are seen (saline contrast at rest given). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. The mitral valve leaflets are myxomatous. There is partial flail of the posterior mitral valve leaflet with visibly torn chordae. No clear mass or vegetation is seen on the mitral valve although cannot exclude a prior, or healed vegetation. An eccentric jet of severe (4+), anteriorly mitral regurgitation is seen with systolic flow reversal in the pulmonary veins. There is no pericardial effusion. IMPRESSION: No valvular vegetations or paravalvar abcess seen. MVP with partial flail and severe mitral regurgitation. . [2193-7-30]: CTA head: NONCONTRAST HEAD CT: Noncontrast images demonstrate persistent hyperdense hemorrhage within the left central sulcus extending into the surrounding sulci. There is no interval change when compared to the CT from two days prior. There are several other hyperdense foci within the right frontal lobe and within the white matter, just posterior to the occipital [Doctor Last Name 534] of the right lateral ventricle. The latter hyperdensity was not present on the initial head CT, but was visualized on the recent MRI. Overall, no new areas of acute intracranial hemorrhage are identified. There is no significant associated mass effect. There is no shift of normally midline structures, or evidence of major vascular territorial infarction. The patient remains intubated. The visualized portions of the paranasal sinuses and mastoid air cells are unremarkable. CT ANGIOGRAM OF THE HEAD: The intracranial portions of the carotid arteries, the middle cerebral arteries, the anterior cerebral arteries, the middle cerebral arteries, the posterior cerebral arteries, the basilar and the vertebral arteries are normal in caliber and contour. No focal areas of stenosis or aneurysmal dilatation are identified. Specifically within the area of the subarachnoid hemorrhage in the left parietal area, no specific vascular abnormality is identified. IMPRESSION: Overall, distribution of intracranial hemorrhage appears to suggest recent trauma although no such history is specifically given. Stable appearance of predominantly left central sulcus subarachnoid hemorrhage. No specific vascular abnormality is identified on the CT angiogram; however, catheter angiography may be a more sensitive method to further investigate the underlying pathology. . [2193-7-30] TTE: GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic root is moderately 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 present. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are moderately thickened. The mitral valve leaflets are myxomatous. There is moderate/severe mitral valve prolapse. There is partial posterior mitral leaflet flail. A mass or vegetation on the mitral valve cannot be excluded. Torn mitral chordae are present. An eccentric jet of at least moderate (2+) mitral regurgitation is seen, although this may be underestimated given the eccentricity of the jet. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2192-11-14], partial flail of the posterior leaflet of the mitral valve is probably new. Probable torn chordal structures are seen, although views are technically suboptimal and cannot exclude vegetation. If clinically indicated, a TEE may better assess for endocarditis. The severity of mitral regurgitation has also increased. The aorta is slightly larger. . . [2193-7-29] MRI HEAD: FINDINGS: Unfortunately, many of the images, particularly those with contrast administration, are grossly degraded by patient motion. Within these significant limitations, there is no definite pathological enhancement of lesions within the brain, seen on the CT scan, and also identified on the FLAIR and gradient echo MR images. Certainly, a number of the lesions demonstrate susceptibility, consistent with the suspected multiple areas of hemorrhage. There is no hydrocephalus or shift of normally midline structures. The diffusion-weighted scans suggest that there may be scattered punctate foci of restricted diffusion in the white matter of both cerebral hemispheres, as well as some periventricular locales, but I cannot identify most of them on the accompanying ADC map. As they are not demonstrable on the axial FLAIR images, their true pathologic significance, if any, is uncertain. The principal vascular flow patterns are observed. No overt extracranial abnormality is seen. CONCLUSION: Multiple areas of probable hemorrhage within the cerebral hemispheres and likely within a subarachnoid locale on the left side, similar to that seen on CT scanning. The poor quality of the contrast enhanced scans makes it difficult to determine whether there is any associated pathological enhancement of these lesions. In view of the known positive blood cultures, a septic etiology of the above-noted findings needs to be considered. MR ANGIOGRAPHY OF THE BRAIN: FINDINGS: This is a normal study. However, the area of the subarachnoid hemorrhage in the left parietal region was not encompassed on this standard imaging protocol. Thus, it is impossible to assess whether a mycotic aneurysm is, in fact, present in this locale. If, after surgical consultation, there is strong suspicion for a mycotic aneurysm, standard catheter angiography remains the definitive imaging test to verify or exclude this diagnosis. . . [2193-7-29] CT HEAD: NONCONTRAST CT HEAD: Left frontal subarachnoid hemorrhage is noted near the vertex. Smaller hyperdense foci within right-sided frontal sulci likely also represents subarachnoid blood. A 6 mm hyperdense focus in the right centrum semiovale may represent a small intraparenchymal hemorrhage v. a mass lesion. No intraventricular blood is identified and there is no shift of normally midline structures or evidence of acute major vascular territorial infarct. Imaged portions of the paranasal sinuses and mastoid air cells are well aerated. Surrounding osseous structures are unremarkable. IMPRESSION: Several foci of subarachnoid blood, the largest of which is at the left frontal lobe near the vertex. Small right centrum semiovale intraparenchymal hemorrhage v. mass also noted. . [7-28] CXR - no acute cardiopulm. process. Brief Hospital Course: Pt presented [7-29] after 2-3d fever (Tm 103), malaise. In [Hospital1 18] ED CT HEAD was obtained which revealed left frontal SAH with multiple foci of possible hemorrhage vs emboli. ID and neurosurgical consult were obtained. Nsg recommended cerebral angio. Regarding fever, ddx was broad, pt started on vanco, doxycycline, CTX, acyclovir. Blood cultures on [7-29] subsequently grew [Month/Year (2) 8974], raising concern for septic emboli. Given his h/o MVP, pt underwent TTE and TEE which were negative for vegetation, but did reveal new flail mitral valve. Cardiothoracic surgery consulted [7-31], with plan for likely outpt valve replacement. Pt received MRI [7-29] to further evaluate multiple foci of hemmorhage in head and for concern of mycotic aneurysm, however shortly after study developed respiratory distress, ultimately requiring intubation [7-30]. Resp distress thought to be [3-8] vol overload. Pt was diuresed, and quickly weaned from vent on [7-31]. Cerebral angiogram performed on [8-2] which was limited by motion, but unremarkable. He was transferred from the MICU and kept on nafcillin. He symptomatically improved but had persistent low grade fevers (T=99-100). On [2193-8-5] he had a cerebral angiogram under general anesthesia done both to get [2193-8-6]: better images to evaluate for aneurysm given artifact initially. The procedure was complicated by hypotension while intubated, for which he was on neosynephrine transiently. He received 1600ml of LR during the case. He was extubated, but in the PACU developed respiratory distress with oxygen sats in the 80's and reintubated. Overnight he was briefly hypotensive on propofol and again required neosynephrine. Patient was extubated in the MICU [2193-8-6] after diuresis and breathing on room air prior to transfer back to the floor. Noted to have temperature spike to 102.3. Repeat echocardiogram was done and no change was noted. Cause of persistent fever was unclear. CT abdomen done did not show significant signs of infection. An ultrasound of the abdomen/spleen showed possible infarcts but no signs of infection. However, he continued to have elevated temperature with rigors while on nafcillin. Therefore antibiotics were changed to vancomycin. This resulted in improvement of his fever and symptoms. By problem list: 1) [Name2 (NI) 8974] endocarditis: diagnosed based on echo findings and culture data. Initially Received 4 days gentamycin + nafcillin and the just Nafcillin, but found to still have fevers so wastransitioned to vancomycin. Will likely need valve replacement, but will hold off until SAH resolved and s/p abx course. Plan for 6 week course with follow up with ID after teh course finishes. 2) SAH - Followed by neurosurgery initially. Cerebral angiogram x 2 and other imaging shows no signs of aneurysm. Will have follow up 4 weeks after diagnosis with neurosurgery while continuing with seizure prophylaxis (keppra) until then (dilantin was initially started but changed to keppra for concern of drug fever, there was no change in fever curve with the change). 3) Valvular disease: was evaluated by CT surgery and felt to be a candidate for valvular replacement. Pre-op studies were done. Prior to surgery he should have cardiac catherization. This will be scheduled the week after completion of antibiotics. At the time of the catherization, CT surgery should be notified and evaluated for surgery on that same admission (Dr. [Last Name (STitle) ] initially evaluated patient). Given severity of valvular disease and frequency of pulmonary edema, the patient was discharged on a small dose of lasix. 4) Elevated LFTs - Initially elevated with an unclear source. Resolved prior to change in antibiotics. 5) anemia - normocytic. was in low 30s on admission. But continues to trend downwards. No signs hemolysis. Labs seem consistent with anemia of inflammation which is consistent with current disease. No signs of deficiencies and guaiac negative. 6) hyponatremia - Persisted despite volume repletion and improved with fluid restriction. Urine lytes inconsistent but given improvement with fluid restriction it seems there is likely an element of SIADH. 7) thrombocytopenia - RESOLVED. etiology unclear, initial concern was for [Name (NI) 36281] though normal renal function only mildly elevated (1.3) and no schistocytes. fibrinogen and d-dimer elevated, though difficult to interpret in setting of endocaditis. coags wnl. no known recent heparin to suggest HIT, no appreciable splenomegaly, Possibly due to secondary to splenic infarcts and brief splenic enlargement. 8) hypertension - Resumed betablocker 9) hyperlipidemia: should be restarted on statin if outpatient lfts are normal Medications on Admission: Atenolol 100 mg-once a day Dyazide 37.5-25 mg--once a day Lipitor 10 mg once a day Discharge Medications: 1. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 12H (Every 12 Hours) for 4 weeks: Finishes [9-10]. Disp:qs mg Refills:2 2. Outpatient Lab Work Weekly LFTs, Chem 7, CBC. Please fax results to Dr. [Last Name (STitle) 4020] [Telephone/Fax (1) 1419] 3. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:0 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 5. PICC line Please flush PICC line per protocol 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO QOD. Disp:30 Tablet(s) Refills:2 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Endocarditis, [Telephone/Fax (1) 8974] Mitral valve regurgitation Subarachnoid hemorrhage Secondary: hypertension anemia Discharge Condition: afebrile and pain free Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1500 mL . You were admitted to the hospital with endocarditis. You were found to have a staph infection in your heart. You also had bleeding around your brain. Finally your heart valve is damaged and you will have to have surgical repair. Please return to the hospital if you have any chest pain, shortness of breath, dizziness, passing out, fever, chills, rigors or any other concerning symptoms. Followup Instructions: Cardiology: Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437], [Telephone/Fax (1) 4451]. You should see him in the next 2 weeks on a wednesday. Please call if you are not called with an appointment in the next few days. Neurosurgery: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12760], MD Phone:[Telephone/Fax (1) 1669] Date/Time:[2193-9-3] 11:30. Infectious disease: you should follow up with Dr. [Last Name (STitle) 4020] on [9-12] at 11:00AM. This is in the [Hospital ] medical office building on the [Hospital Ward Name ] of [Hospital1 18] on [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. [Telephone/Fax (1) 457] Date/Time:[2193-9-12] 11:00 Echocardiogram: ECHOCARDIOGRAM Phone:[Telephone/Fax (1) 128] Date/Time:[2193-9-5] 1:00 Cardiac surgery: You will follow up with Dr. [Last Name (STitle) ] [9-17] at 1:15PM. His office is in the [Hospital ] Medical office Building Phone: [Telephone/Fax (1) 26721]. You should also follow up with your primary care physician in the next 3-4 weeks by calling [Telephone/Fax (1) 1579] Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. You will need a catherization and valve surgery. The catherization will be planned after [9-17]. The cardiology office will schedule this procedure and will be calling you. For more information [Telephone/Fax (1) 36282].	[ "253.6", "518.81", "038.11", "272.0", "421.0", "995.92", "401.9", "430", "V17.4", "458.29", "429.5", "424.0", "287.5", "285.29", "327.23", "518.0", "V09.0", "428.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "88.91", "99.05", "96.71", "88.72", "88.41", "99.21", "38.93" ]	icd9pcs	[ [ [] ] ]	20846, 20898	15025, 17379	325, 373	21067, 21091	4246, 8741	21660, 23135	3630, 3747		19946, 20823		20919, 21046		19838, 19923			21115, 21637									3762, 4227																					276, 287							401, 3358			14192, 15002			8750, 14162		17393, 19812									3380, 3497	3513, 3614
10,246	150,081	2731	Discharge summary	report	Admission Date: [2167-3-22] Discharge Date: [2167-3-31] Date of Birth: [2122-3-9] Sex: F Service: MEDICINE Allergies: Succinylcholine / Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 30] Chief Complaint: resp distress, somnolence Major Surgical or Invasive Procedure: intubated [3-22], extubated [3-28] History of Present Illness: This is a 44 y/o female with CAD s/p multiple stents, s/p CABG at age 34, who was recently at [Hospital1 18] from [Date range (1) 13514] for hypoxic respiratory failure requiring intubation and ARF thought to be [3-13] rhabdo and hypovolemia, who now p/w hypoxia, lethargy, and acute renal failure. Per report, she was found by her sister to be unresponsive today at home, and per son who saw her this morning, thought she was just "sleeping" but difficult to arouse. Her sister last talked to the patient yesterday evening around 6pm. Per history, pt was c/o of worsening back pain. It is unknown how long patient was down. [Name (NI) 1094] sister called EMS and pt was brought into the ED. Pt was noted by EMS to be cyanotic and no O2 sats were obtainable. . In the ED, VS were Tc 98.8, BP 138/77, HR 100, RR 28, SaO2 100%/NRB, AO x 1. Labs were significant for an ABG 7.01/77/113 on a NRB, K of 8.0 initially, Cr of 6.0. Phos was also markedly elevated at 16.7. She was given a dose of narcan and awoke marginally, but was still somnolent. For hyperkalemia, she was given 1 amp calcium gluconate, insulin 10 units IV, 1 amp of D50, 60 mg of kayexalate, and 1 amp of bicarb. She was afebrile, but given an elevated WBC of 19, was pan-cultured and given one dose of Levofloxacin. During her course, her SBP's dropped to the 60's-70's systolic and she was given a total of 5 L NS with response of SBPs to 110's. She was also started on a bicarb gtt given the metabolic acidosis. She was tried on BiPAP initially for a hypercapnia, however patient did not tolerate and was subsequently intubated. Post-intubation, she was hypotensive to 70's and was started on dopamine transiently, now weaned off. She is currently receiving her 6th L of NS, with 7th L hanging. Continues on bicarb gtt. Serum tox was negative, urine tox not obtainable at that time as pt was anuric in ED. . From the ED, she was transferred to the MICU for respiratory failure and ARF. Pt is currently sedated and intubated. Past Medical History: Stent of RCA graft ([4-12], [6-12], 5 overlapping stents RCA to PDA in [10-13]), OM1 DES in [11-12]) CHF (EF 30-40%, 2+MR, 2+ TR in [7-13]) HTN Hypercholesterolemia Obesity GERD Depression PVD Hypothyroidism DM II Social History: Pt lives with husband, mother-in-law and along with two kids. Pt smoked 2ppd x30years and drinks 3 drinks/mo- quit 2 months ago but still smokes occasionally-one or two cigarettes per day. Pt denies any illicit drug use. Family History: as per patient there are 7 generations of women on her mother's side who have all died at a young age of heart disease. Mother - died of MI at age 50 Grandmother - died with ASD Father - DM, EtOH abuse, no CVD Grandfather - DM 2 brothers - one died of fat embolus at age 18 and another died recently of opiod overdose. Physical Exam: VS: Tc 98.1, BP 101/58, HR 84, RR 24 on AC 550 x 24, FiO2 100%, PEEP 5, SaO2 97% General: Sedated and intubated. HEENT: NC/AT, pupils pinpoint and minimally reactive, MM dry, OP clear Neck: supple, difficult to appreciate JVD Chest: diffusely rhonchorous and wheezy anteriorly CV: RRR, s1 s2 normal, 2/6 SEM Abd: obese, mild distension, hyperactive BS, soft, NT Ext: no c/c/e, w/w/p, faint distal pulses Neuro: sedated Pertinent Results: [2167-3-22] 02:30PM BLOOD WBC-19.0# RBC-4.52 Hgb-13.6 Hct-42.0# MCV-93 MCH-30.0 MCHC-32.3 RDW-15.5 Plt Ct-320 [2167-3-30] 04:12AM BLOOD WBC-12.9 RBC-3.35* Hgb-10.0* Hct-29.3* MCV-88 MCH-29.9 MCHC-34.2 RDW-15.8* Plt Ct-190 [2167-3-22] 02:30PM BLOOD Neuts-90.5* Bands-0 Lymphs-6.1* Monos-3.2 Eos-0.1 Baso-0.1 [2167-3-30] 04:12AM BLOOD PT-11.5 PTT-30.9 INR(PT)-1.0 [2167-3-22] 05:10PM BLOOD PT-11.5 PTT-29.8 INR(PT)-1.0 [2167-3-30] 04:12AM BLOOD Glucose-105 UreaN-24* Creat-0.9 Na-137 K-3.9 Cl-99 HCO3-32 AnGap-10 [2167-3-22] 02:30PM BLOOD Glucose-213* UreaN-64* Creat-6.0# Na-128 K-8.0* Cl-89* HCO3-19* AnGap-28* [2167-3-27] 03:39AM BLOOD ALT-37 AST-33 LD(LDH)-344* CK(CPK)-850* AlkPhos-54 Amylase-88 TotBili-0.3 [2167-3-22] 02:30PM BLOOD ALT-31 AST-74* CK(CPK)-5593* AlkPhos-80 Amylase-167* TotBili-0.4 [2167-3-27] 03:39AM BLOOD Lipase-88* [2167-3-22] 02:30PM BLOOD Lipase-122* [2167-3-22] 02:30PM BLOOD CK-MB-69* MB Indx-1.2 cTropnT-.23* proBNP-[Numeric Identifier 13515]* [2167-3-30] 04:12AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2 [2167-3-27] 03:39AM BLOOD Hapto-445* [2167-3-22] 11:43PM BLOOD Cortsol-48.2* [2167-3-23] 01:15AM BLOOD Cortsol-49.7* [2167-3-22] 04:00PM BLOOD HCG-<5 [2167-3-22] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2167-3-28] 05:49PM BLOOD Type-ART pO2-102 pCO2-47* pH-7.42 calTCO2-32* Base XS-4 [2167-3-26] 03:53PM BLOOD Lactate-3.4* [2167-3-22] 02:42PM BLOOD Lactate-5.5* [2167-3-25] 03:29AM BLOOD freeCa-1.11* [2167-3-27] 09:05PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 [2167-3-27] 09:05PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2167-3-27] 09:05PM URINE RBC-[7-19]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-<1 [2167-3-25] 04:04PM URINE Hours-RANDOM UreaN-491 Creat-44 Na-64 [2167-3-22] 07:48PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG . CXR [3-22]: Right subclavian vascular catheter has been placed, with the tip terminating within the lower superior vena cava. No pneumothorax is evident on this semi-upright radiograph. The lung volumes are lower on the current study compared to the previous exam. New area of air space opacity has developed in the right lower lung region, and may be due to an area of asymmetrical edema or acute aspiration superimposed upon underlying edema. Small right pleural effusion is also noted. Examination is otherwise without change from the recent study of earlier the same date. . CXR [3-22]: Single portable radiograph of the chest demonstrates an endotracheal tube with its tip at the level of the clavicular heads. There is a nasogastric tube present with its tip in the stomach. Cardiomediastinal contours are similar to that seen on radiographs obtained earlier the same day. The patient is status post CABG. There may be a small left-sided pleural effusion. Surgical staples project over the epigastrium, left upper quadrant, and left lateral chest wall. No pneumothorax. No consolidation. IMPRESSION: Support lines in place. No consolidation. . CT Abd/Pelvis/Chest [3-22]: 1. No evidence of dissection or aortic aneurysms is seen. 2. Status post CABG with dehiscence of sternum. 3. Moderate fatty stranding around the pancreas. This is of undetermined significance and might suggest pancreatitis. 4. Compressive atelectatic changes at both lung bases. . CT Head [3-22]: The study is limited by motion artifact. There is no evidence of hemorrhage, mass effect, hydrocephalus, shift of normally midline structures, or infarction. The density values of the brain parenchyma are within normal limits. Surrounding osseous and soft tissue structures are unremarkable. IMPRESSION: Limited study due to motion. No abnormalities detected. . CXR [3-22]: Comparison is made to [2166-11-28] and multiple prior chest radiographs dating back to [2165-4-17]. There is stable marked cardiomegaly. No evidence of pulmonary edema or sizable effusions. There are no focal consolidations. There may be mild plate-like atelectasis at the left lung base. Again seen are CABG markers. IMPRESSION: Stable cardiomegaly without evidence of CHF or pneumonia. . Echo [3-23]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate global left ventricular hypokinesis. The right ventricular cavity is mildly dilated. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CXR [3-28]: A right subclavian central line is present, tip over distal SVC. No pneumothorax is identified. There is cardiomegaly. Clips overlie the mediastinum. No CHF or gross effusion is identified. There is minimal blunting at the right costophrenic angle. There is some increased retrocardiac density, which is likely accentuated by technique and patient body habitus. No definite focal infiltrate is identified. If clinical suspicion for a focal infiltrate remains high, then this could be further evaluated with a lateral view. Compared with [2167-3-23], the ET tube and the NG tube have been removed. The CHF findings are improved and the atelectasis is also somewhat improved. . CXR [3-29]: 1. Vague areas of consolidation at the lung bases concerning for developing infiltrate. Aspiration cannot be excluded. 2. Cardiomegaly, stable. . Sputum [3-26]: STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ <=1 S . Sputum [3-22]: STREPTOCOCCUS PNEUMONIAE \| CEFTRIAXONE----------- <=1 S ERYTHROMYCIN---------- R LEVOFLOXACIN---------- S PENICILLIN------------ I TETRACYCLINE---------- R TRIMETHOPRIM/SULFA---- R VANCOMYCIN------------ S Brief Hospital Course: She was found in the ED to have SaO2 100% on NRB, with severe acidosis (7.01/77/113 on NRB), hypercalemia, and acute renal failure (creat 6.0). She awoke somewhat to Narcan. She was pan-cultured, given one dose of levofloxacin, and started on bicarb gtt; she was eventually intubated after a trial of BiPap was not tolerated. Post-intubation, she was hypotensive but responded to 7 liters of fluid resuscitation and Levophed. Serum tox was negative, urine tox (not obtainable in ED secondary to anuria) eventually was positive for opiates and cocaine. Her initial BNP was [Numeric Identifier 13515] and CK 5593 (peaked [Numeric Identifier 13516]). She was transferred to the MICU for respiratory failure and ARF. . In the MICU, she was on a ventilator and treated for COPD and broadly covered for pneumonia (levo/flagyl). the renal team was consulted for emergent hemodialysis. A hemodialysis catheter was placed in preparation for HD, which was never required. TTE showed global hypokinesis. Sputum grew 4+ GPC's (speciated Strep pneumo, MRSA). Vancomycin was added. She had copious purulent sputum suctioned early in the course and had episodes of hypoxia; she was placed on a Lasix drip with good response. She had fevers, which prompted a change in antibiotic coverage from levofloxacin to aztreonam and ciprofloxacin. Given persistent fevers, clindamycin was started for question of sinusitis. She self-extubated on [3-28] and was tolerating room air on [3-30] and was transferred to the floor. . She was discharged the day after admission with a prescription for clindamycin to complete a 7-day course. At that time, she had completed a 10day course of vancomycin. She had follow up in the renal clinic as well as with her PCP. Medications on Admission: 1. Atorvastatin 80 mg qd 2. Toprol XL 50 mg qd 3. Lisinopril 5 mg qd 4. Clopidogrel 75 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Aspirin 325 mg PO DAILY 7. Furosemide 80 mg qd 8. Citalopram 40 mg qd 9. Glyburide 5 mg [Hospital1 ] 10. Synthroid 50 mcg qd 11. Percocet 2 tabs q4 hrs 12. Folic acid 1 mg qd 13. Morphine sulfate 60 mg tid 14. Prilosec 15. Trazadone 300 mg qhs 16. Albuterol prn 17. Cytomel 5 mg qd 18. Compazine 5 mg prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Clopidogrel 75 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. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Synthroid 50 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Morphine 30 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HRS ON; 12 HRS OFF (). Disp:30 Adhesive Patch, Medicated(s) Refills:2 16. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 4 days. Disp:16 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Respiratory failure, respiratory acidosis + anion gap metabolic acidosis MRSA/Strep pneumoniae pneumonia Acute renal failure Rhabdomyolysis Septic shock . Secondary: Coronary artery disease Congestive heart failure Diabetes mellitus Hypercholesterolemia Hypertension Discharge Condition: Stable, satting well on room air Discharge Instructions: You were admitted with respiratory failure and acute renal failure. You were intubated in the emergency and treated in the intensive care unit for eight days. Your renal improved with IV fluids. You had fevers and were given broad coverage with antibiotics. Your respiratory failure was resolved, the breathing tube was removed on [3-29], and you were transferred to the regular medicine floor. . Please complete your course of antibiotics as prescribed. All of your other medications should be continued. . Please keep all of your follow up appointments as listed below (note: you have a follow up appointment with your PCP on [Name9 (PRE) 2974] of this week). . If you notice any worsening shortness of breath, chest pain, diarrhea, fever, nausea, vomiting, or other concerning symptoms, please seek medical attention immediately. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 10145] on Friday, [4-3], at 1pm. . Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 435] Date/Time: [2167-4-27] 1:00	[ "428.0", "518.81", "785.52", "491.21", "276.4", "481", "272.0", "584.9", "995.92", "038.9", "482.41", "401.9", "414.00", "V45.81", "728.88", "250.00", "V09.0" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.04", "38.93", "38.95", "96.6" ]	icd9pcs	[ [ [] ] ]	13885, 13891	10226, 11977	336, 380	14211, 14246	3708, 10203	15135, 15373	2931, 3254		12469, 13862		13912, 14190		12003, 12446			14270, 15112									3269, 3689																					271, 298							408, 2418																	2440, 2676	2692, 2915
6,702	132,390	6934	Discharge summary	report	Admission Date: [2123-4-28] Discharge Date: [2123-5-1] Date of Birth: [2048-10-16] Sex: M Service: Medical Intensive Care Unit, [Location (un) ] Team HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 5239] is a 74-year-old male with a history of gastrointestinal bleeding, gastric adenocarcinoma, and stroke who was in his usual state of health until the date of admission when he began feeling dizzy and weak. He called his daughter, who is a nurse, who checked his blood pressure and found that it was a systolic of 80. He was brought by ambulance to the Emergency Department. On the way to the Emergency Department the patient had one episode of melena. The patient reported that he had several episodes of black stool for the past several days which he attributed to eating liquorice. In the Emergency Department the patient had an initial blood pressure of 80/palp which became 120 systolic after a 1-liter normal saline fluid bolus. A nasogastric tube was placed which was positive for bright read blood and coffee-grounds and did not clear. Initial INR was checked which was 2, and initial hematocrit was 27, significantly lower than his baseline of 38 from [2122-12-14]. The Gastrointestinal Service was consulted, and the patient was transferred to the Medical Intensive Care Unit for further management. PAST MEDICAL HISTORY: (Past medical history is notable for) 1. A gastrointestinal bleed in the [2091], treated with a Billroth II surgery. 2. Atrial fibrillation since the [2101] for which the patient was placed on anticoagulation with Coumadin. 3. Gastric adenocarcinoma discovered in [2119] after a recurrent gastrointestinal bleed, treated with partial esophagogastrectomy. This adenocarcinoma is stage IB. The patient's Coumadin was discontinued at that time. 4. History of stroke in [2121-4-12]. The patient was placed back on Coumadin at this time. He has been on Coumadin since. 5. Hypertension. 6. Osteoarthritis. MEDICATIONS ON ADMISSION: Coumadin. ALLERGIES: PENICILLIN. SOCIAL HISTORY: The patient is normally healthy and active. He lives with his wife. PHYSICAL EXAMINATION: Initial physical examination revealed the patient had a temperature of 98.6, heart rate 100, blood pressure 123/53, respiratory rate 18, oxygen saturation 98% on room air. In general, he was pleasant, well-appearing, lying in bed in no acute distress. HEENT showed normocephalic and atraumatic. Head examination revealed pupils were equal, round, and reactive to light. Sclerae were anicteric. Mucous membranes were moist. Neck was supple. There was no jugular venous distention and no lymphadenopathy. Heart was irregularly irregular with a normal S1 and S2, a 2/6 systolic murmur was auscultated at the apex. Chest was clear to auscultation except for right lower lobe crackles. The abdomen was soft, nontender, and nondistended with normal active bowel sounds. There was a well-healed midline incision. Extremities were without clubbing, cyanosis or edema. LABORATORY/RADIOLOGY: Initial laboratory studies showed a white blood cell count of 8.3, hematocrit 27.4, platelets 220, MCV 96. Sodium 138, potassium 4.9, chloride 105, bicarbonate 23, BUN 42, creatinine 0.7, glucose 207. INR was 1.9, PTT was 28.7. A chest x-ray was obtained which showed no abnormalities. HOSPITAL COURSE: Again, the patient was brought to the Medical Intensive Care Unit for further workup. He had an urgent endoscopy by the Gastrointestinal Service which showed diffuse erosive esophagitis, grade IV, in the mid to distal esophagus. Stomach had positive bile reflux. There was no sign of acute or recent bleed. It was recommended that the patient be started on Prilosec 40 mg p.o. b.i.d., that his anticoagulation be held, and that he be observed very closely. The patient received 2 units of fresh frozen plasma and 4 units of packed red blood cells prior to the procedure. On hospital day two the patient remained asymptomatic, although he had about 2 liters of melenas stool overnight. His hematocrit had fallen to 25 (down from 27.4). This had not appropriately increased since receiving his 4 units of blood. The patient was given vitamin K and an additional 2 units of packed red blood cells. It was decided to repeat the esophagogastroduodenoscopy which showed similar findings as the prior study without any evidence of new bleeds. The patient was bowel prepped and brought to colonoscopy on [2123-4-30]. Colonoscopy revealed diverticulosis of the sigmoid colon and a polyp in the cecum. There was no site of active or recent bleeding. The patient was continued to be watched very closely in the Intensive Care Unit. His hematocrit increased to 33.8, and by [2123-5-1], increased to 35.8. There were no signs of continued bleeding. The patient ambulated without orthostasis or symptoms. Throughout his hospital stay, he had no shortness of breath or chest pain. Although, the exact source of his bleeding was still unknown, it was hypothesized that he either had bleeding from his esophagitis or a bleeding diverticula which has since stopped. The patient's diet was advanced, and he was tolerating a regular diet. DISCHARGE STATUS: The patient was to be discharged to home. CONDITION AT DISCHARGE: Stable. FOLLOWUP: He was to follow up with Gastrointestinal in six to eight weeks for repeat colonoscopy. For now, he is to hold his Coumadin. After several weeks the decision to restart Coumadin based on the risks of stroke or gastrointestinal bleeding will need to be discussed with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed, upper versus lower. 2. Grade IV esophagitis. 3. Diverticulosis. 4. History of cerebrovascular accident. 5. History of osteoarthritis. MEDICATIONS ON DISCHARGE: Prilosec 40 mg p.o. b.i.d. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3090], M.D. [MD Number(1) 3091] Dictated By:[Last Name (NamePattern1) 3600] MEDQUIST36 D: [2123-5-1] 11:15 T: [2123-5-3] 15:47 JOB#: [Job Number ]	[ "458.0", "401.9", "V58.61", "427.31", "562.10", "530.10", "578.9", "280.0", "V10.04" ]	icd9cm	[ [ [] ] ]	[ "45.13", "96.07", "45.23" ]	icd9pcs	[ [ [] ] ]								5723, 5890				5917, 6215	2040, 2076	3389, 5309																							2185, 3371		5324, 5702														212, 1363																	1386, 2013	2093, 2162
25,225	150,221	3972	Discharge summary	report	Admission Date: [2179-1-28] Discharge Date: [2179-2-21] Date of Birth: [2147-8-13] Sex: F Service: SURGERY Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine / Neurontin Attending:[First Name3 (LF) 1384] Chief Complaint: hypotensive at dialysis with lightheadedness Major Surgical or Invasive Procedure: [2179-2-4] I&D of Right upper arm ligated AVG site with exteernal sutures placed to control post-I+D bleeding [2179-2-10] Removal remnant AVG, patch angioplasty History of Present Illness: Pt is 31 y/o F with multiple medical problems including SLE complicated by lupus nephritis and ESRD requiring hemodialysis who presents from dialysis center today with fevers to 103 and hypotension with SBP in 80s. Pt states that fevers just started today. She feels a little lightheaded and dizzy. The pt is also complaining of some soreness in her right arm where she had a MRSA infected AV graft removed 3 months ago. The wounds had opened up a few weeks ago and had recently been draining pus. She is currently on a course of Vancomycin for this. She otherwise denies cough, chest pain, shortness of breath, abd pain, nausea/vomiting, or diarrhea. Past Medical History: -SLE diagnosed [2166] complicated by lupus nephritis, anemia, serositis and ascites - End stage renal disease secondary to lupus, HD T/Th/Sat - History of VSD s/p corrective surgery, age 13 - Hypertension - ITP - h/o MSSA endocarditis - Sickle cell trait - S/p left oophorectomy related to IUD associated infection - Restrictive lung disease noted on PFTs [2166]. In [2173], chest CT with diffuse ground glass opacities. - GERD - S/p cadaveric renal transplant on [8-/2175] complicated by rejection and capsule rupture 11/[2174]. - Right pelvic abscess s/p TAH/RSO - B/L renal solid masses s/p resection pathology was negative for carcinoma - R tib/fib fx with ORIF [2177-6-24]. Complicated by wound./Hardware infection requiring BKA [2177-11-21] - [2178-4-2] RUE AVG excision - s/p CVA -[2179-2-4] RUE AVG I&D Social History: Recently discharged from [Hospital1 18] to home with services. Lives with husband and son. [Name (NI) ] smoking, occasional alcohol, no drug use. Originally from [Country ]. Used to work at [Hospital1 18]. Family History: Noncontributory Physical Exam: T 98 P 67 BP 89/57 R 18 SaO2 100% Gen: nad Heent: an-icteric, oropharyngeal mucosa moist Neck: supple Lungs: clear Heart: RRR Abd: soft, nontender, nondistended, BS +, no guarding, non rigid Extrem: right arm AV graft site draining small amounts of pus at opposite ends of incision, no fluctuance, induration, or swelling, right hand neurovascularly intact, 1+ right radial pulse Pertinent Results: [2179-2-9] 07:00AM BLOOD WBC-6.0 RBC-2.60* Hgb-7.6* Hct-23.4* MCV-90 MCH-29.3 MCHC-32.6 RDW-19.9* Plt Ct-52* [2179-2-9] 07:00AM BLOOD PT-15.0* PTT-31.7 INR(PT)-1.3* [2179-2-9] 07:00AM BLOOD Glucose-85 UreaN-44* Creat-8.6# Na-140 K-4.9 Cl-101 HCO3-30 AnGap-14 [2179-2-8] 06:45AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.5 Brief Hospital Course: She presented to the ED where she was given a fluid bolus and pan-cultured. WBC was 6.1 on admission. IV Vancomycin was administered. Transplant surgery was consulted for her access issue and recommendations were made for a RUE ultrasound which was done. This showed an ill defined 1.3 x 0.5 cm fluid collection within the superficial subcutaneous tissues of the right antecubital fossa. She was transferred to the ICU for care where BP responded to small fluid bolus. Dialysis was done via the L tunnelled line. Nephrology was consulted and followed her throughout this hospital stay. On [1-29] she required small fluid boluses x 3 for BP as low as 74/39 with response. CVVHD was performed. IV Vanco was changed to Dapto per ID recommendations. These included serial blood cultures. Repeat blood cultures were done almost on a daily basis with all negative until [2-3]. Blood cultures from [2-4] and [2-6] were negative to date. On [1-29], a TTE was performed revealing mild symmetric LVH(LVEF 70%). There was no ventricular septal defect. The aortic valve, mitral and tricuspid valve leaflets were mildly thickened. No masses or vegetations were seen. There was severe mitral annular calcification. Significant pulmonic regurgitation was seen. There was no pericardial effusion. Compared with the findings of the prior study (images reviewed)from [6-16], a vegetation on the mitral valve was no longer seen. The open areas on her right upper arm was packed with Nu Guaze. She was given IV dilaudid for pain management. The wound was cultured. Antibiotic coverage was broadened switched backt to vanco on [2-1] as there was no GN growth and the wound grew MRSA. Gentamycin and Aztreonam were stopped on [2-1]. She was transferred out of the ICU on [2-1]. She continued on vanco at HD sessions on a Tuesday-Thursday-Sat schedule. Right arm dressings were continued with persistent purulence noted in wounds. Endocrine was consulted for low basal cortisol levels and she was found to have secondary adrenal insufficiency based cosyntropin stim test. Recommendations included increasing prednisone to 10mg qd and giving stress dose steroids if she is febrile or hypotensive. She did not require this. Recs included: -Prednisone 10mg PO x3 days for minor illness, would not recommend starting this now as pt is clinically improving. -If the patient is undergoing surgery or has severe illness would recommend stress dose steroids -d/c prednisone and start Hydrocortisone 100mg iv q 8 hours then taper. -Recommend discharging pt with dexamethasone 4mg IM to take PRN when having emesis and unable to keep down PO meds. -Follow [Location (un) ] like features and once pt fully recovers from this hospitalization would slowly taper steroids as pt tolerates but also steroids may be for ITP so her labs would need to be followed closely if a taper is attempted. 3. Osteoporosis prevention: last bone density test was in [7-14] and showed osteopenia. Pt is currently a dialysis pt and on calcium and vit D. Pt needs repeat DEXA scan as outpatient and follow up with bone clinic. Her risk for fracture is high given she has amenorrhea, is weak from recent stroke, and is on steroid treatment. Prednisone was increased to 10mg qd starting on [2-3]. On [2-3], she spiked a temperature to 101. Repeat blood cultures were sent were negative to date. On [2-4], the avg site was I&D'd at the bedside for purulent areas. She bled extensively requiring suturing with cessation of bleeding. Pain in R arm worsened after I&D. Fentanyl patch was increased to 125mcg and prn dilaudid was increased to 6mg prn q 4 hours with intermittent doses of dilaudid 0.5-1mg prn q 3. A Pain consult was obtained with recommendations to not increase fentanyl, resume neurontin and increase po dose of dilaudid as well as premed for dressing changes with 1mg iv dilaudid. She did not tolerate neurontin due to "twitching". This was discontinued. On [2-10], she was taken to the OR the following day to remove remnant infected graft and a patch angioplasty was placed. Patient was extubated and transferred to the post anesthesia care unit in stable condition. Patient remained in the hospital due to poor pain control and persistent oozing of blood at incision sites. Hct dropped to 20 and PRBC were transfused on several days. Platelets and cryo were also administered. Right arm incisions continued to ooze necessitating in patient management. Bleeding was partially due to a hematoma of the more distal incision. Oozing decreased to one dressing change per day. VNA was arrange to do dressing changes. Incisions appeared without redness or purulence. PT evaluated and recommended ace wrapping of R leg to decrease edema. Home PT was recommended for strength, balance and safety. [Hospital 119] Homecare [Telephone/Fax (1) 13046] was arrange for right arm dressings,PT and social work. Samaritan Ambulance was arrange for transort. She was discharged home on [2-21]. Last hemodialysis was [2-20]. Vancomycin was to continue until [3-10] for MRSA. Medications on Admission: Dilaudid 8 mg q3hr prn Gabapentin 300 mg daily Fentanyl 75 mcg q72hr Amitriptyline 100 mg qHS Lorazepam 1 mg daily prn Tizanidine 2 mg tid Topiramate 50 mg qHS Keppra 500 mg [Hospital1 ] Calcium acetate 1334 mg TID with meals Nephplex 1 tablet daily Calcitriol 0.25 mcg daily Benadryl 25 mg q8h prn Epoetin [Numeric Identifier 961] mL SC qHD Lactulose 30 mL daily Pantoprazole 40 mg daily Prednisone 5 mg daily Aspirin 81 mg daily Colace Senna Tylenol Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol). 2. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s)* Refills:0 3. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:50 Tablet(s) Refills:2 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:50 Cap(s) Refills:2 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:50 Capsule(s) Refills:2 6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:50 Capsule(s) Refills:2 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). Disp:50 ML(s) Refills:2 8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. 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 10. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:50 Tablet(s) Refills:2 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:50 Tablet, Chewable(s) Refills:2 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. Disp:50 Tablet(s) Refills:0 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:50 Capsule(s) Refills:0 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. Disp:50 Tablet(s) Refills:0 15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:50 Tablet(s) Refills:2 16. Hydromorphone 4 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection PRN (as needed) as needed for line flush. 19. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 20. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-11] Drops Ophthalmic PRN (as needed). Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Fever hypotension sepsis secondary adrenal insufficiency esrd on HD Lupus right arm old avg site infection, MRSA h/o R BKA Discharge Condition: fair Discharge Instructions: * Please call Dr.[Name (NI) 1381] office [Telephone/Fax (1) 673] if fever, chills, malfunction of dialysis catheter or right arm wound redness/bleeding/drainage or if right arm appears swollen, discolored, or feels cold/numb * Please call Dr.[Name (NI) 1381] office in nine days for suture removal of the tissue ligation * Care Group VNA [Telephone/Fax (1) 17589] arranged for dressing changes twice daily, nursing visits, Physical therapy continue usual scheduled dialysis Followup Instructions: [First Name8 (NamePattern2) 5969] [Last Name (NamePattern1) 5970], RN [Telephone/Fax (1) 7207] will call you with a follow up appointment Provider: [First Name11 (Name Pattern1) 1216] [Last Name (NamePattern4) 1217], MD Phone:[Telephone/Fax (1) 2928] Date/Time: reschedule *** Provider: [Name10 (NameIs) 306] [Name Initial (MD) 307] [Name8 (MD) 308], M.D. Date/Time:[2179-4-2] 11:20 Completed by:[2179-2-22**]	[ "995.91", "403.91", "710.0", "038.12", "255.41", "518.89", "582.81", "V12.54", "282.5", "V49.75", "585.6", "E878.2", "V45.11", "996.62", "530.81", "V42.0", "287.31" ]	icd9cm	[ [ [] ] ]	[ "39.43", "39.56", "39.95", "86.04" ]	icd9pcs	[ [ [] ] ]	11082, 11140	3174, 8289	399, 569	11307, 11314	2820, 3151	11852, 12309	2383, 2400		8800, 11059		11161, 11286		8315, 8777			11338, 11829									2415, 2801																					315, 361							597, 1256																	1278, 2127	2143, 2367
4,688	150,090	20750+57196	Discharge summary	report+addendum	Admission Date: [2125-7-31] Discharge Date: [2125-8-27] Date of Birth: [2068-2-16] Sex: M Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: This is a 57-year-old man with past medical history significant for recurrent pancreatitis with pancreatic ductal stricture, hypertension, increased cholesterol, peripheral vascular disease admitted for distal pancreatectomy and splenectomy for presence of pancreatic mass. Patient is a man, who in the past has been in overall poor health, who has had 7-8 episodes of pancreatitis requiring hospitalization since [2125-1-21]. During this time he would be in the hospital for 3-4 days, go home and eat, and return with pain shortly thereafter. Upon imaging by Dr. [Last Name (STitle) ], a stricture was identified in the distal pancreatic duct, which was temporarily treated with a stent. The stent was left in place for a period of time and then was removed. MEDICATIONS ON ADMISSION: 1. Atenolol 100 mg p.o. b.i.d. 2. Clonidine 0.2 mg p.o. b.i.d. 3. Neurontin 400 mg p.o. q.i.d. 4. Hydralazine. 5. Lopid. 6. Imipramine. 7. Darvocet. 8. Dilaudid. 9. Aspirin. PHYSICAL EXAMINATION: Vital signs: Temperature 96.8, heart rate 86, blood pressure 164/84, respiratory rate 23, and patient was 99 percent on room air. Patient was noted to be in no apparent distress and to be comfortable. Heart was a regular rate and rhythm with no murmurs, rubs, or gallops. Lungs were clear to auscultation bilaterally with no wheezes, rales, or rhonchi. Abdomen was soft, nondistended, normoactive bowel sounds, it was nontender. Neurologically, patient was within normal limits throughout. Patient has incisions in the neck, abdomen, and legs. HOSPITAL COURSE: Thus, the patient at this time was admitted to [Hospital1 69] for surgical treatment of this likely mass in the tail of the pancreas. CTA showed pancreatic tail mass that had been increasing in size near the tail of the pancreas. The plan at this time was for likely distal pancreatectomy and possible splenectomy. Patient was prepared properly in the preoperative period and was noted to be of small risk for this procedure. Laboratory values were within normal limits at this time, and the patient was brought to the operating room for distal pancreatectomy and splenectomy. After extensive lysis of adhesions in the operating room, the splenic artery was suture ligated. The pancreas and splenic vein were divided with a TA stapler and oversewn and the specimen was removed. Patient tolerated the procedure well. Estimated blood loss was 800 cc and he received no transfusions. He was extubated and eventually brought to the floor. He received a total of three doses of Kefzol in the perioperative period and received beta blockers both pre and postoperatively. Patient was hypertensive postoperatively and on postoperative day number two, became tachycardic to the 120s. EKG showed ST depression in leads V2 through V5. CK's were elevated as was his troponin. He was started on aspirin and transferred to a monitored setting for better management of his heart rate and blood pressure with IV beta blockers and nitroglycerin. Cardiology was consulted and played an integral part in his management. His CK's were trending down. It was felt that he had completed a cardiac event and catheterization was delayed. On postoperative day four, he became agitated, tachypneic, and had decreasing oxygen saturations on 100 percent FIO2. He was intubated and a CTA was negative for pulmonary embolism, but there was evidence of pneumonia and CHF. He was treated with empiric antibiotics and Lasix, and his respiratory status improved. Two days later he began having diarrhea and was found to have a Clostridium difficile infection. He was treated with p.o. and p.r. Vancomycin as he had an allergy to Flagyl. He remained intubated over the next five days, where he had fevers and an elevated white blood cell count. Sputum cultures grew out MRSA and he was treated with a course of IV Vancomycin. He was extubated for a short amount of time, but then became agitated, tachypneic, tachycardic despite esmolol drip with elevated blood pressure. CK's and troponins again became elevated and he was begun on Heparin. Repeat echocardiogram showed new anterior wall motion abnormalities and he was taken for cardiac catheterization. His catheterization showed a right dominant system with 100 percent occlusion of his right coronary artery and 80 percent stenosis of his left main coronary artery, which was stented. He was continued on Plavix and aspirin postcatheterization and then was eventually extubated. He then improved from a respiratory standpoint and was getting physical therapy on the floor, and was noted to be progressing well during this time. Apparently, he will likely be discharged to rehabilitation. During this time on the floor, patient was also noted to have symptoms of depression and anxiety, and Psychiatry was consulted. Psychiatry suggestions at this time were to discharge imipramine and to decrease his mirtazapine dose from 30 mg q.d. to 7.5 mg q.h.s. These two medications were implicated by Psychiatry to be possibly causing some anticholinergic symptoms in this patient. Psychiatry's recommendations were followed, and the above stated adjustments were made. On [2125-8-27], the patient was noted to be stable and to have vital signs within normal limits. On physical exam, to be in no apparent distress. To be comfortable. His heart is regular rate and rhythm with no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. His abdomen is nondistended with normoactive bowel sounds and to be nontender throughout with a well-healing wound without drainage or erythema. Patient's activity level at this time also seem to be improving as he had been noted to be walking 3-5x/day in the days leading up to his discharge with his spirits seeming to be improved. On the day of discharge, patient had been noted to be now tolerating a full diet for a period of two days. Patient at this time also received his immunizations against pneumococcal, Hemophilus influenza B, and the meningococcal vaccine. DISCHARGE DIAGNOSES: Distal pancreatic mass status post distal pancreatectomy. Splenectomy. Hypertension. Gastritis. Hypercholesterolemia. Peripheral vascular disease status post aortobifemoral bypass. Gastroesophageal reflux disease. Coronary artery disease. DISCHARGE CONDITION: Stable. DISCHARGE INSTRUCTIONS: The patient was instructed to call if having increasing abdominal pain, fevers, chills, nausea, vomiting, or increased drainage or redness from his wound site or if there are any other questions or concerns. DISCHARGE MEDICATIONS: 1. Albuterol 1-2 puffs q.6h prn for respiratory distress. 2. Albumin/ipratropium two puffs q.6h prn. 3. Aspirin 325 mg p.o. q.d. 4. Atorvastatin 40 mg p.o. q.d. 5. Atenolol 150 mg p.o. b.i.d. 6. Clonidine patch one patch q Thursday. 7. Plavix 75 mg p.o. b.i.d. 8. Gabapentin 400 mg p.o. q.i.d. 9. Losartan 50 mg p.o. q.d. 10. Remeron 7.5 mg p.o. q.h.s. 11. Protonix 40 mg p.o. q.d. DISPOSITION: The patient will be discharged to rehabilitation facility. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [Last Name (STitle) 468] in two weeks. [Name6 (MD) ] [Last Name (NamePattern4) 7542], [MD Number(1) 7543] Dictated By:[Last Name (NamePattern1) 15912] MEDQUIST36 D: [2125-8-26] 00:15:56 T: [2125-8-26] 04:40:09 Job#: [Job Number 55370] Name: [Known lastname 10370],[Known firstname 422] Unit No: [Numeric Identifier 10371] Admission Date: [2125-7-31] Discharge Date: [2125-8-28] Date of Birth: [2068-2-16] Sex: M Service: [Doctor First Name 1379] Allergies: Penicillins / Ibuprofen / Skelaxin / Flagyl / Percocet / Morphine / Zestril / Lecithin Attending:[First Name3 (LF) 4987] Chief Complaint: abdominal pain, pancreatitis w/ distal stricture Major Surgical or Invasive Procedure: distal pancreatectomy, splenectomy, coronary stent placement Brief Hospital Course: Due to difficulty with rehabilitation placement patient remained at [Hospital1 8] and was not discharged on [2125-8-26]. Patient was then seen by physical therapy again and was cleared to be discharged to home. Patient was thus discharged to home with VNA services on [2125-8-28], and on the day of discharge was stable, was taking significant amounts of oral intake and was on a regular diet, his vital signs were stable, and his laboratories were within normal limits. Discharge Disposition: Home With Service Facility: [Location (un) ] VNA Discharge Diagnosis: pancreatitis w/distal stricture, coronary artery disease, s/p distal pancreatectomy, splenectomy, pancreatitis, HTN, gastritis, increased cholesterol, CAD s/p stent placement, GERD Discharge Condition: stable Discharge Instructions: Patient to be discharged to home with daily visiting nurse assistance. MD to be called if having increasing abdominal pain, fevers, chills, nausea, vomiting, drainage or redness about the wound, or if there are any questions or concerns. Followup Instructions: Patient to follow up with Dr. [Last Name (STitle) 1099] in 2 weeks. Patient to call [Telephone/Fax (1) 10372] [Name6 (MD) 116] [Last Name (NamePattern4) 4988] MD [MD Number(1) 4989] Completed by:[2125-8-28]	[ "997.1", "578.0", "518.5", "482.41", "568.0", "008.45", "428.0", "410.71", "577.0" ]	icd9cm	[ [ [] ] ]	[ "41.5", "89.64", "99.04", "99.15", "52.52", "96.72", "88.56", "96.6", "36.01", "96.04", "37.22", "34.91", "54.59", "36.07" ]	icd9pcs	[ [ [] ] ]	8746, 8801	8237, 8723	8152, 8214	9025, 9033		9319, 9580		6253, 6500	6788, 7257		8822, 9004		982, 1159	1751, 6231		9057, 9296																					1182, 1733									8064, 8114							183, 956															7282, 8047
81,004	185,213	40018	Discharge summary	report	Admission Date: [2119-9-29] Discharge Date: [2119-10-11] Date of Birth: [2052-11-25] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 4891] Chief Complaint: cc:[CC Contact Info 88023] Major Surgical or Invasive Procedure: Endoscopic ultrasound Endoscopic retrograde cholangiopancreatography (ERCP) Interventional Radiology drain placement History of Present Illness: Mr. [Known firstname 88024] is a 66yo male with past medical history significant for diabetes, obesity and HTN who presented to an outside hospital with complaints of jaundice and swollen lower extremities and found to have new LLE DVT on imaging and new pancreatic head mass on CT scan with extensive liver metastasis. Lung with additional spiculated density in RLL noted on imaging. He is being transferred now for additional surgical and oncology consultations. Of note, he states that he has lost about >140 lbs over the past year which he feels has been from diet and exercise. States his jaundice has gotten worse over the past 3 weeks. Also having occasional non-bloody diarrhea and slight fatigue. At the outside hospital, vital signs recorded as : BP 106/58, weight 204 lbs but no HR or temperature recorded in transfer notes. OSH labs also notable for anemia with HCT 29.5, d-dimer 7075, hyperbilirubinemia of 20.9, INR elevation to 3.0, AST 147, ALT 73 and ALP 868. Albumin 2.9 and total protein also low at 5.9. Gallbladder US done and showed distended GB with sludge, mild prominence of common hepatic duct and intra-hepatic biliary ducts. LE ultrasound of left leg revealed DVT involving the superficial femoral vein to the calf muscles. He was given IV heparin and transitioned to Lovenox this morning prior to transfer, otherwise continued on his usual home diabetes medications and his lisinopril was held given his very mild blood pressures in low 100s systolic. On arrival to the medical floor at [Hospital1 18], initial vitals were: Temp 96.7F, BP 118/68, HR 61, RR 18, 100% O2 sat RA. FSG was 174. Patient appeared to be in no acute distress and was extremely jaundiced. Review of systems: (+) Per HPI, diarrhea, fatigue as above. (-) Denies fevers,denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation, bloody stools or abdominal pain. No recent change in bowel or bladder habits except darker urine. No dysuria. Denied arthralgias or myalgias. Past Medical History: Diabetes Mellitus, on insulin Obesity (now s/p significant weight loss) Hypertension Social History: Social History: Lives in [Location ] where he works as a business manager, visiting [Location (un) 86] on business. Denies smoking cigarettes but smokes 1 cigar per month. He is divorced with 2 children. Lost more than 140 lbs with diet and exercise over past year but more recent loss may be related to cancer. He has been visiting several business partners on the [Location (un) ] over the past few weeks. Denies any ETOH intake or illic substances. Family History: Family History: Father died of "bone cancer", otherwise non-contributory. Physical Exam: Admission examination: Vitals: Temp 96.7F, BP 118/68, HR 61, RR 18, 100% O2 sat RA. General: Fully alert and oriented, no acute distress. Very jaundiced diffusely. HEENT: Sclera icteric bilaterally, dry MM, oropharynx clear and nares clear, EOMI Neck: supple, JVP not elevated, no LAD, no thyromegaly Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Neuro: CNs [1-20] in tact. Sensation to light touch in tact. Gait WNL and full [4-12] upper and lower extremity strength. Abdomen: soft with very loose skin with multiple layers and stretch marks, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly noted, negative [Doctor Last Name ] Sign Ext: well perfused, 2+ pulses, no clubbing, cyanosis. LLE with 1+ edema and markedly larger than RLE Pertinent Results: Hematology: [2119-10-10] 07:25AM BLOOD WBC-6.9 RBC-3.01* Hgb-9.0* Hct-27.5* MCV-91 MCH-30.0 MCHC-32.8 RDW-25.3* Plt Ct-184 [2119-10-9] 07:00AM BLOOD WBC-8.5 RBC-3.13* Hgb-9.5* Hct-29.1* MCV-93 MCH-30.2 MCHC-32.5 RDW-25.2* Plt Ct-195 [2119-10-5] 03:00AM BLOOD WBC-8.0 RBC-3.56* Hgb-10.6* Hct-30.1* MCV-85 MCH-29.7 MCHC-35.1* RDW-24.1* Plt Ct-253 [2119-10-1] 05:48AM BLOOD WBC-8.1 RBC-3.56* Hgb-10.2* Hct-30.5* MCV-86 MCH-28.7 MCHC-33.6 RDW-22.5* Plt Ct-279 [2119-9-30] 06:00AM BLOOD WBC-7.2 RBC-3.42* Hgb-9.8* Hct-29.6* MCV-87 MCH-28.7 MCHC-33.2 RDW-22.1* Plt Ct-258 [2119-10-5] 03:00AM BLOOD Neuts-71* Bands-1 Lymphs-15* Monos-6 Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-1* Coagulation: [2119-10-10] 07:25AM BLOOD PT-23.2* INR(PT)-2.0* [2119-10-9] 07:00AM BLOOD PT-19.4* PTT-32.7 INR(PT)-1.8* [2119-10-8] 08:15AM BLOOD PT-16.9* PTT-30.5 INR(PT)-1.5* [2119-10-3] 04:45AM BLOOD PT-20.2* PTT-29.3 INR(PT)-1.9* [2119-10-2] 05:49AM BLOOD PT-19.6* PTT-33.8 INR(PT)-1.8* [2119-9-30] 06:00AM BLOOD PT-23.2* PTT-48.2* INR(PT)-2.2* Chemistries: [2119-10-10] Glucose-246* UreaN-13 Creat-0.9 Na-134 K-3.7 Cl-101 HCO3-25 [2119-10-9] Glucose-184* UreaN-11 Creat-0.8 Na-134 K-3.9 Cl-101 HCO3-25 [2119-10-8] Glucose-278* UreaN-11 Creat-0.9 Na-133 K-4.0 Cl-99 HCO3-26 [2119-10-10] 07:25AM BLOOD ALT-29 AST-65* AlkPhos-281* TotBili-17.5* [2119-10-9] 07:00AM BLOOD ALT-31 AST-55* LD(LDH)-180 AlkPhos-310* TotBili-18.0* DirBili-13.8* IndBili-4.2 [2119-10-8] 08:15AM BLOOD ALT-32 AST-58* LD(LDH)-204 AlkPhos-382* TotBili-20.3* [2119-10-2] 05:49AM BLOOD ALT-59* AST-109* LD(LDH)-173 AlkPhos-688* TotBili-18.3* [2119-9-30] 06:00AM BLOOD ALT-70* AST-138* LD(LDH)-190 AlkPhos-778* TotBili-18.5* [2119-10-8] 08:15AM BLOOD Albumin-2.9* Calcium-8.5 Phos-1.9* Mg-2.1 [2119-10-4] 01:17PM BLOOD Albumin-2.8* Calcium-8.5 Phos-2.8 Mg-1.8 Tumor Markers: [2119-9-30] 06:00AM BLOOD CEA-352* Pathology: IR-guided biopsy results pending at discharge, includes brushings and FNA. Brief Hospital Course: The patient is a 66 year old man who was admitted with newly diagnosed pancreatic mass, concerning for malignancy. The patient had an extensive workup, and a series of attempts at obtaining pathology. Several meetings with the patient and his family were conducted by the medical team, in order to clarify the current medical plans and recommended next steps. One meeting, including both of the patient's daughters at the bedside, occurred several days prior to admission. The family's questions were addressed, including those surrounding the pending pathology, and the procedures done to that point to both obtain pathology and relieve the patient's biliary obstruction. The patient expressed his interest at that time, and in two subsequent family meetings, that he wants to continue his medical treatment out of [Location (un) 86]. He also stated that he would defer all medical appointments being made on his behalf at this time, in the [Location (un) 86] area, and did not need the team to make any followup for him at this time. He did not have the name of the clinician who would be taking over his care, in the city where he hoped to obtain further care. He did feel strongly that the writer meet a trusted friend who would be helping him arrange care, through a holistic medicine group, during one of the latter family meetings. The patient was provided information to obtain his records for release to his new clinician, once he knew who he would be seeing. He was aware that his plan, including no planned followup, was not recommended by his [Hospital 18] medical team, and noted he was willing to accept the risk associated with his choice. He was felt to have capacity to make his decisions, on several assessments, lacking signs or symptoms of delirium or encephalopathy. His family felt his medical choices were in keeping with his usual wishes. #Pancreatic Mass / metastatic cancer: Newly diagnosed metastatic pancreatic cancer at OSH but not definitive with any biopsies just yet. He presented to new PCP c/o 2 weeks worse jaundice and new LLE edema which was found to be new DVT. Obstruction from pancreatic head mass is likely etiology of his jaundice with direct bilirubin in 18 -19 range now. Metastatic lesions suspected on recent CT both throughout the liver and on RLL area. The patient underwent an endoscopic U/S and FNA of the pancreas, although biopsies were inconclusive. Unable to biopsy liver mets. He had ERCP x2 and during the second procedure there was significant bleeding following the procedure. The patient bled 250-500cc during the procedure, and subsequently bled further and required an ICU stay for observation. He later stabilized and was transferred back to the medical service. He underwent a per cutaneous biliary drain placed by IR, which was later internalized during a followup procedure. His total bilirubin improved daily, although it remained elevated at the time of discharge. He remained on oral antibiotics for 8 days following discharge, after completing an IV antibiotics course during his admission. Pathology from the IR-guided biopsy sample was pending at discharge, and the patient was given detailed instructions on how to call the pathology department (with the pathologist's verbal approval in advance) for the final result. The patient again noted that he did not have a clinician's name or contact information to provide the medical team, in order to ensure the results would be passed along to him. GI bleed: During work-up for pancreatic mass, Pt had ERCP x2 and during the second procedure a blood vessel was nicked and pt began bleeding. Pt bled 250-500cc during the procedure. He was reportedly hemodynamically stable, but was transferred to the [Hospital Unit Name 153] for further observation. Pt had PTBD placed by IR. He had some post precudural pain, but was otherwise pt was hemodynamically stable and ready for call out back to the floor. LLE DVT: Most likely secondary to hypercoaguable state with pancreatic cancer. He also takes frequent long airplane flights between South America and US which is another risk factor that may have provoked his DVT. Last INR 3 range. He was transitioned from IV heparin to Lovenox [Hospital1 ] at OSH. IVC filter was placed. Anticoagulation was not restarted after discussion with GI, advanced endoscopy and hematology teams prior to discharge, due to his high bleeding risk. The patient's INR was elevated during his stay, attributed to his liver synthetic dysfunction, but we did not feel this would be protective against further clotting. [State 2690] but since he lost more than 140 lbs his blood pressures have been low to normotensive ranges and he has not been taking his usual lisinopril. His lisinopril was held at this time and HTN was not an active issue during the course of his stay. Diabetes: Longstanding type II DM and he states he has been on Lantus for over 6 months. FSG now in 170s range. Recent weight loss may have impacted his need for Lantus 40 Units which he had taken at home. [Month (only) 116] have changes also due to insulin production impairment due to destruction at level of pancreas from primary malignancy. Pt was placed on an insuling sliding scale in the ICU, and his lantus dosing was later restarted prior to discharge, when the patient was taking adequate oral intake. Prophylaxis: No indication for PPI, bowel regimen PRN Code: Full, confirmed with patient and family. Communication: Patient, daughters. [Name (NI) ] [Name (NI) 110] [Name (NI) 88025] H-[Telephone/Fax (1) 88026]. C-[Telephone/Fax (1) 88027]. Medications on Admission: Medications on transfer from outide facility: -Lovenox 90mg q12 hrs -Glucophage 500mg [Hospital1 ] -lisinopril --states he has not been taking (does not know old dose) -Lantus 40 Units qhs (patient has been taking this medication long-standing) Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Forty (40) Units Subcutaneous at bedtime. 2. Augmentin 250-125 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days. Disp:16 Tablet(s) Refills:0 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day for 1 weeks. Disp:7 Capsule, Delayed Release(E.C.)(s) Refills:0 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 4 days. Disp:16 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Pancreatic mass with probable metastases Gastrointestinal bleeding, resolved Jaundice, hyperbilirubinemia Secondary: Left Leg blood Clot Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 75980], It was a pleasure caring for you at [Hospital1 827]. You were admitted to [Hospital1 18] as a transfer from another hospital. You came to [Hospital1 18] for referral regarding the management of your newly diagnosed pancreatic tumor with liver masses. You were seen by our oncologists, as well as gastroenterologists and radiologists. You had a procedure performed called an "Endoscopic Ultrasound" or "EUS" where biopsies of the tumor were taken for tissue identification. Additionally, you had an "Endoscopic Retrograde Cholangiopancreatography" or "ERCP" performed. You later had an interventional radiology procedure that was able to develop way to drain your bile despite the blockage. Your biliary ducts were blocked by the mass, and that obstruction from the tumor caused your skin to be yellow, or "jaundiced". We think it is not advisable to leave the hospital without plans to see any of the doctors that have [Name5 (PTitle) ] the specialized procedures while you were here, including the interventional radiology doctors and the [Name5 (PTitle) ] specialists. We have cancelled the followup appointment with oncology that we previously scheduled, at your request. We have developed some recommendations that apply to the current issues you are facing, but it is extremely important that you see a doctor as soon as possible, to continue workup and treatment of your medical conditions. We changed the following medications: 1. Added Augmentin for 8 more days, to complete a 14 day course. 2. Please discontinue your metformin, due to liver dysfunction that you are having. 3. Do not take Aspirin or other blood thinners. 4. We have given you 4 days of oxycodone, for pain at the drain site. We have not scheduled any followup appointments at your request. Your pathology specimen is still under evaluation at the Pathology Department. You can call the Pathology Department at [Telephone/Fax (1) 9363], once you have a new doctor, and ask them to release the results to you. We would normally have your new doctor make this call, but since you do not know that doctor's name or information, we cannot follow our usual protocols. There is a pathology doctor, Dr [Last Name (STitle) ] who is overseeing your case, and you can ask to speak with him. We have also provided you with the adequate information to obtain a records release, so that you can have access to your records. Followup Instructions: You have not been scheduled for followup, at your specific request. We have cancelled the previous appointments we made for you with oncology, at your request. We are strongly recommending that you seek medical attention as soon as possible. We are also recommending that you not travel any long distances, given your acute medical conditions.	[ "E878.8", "998.2", "998.11", "401.9", "576.2", "576.1", "197.0", "197.7", "278.00", "250.00", "453.41", "157.0" ]	icd9cm	[ [ [] ] ]	[ "52.11", "51.85", "51.98", "38.7", "51.14", "51.10" ]	icd9pcs	[ [ [] ] ]	12689, 12695	6242, 11886	324, 443	12904, 12904	4185, 6219	15545, 15894	3198, 3257		12187, 12666		12716, 12883		11912, 12164			13055, 15522									3272, 4166																			2193, 2577		255, 286							471, 2174												12919, 13031					2599, 2685	2717, 3166
29,426	187,735	34370	Discharge summary	report	Admission Date: [2126-3-1] Discharge Date: [2126-3-6] Date of Birth: [2064-1-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2167] Chief Complaint: AMS Major Surgical or Invasive Procedure: change of suprapubic foley RIJ placement History of Present Illness: 62 yo male with hx of CVA, neurogenic bladder with indwelling suprapubic catheter with multiple prior admissions for UTIs, altered mental status, and sepsis (UTI/PNA). Today he is being transferred from the nursing home for fever of 101.4, and mental staus change. He was found by EMS to have a [First Name3 (LF) ] pressure of 70/40. Brought to ED with initial vs: T 98.6 P 105 BP 70/40 R 16 O2 100% satRA. Patient was found to have pyuria, pan cultured, given vanc/zosyn, bladder cath exchanged, IJ placed, initially fluid responsive (3L), but repeat SBP 80, Levophed started. . On the floor, alert oriented with MAP of 90 after 2L NS and 0.05 of levophed . Review of sytems: (-) 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: s/p CVA Neurogenic bladder s/p suprapubic cath Recurrent UTIs with Klebsiella/Pseudomonas Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p R-CHOP x 6 cycles) Bells Palsy BPH Hypertension Partial Bowel obstruction s/p colostomy Hepatitis C Cryoglobulinemia SLE with transverse myelitis, anti-dsDNA Ab+ Insulin Dependant Diabetic Fungal Esophagitis Stage IV? Urinary Tract Infections-pseudomonas & enterococcus Social History: Lives in a nursing home since [3-9]. Denies smoking, ETOH, drug use. Has sister close by ([Name (NI) 79061]) who he is close to. Is a Jehova's Witness and in the past did not agree to [Name (NI) ] transfusions. Family History: Non-Contributory 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 Pertinent Results: [2126-3-1] 09:05AM [Month/Day/Year 3143] WBC-28.2# RBC-5.25 Hgb-13.6 Hct-42.6 MCV-81* MCH-25.8* MCHC-31.8 RDW-15.9* Plt Ct-167 [2126-3-1] 01:23PM [Month/Day/Year 3143] WBC-37.8* RBC-4.87 Hgb-12.7* Hct-40.5 MCV-83 MCH-26.1* MCHC-31.3 RDW-15.9* Plt Ct-153 [2126-3-1] 06:27PM [Month/Day/Year 3143] WBC-38.3* RBC-5.02 Hgb-13.1* Hct-41.6 MCV-83 MCH-26.2* MCHC-31.6 RDW-16.5* Plt Ct-157 [2126-3-1] 10:08PM [Month/Day/Year 3143] WBC-34.9* RBC-5.26 Hgb-13.8* Hct-43.4 MCV-83 MCH-26.2* MCHC-31.8 RDW-16.6* Plt Ct-152 [2126-3-2] 03:26AM [Month/Day/Year 3143] WBC-26.8* RBC-4.66 Hgb-12.4* Hct-38.2* MCV-82 MCH-26.6* MCHC-32.4 RDW-16.5* Plt Ct-131* [2126-3-1] 01:23PM [Month/Day/Year 3143] PT-16.4* PTT-38.4* INR(PT)-1.5* [2126-3-2] 03:26AM [Month/Day/Year 3143] PT-18.1* PTT-35.1* INR(PT)-1.7* [2126-3-1] 09:05AM [Month/Day/Year 3143] Glucose-82 UreaN-26* Creat-3.3# Na-135 K-4.6 Cl-98 HCO3-25 AnGap-17 [2126-3-1] 01:23PM [Month/Day/Year 3143] Glucose-117 UreaN-22* Creat-2.3* Na-140 K-4.6 Cl-109* HCO3-20* AnGap-16 [2126-3-1] 06:27PM [Month/Day/Year 3143] Glucose-158* UreaN-21* Creat-2.2* Na-140 K-6.3* Cl-110* HCO3-21* AnGap-15 [2126-3-1] 08:48PM [Month/Day/Year 3143] Glucose-166* UreaN-21* Creat-2.0* Na-141 K-5.9* Cl-108 HCO3-23 AnGap-16 [2126-3-1] 10:08PM [Month/Day/Year 3143] Glucose-183* UreaN-21* Creat-2.0* Na-142 K-5.5* Cl-110* HCO3-24 AnGap-14 [2126-3-2] 03:26AM [Month/Day/Year 3143] Glucose-287* UreaN-19 Creat-1.7* Na-142 K-4.7 Cl-110* HCO3-25 AnGap-12 [2126-3-2] 03:07PM [Month/Day/Year 3143] Glucose-239* UreaN-17 Creat-1.3* Na-142 K-4.2 Cl-107 HCO3-27 AnGap-12 [2126-3-1] 01:23PM [Month/Day/Year 3143] ALT-43* AST-62* LD(LDH)-331* CK(CPK)-3687* AlkPhos-74 TotBili-2.2* [2126-3-1] 06:27PM [Month/Day/Year 3143] ALT-47* AST-87* LD(LDH)-394* CK(CPK)-5931* AlkPhos-75 TotBili-2.5* [2126-3-1] 10:08PM [Month/Day/Year 3143] ALT-49* AST-92* LD(LDH)-356* CK(CPK)-6489* AlkPhos-76 TotBili-2.1* [2126-3-2] 03:26AM [Month/Day/Year 3143] CK(CPK)-5158* [2126-3-2] 03:07PM [Month/Day/Year 3143] CK(CPK)-3133* [2126-3-1] 01:23PM [Month/Day/Year 3143] CK-MB-9 cTropnT-0.06* proBNP-777* [2126-3-1] 06:27PM [Month/Day/Year 3143] CK-MB-13* MB Indx-0.2 cTropnT-0.03* [2126-3-1] 09:05AM [Month/Day/Year 3143] Albumin-4.1 Calcium-9.6 Phos-2.3* Mg-2.0 [2126-3-1] 08:48PM [Month/Day/Year 3143] Calcium-8.1* Phos-4.1 Mg-2.4 [2126-3-1] 09:13AM [Month/Day/Year 3143] Glucose-82 Lactate-4.3* Na-136 K-4.2 Cl-94* calHCO3-25 [2126-3-1] 09:53AM [Month/Day/Year 3143] Lactate-2.7* [2126-3-1] 10:27PM [Month/Day/Year 3143] Lactate-1.8 . CXR: Left IJ catheter tip is in the upper SVC. There is moderate pulmonary edema. There are low lung volumes. Cardiac silhouette is top normal. Bilateral pleural effusions are small. The cardiomediastinum is deviated towards the right side. This is a chronic finding. Brief Hospital Course: This is a 62 yo male with neurogenic bladder and suprapubic cath, multiple past UTIs and urosepsis, with resolved septic shock on vanc/meropenem for urosepsis and flagyl for cdiff ppx. . # Urosepsis: Patient initially presented in septic shock and was hypotensive requiring levophed. Given gross pyuria was assumed to be source, other possible considerations included infected stoma, suprapubic cathether site, cdiff. HCT stable w/o signs of bleed, cardiogenic shock not consistent with current presentation, elevated trop, in the setting of shock and renal failure with flat CK suggesting demand ischemia. Mixed svO2 suggesting septic shock. Patient placed on vanc/meropenem for pyuria, WBC, bandemia, hypotension, fever, suggestin sepsis, given past sensitivity profile would favor changing to meropenem until new cultures back. Hypotension appears to have caused acute renal failure. Given stress dose steroid and tapered back to home dose. Remains on meropenenem and flagyl until f/u with [Month/Day/Year ] next week. . # Neurogenic bladder with nephrolithiasis: pt reports scheduled surger on [2126-3-5] by Dr. [Last Name (STitle) 11189]. Per CT, no change of his non obstructing stone. Significant leaking around suprapubic cath site. D/w [Last Name (STitle) ], started on ditropan changed over to detrol. [Last Name (STitle) 159] not concerned with leaking and will f/u with pt next week. . # History of C diff. Given the severity of the sepsis on initial presentation, recent prolonged antibiotic use and hospitalization and previous c diff, started PO vanc and IV flagyl. remains on flagyl until meropenem is stopped. . # Rhabdomylasis ?????? CKs peaked and now trending down, no evidence of significant muscle breakdown or compartment syndrome. Stopped statin. Fluid resuscitated. Ck's trending down with improved renal fxn. . #. Resolved altered mental status: Appears similar to prior episode per review of discharge summary and patient is clinically infected. Most likely due to sepsis and hypotension with underlying poor reserve. On the floor, MS change seems to have resolved. . #. Acute renal failure: Creatinine up to 3.3 in the setting of septic shock. Most likely prerenal over the past several days and perhaps some ATN. Although pt with diagnosis of SLE and anti-dsDNA Ab+ , his most recent creatinine 0.8 indicates acute process. . # Completed ROMI: Patient had elevated Troponin in the setting of renal failure and shock. CK MBI negative. Elevated CK from non-cardiac source. No EKG changes. Issue resolved. . # Leg pain: Patient states pain is bilateral and longstanding. On gabapentin & oxycodone at nursing facility. On gabapentin, percocet (because of inavailability of oxycodone) and started on nortriptyline. . # Stoma: Likely benign given that stoma appears pink and is soft. No abd tenderness. Stoma remained pink and non-tender t/o hospitalization. . # DM: On lantus & humalog (with meals & sliding scale) at baseline. D/c on meds close to home dose . . #. FEN - regular diet. Lytes were repleted prn. . #. PPx - Hep SC TID. PPI (recent gastritis). Hx of cdiff giving flagyl . # Access: 2 PIVs, R IJ CVL . #. Code - Full, confirmed with patient. sister is HCP. [Name (NI) ] [Name2 (NI) ] products as patient is Jehovah's witness (confirmed with him). . # Communication: With patient and sister, [Name (NI) 79064] [Name (NI) 79065] [Telephone/Fax (1) 79066]. Medications on Admission: Bactrim DS daily for UTI PPx (finished 1 month course [2-15]) MVI Prednisone 10 mg daily Prilosec 40 daily Ca/Vit D 600 [Hospital1 ] Colace [Hospital1 ] Iron 325 Gabapentin 1200 TID Zocor 10 mg daily Lantus 18 IU qhs Humalog 8 IU with each meal standing Humalog SS Percocet 5/325 2TAB TID Senna 2 Tabs Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). X 4 days 9. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 10. 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. 11. Meropenem 1000 mg IV Q12H X 4 days 12. Pantoprazole 40 mg IV Q24H 13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 16. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for 1 days. 17. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 18. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 19. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) injection Subcutaneous at bedtime: See attached insulin flowsheet. 21. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) inj Injection QAWHS: See attached flowsheet. 22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day): Please administer for DVT prophylaxis if pt remains in bed. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare-[Location (un) 86] Discharge Diagnosis: Primary: Urosepsis Altered Mental Status Acute Renal Failure Secondary: Neurogenic bladder DM2 Peripheral Neuropathy Discharge Condition: Improved Discharge Instructions: You were evaluated and treated in the hospital for a systemic infection which likely originated with a urinary tract infection and acute renal failure. Your renal function has returned to baseline and your infection is currently being treated with the appropriate antibiotics. You will need to continue the antibitoics for a total of 2 weeks and then you will continue on other antibiotics to prevent against further infections. You will also need to follow-up with your primary care doctor and your urologist. Followup Instructions: Please follow-up with your primary care doctor Dr. [First Name (STitle) ]. We called his office today and were unable to get a follow-up appointment. He can be reached at [Telephone/Fax (1) 6019]. Please follow-up with the [Telephone/Fax (1) ] UNIT Phone:[Telephone/Fax (1) 164], your appointment is scheduled for [2126-3-13] at 10:00AM	[ "995.92", "V10.79", "590.10", "070.54", "728.88", "729.5", "785.52", "356.9", "323.82", "V44.3", "596.54", "273.2", "E879.6", "710.0", "344.1", "038.9", "584.9", "250.00", "514", "276.2", "600.00", "V58.67", "V12.54" ]	icd9cm	[ [ [] ] ]	[ "93.93", "38.93", "59.94" ]	icd9pcs	[ [ [] ] ]	11431, 11507	5670, 7550	317, 359	11669, 11680	2652, 5647	12243, 12606	2145, 2163		9473, 11408		11528, 11648		9134, 9450			11704, 12220									2178, 2633																					274, 279					1068, 1436		387, 1050												7565, 9108					1459, 1889	1905, 2129
63,865	123,902	53954	Discharge summary	report	Admission Date: [2111-4-2] Discharge Date: [2111-4-14] Date of Birth: [2030-10-23] Sex: M Service: NEUROSURGERY Allergies: Cipro Attending:[First Name3 (LF) 78] Chief Complaint: left SDH Major Surgical or Invasive Procedure: [4-6] Left sided craniotomy for SD/EDH evacuation History of Present Illness: 80M who was taken to an OSH with MS changes and a question of left sided weakness. A CT head showed a large left sided subacute SDH with midline shift. He was transferred to [Hospital1 18] for further care. Patient is aphasic and unable to provide history. There is no family currently at the bedside and OSH records do not offer much info. Past Medical History: NIDDM HTN frequent UTI's HLD h/o CVA - w/ residual right-sided weakness, expressive aphagia PSH: possible right ankle surgery Social History: Lives in [Location 78305] [Hospital3 400] Family History: nc Physical Exam: O: T: 98.6 BP: 119/96 HR: 67 R 16 O2Sats 98% Gen: WD/WN, comfortable, NAD. Aphasic. Neuro: Mental status: Awake and alert, follows exam with visual cues. PERRL, EOM appear full, face appears [Last Name (LF) ], [First Name3 (LF) 2995] with no gross motor deficit, strength is symmetric bil. No pronator. Aphasic- appears to be global. Follows commands with visual cues. Discharge exam: AOX2, agitated at times, follows commands, RUE weakness (baseline) otherwise full, sensory intact grossly, speech is aphasic but does say several words. Babinski upgoing on the right, no clonus Pertinent Results: CXR [4-3] - There are no prior studies available for comparison. There are low lung volumes. Cardiac size is top normal, is accentuated by the low lung volumes. There are bibasilar atelectases. There is no pneumothorax or pleural effusion. [4-6] CT Head- IMPRESSION: Post-surgical changes after evacuation of left subdural hemorrhage, with interval decrease in the size of the extra-axial subdural collection, now measuring 2.3cm from the inner table. Increased hyperdense fluid within the collection is blood products, which can be seen post surgically. Unchanged hypodense area in the left frontal and parietal lobes, unchanged and relates to subacute-chronic ischemic changes or prior insult and possibly some degree of vasogenic edema. [4-7] CT Head- IMPRESSION: Moderate-sized left hemispheric subdural hematoma, slightly smaller since the earlier study [2111-4-6].Mild interval decrease in the amount of pneumocephalus. No significant rightward shift of midline structures. Stable positioning of surgical drainage catheter in the left subdural space. No new intracranial hemorrhage. [4-8] CT head - Moderate-sized left hemispheric subdural hematoma is slightly smaller than on [2111-4-7]. Slight interval decrease in pneumocephalus. No significant rightward shift of midline structures. No new hemorrhage. [4-10] LENIs - No evidence of right lower extremity DVT. [4-13] CT brain reprot not out / images reviewed by Dr [First Name (STitle) ] / there is acute component of subdural collection that is without mass effect and does not require surgical treatment at this time. Brief Hospital Course: Patient was admitted to Neurosurgery ICU on [2111-4-3] for further management. He remained stable overnight and was transferred to floor with telemetry in stable condition. He remained on the floor being monitored neurologically until his surgery on [4-6]. On [4-6], he underwent the above stated procedure. Please review dictated operative report for details. Patient was extubated without incident and transferred to ICU in stable condition. Post op head CT revealed some acute hemorrhage and pneumocephalus. A repeat scan was scheduled 6 hours later, and remained stable. On [4-7] the subdural drain continued to put out significant drainage, though he remained neurologically stable. It was left in place and we held SQH. SBP was liberalized to 160. His drain was removed. Follow up imaging demonstrated new subdural heme without mass effect. He remained stable in ICU and was deemed stable for tx to floor. Foley was removed in routine fashion and pt voided without incident. Now DOD, patient is afebrile, VSS, and neurologically stable. Patient's pain is well-controlled and the patient is tolerating a good oral diet. Pt's incision is clean, dry and intact without evidence of infection. His staples have been removed. Patient is ambulating with assistance and will be discharged to rehab today / [Hospital1 ]. Medications on Admission: proscar 5mg daily, atenolol 50mg daily, simvastatin, amlodipine, aggrenox (for CVA), lisinopril 10mg daily, allopurinol 300mg daily, glyburide 2.5mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/ fever. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 12. Ondansetron 4 mg IV Q8H:PRN nausea Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Subacute left frontal SDH delerium urinary retention Discharge Condition: Mental Status: Confused - sometimes, aphasic, but understands cues Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: YOU WERE ON AGGRENOX BEFORE YOUR ADMISSION / AS OF RIGHT NOW YOU ARE OK TO RESTART THIS MEDICATION IN ONE MONTH FROM YOUR DATE OF SURGERY. [2111-4-6] ?????? 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]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. 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 Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ] , 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]. Completed by:[2111-4-13]	[ "432.1", "599.0", "272.4", "788.20", "780.09", "345.90", "729.89", "348.4", "V58.69", "438.11", "250.00", "401.9" ]	icd9cm	[ [ [] ] ]	[ "01.39", "38.91" ]	icd9pcs	[ [ [] ] ]	5677, 5724	3226, 4575	277, 333	5821, 5821	1580, 3203	7478, 8133	940, 944		4784, 5654		5745, 5800		4601, 4759			6005, 7455									959, 1061						1365, 1561															229, 239							361, 707												5836, 5980					729, 857	873, 924
71,194	150,495	43093	Discharge summary	report	Admission Date: [2181-7-16] Discharge Date: [2181-7-19] Date of Birth: [2114-9-18] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Bactrim / SEROVENT / fentanyl / midazolam Attending:[First Name3 (LF) 23497] Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 66F h/o stage IIa gastric CA s/p 3 cycles of post surtgical chemotherapy who presented to her heme-onc appointment with abnormal labs showing hyperglycemia to bs of 685. Pt reported increased thirst and polyuria but denied any fevers, chills, cough, sick contacts. She reports vomiting but no diarrhea over the past day which she thought was [12-28] her chemotherapy. At heme/onc office found to have bs of 685, she was started on IVF at 500/hr and referred to ED for eval/management. She was noted to have a gap of 21. Patient is [Initials (NamePattern4) ] [Last Name (NamePattern4) 387] patient and was last seen in [2181-6-20], [First Name8 (NamePattern2) ] [Last Name (un) 387] notes she is supposed to be on 30u lantus qday and per her hemeonc she is taking 15U qday. On the day of admission patient reports she took her lantus and only 3U of humaglog in the AM since she did not eat breakfast. In the ED, initial VS were: 17:22 0 98.8 82 153/68 14 99% RA. She was given 10 of regular insulin and then started on a insulin drip at 10u/hr, and received a total of 3L of NS prior to transfer. VS on transfer: 20:41 0 98.0 90 126/45 19 100%. Her On arrival to the MICU, patient had no complaints. She denied any nausea or vomiting. She reports the last time she checked her own finger stick was two days prior and it was 126. She denies any problems checking her sugars or drawing up her lantus. She denies any fevers, chills, cough. She reported she was feeling better than when she went to the clinic today. Past Medical History: Gastric adenocarcinoma (dx [9-/2180]) Ductal carcinoma of breast: T1c, N0, M0 stage IB hypertension hyperlipidemia diabetes venous insufficiency OSA rheumatic heart disease asthma factor VIII inhibitor PSH: Subtotal gastrectomy [2181-2-21] R Mastectomy b/l vitrectomy b/l cataracts Social History: Lives with her husband. [Name (NI) ] tobacco, no EtOH, no drugs. Works as social worker Family History: No family history of cancer. Father with diabetes. Grandmother with diabetes Physical Exam: ADMISSION PHYSICAL EXAM: General: Somnolent, slowed speech and formulation of wards, resting comfortably in bed in NAD. A+Ox3 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, 3/6 systolic murmur heard best at the apex radiating to the axilla. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Midline epigastric scar is well healed Ext: warm, well perfused, 2+ pulses. Dry feet with flaking skin of the toes bilaterally. Some hyperpigmentation of the plantar surfaces of the feet bilaterally Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, DISCHARGE EXAM: Exam unchanged Pertinent Results: ADMISSION LABS [2181-7-16] 01:53PM BLOOD WBC-11.2* RBC-3.01# Hgb-8.4 Hct-27.0# MCV-90 MCH-28.0 MCHC-31.2 RDW-17.5 Plt Ct-341 [2181-7-16] 01:53PM BLOOD Neuts-79.3* Lymphs-11.7* Monos-8.6 Eos-0.3 Baso-0.1 [2181-7-16] 01:53PM BLOOD UreaN-19 Creat-1.3* Na-127* K-4.5 Cl-86* HCO3-20* AnGap-26* [2181-7-16] 03:35PM BLOOD Glucose-685* [2181-7-16] 06:00PM BLOOD Glucose-648* UreaN-21* Creat-1.1 Na-132* K-4.8 Cl-89* HCO3-15* AnGap-33* [2181-7-16] 11:15PM BLOOD Glucose-305* UreaN-19 Creat-1.1 Na-137 K-3.7 Cl-102 HCO3-19* AnGap-20 [2181-7-17] 03:45AM BLOOD Glucose-134* UreaN-17 Creat-0.9 Na-139 K-3.9 Cl-106 HCO3-25 AnGap-12 [2181-7-16] 01:53PM BLOOD ALT-14 AST-19 AlkPhos-76 TotBili-0.6 [2181-7-16] 01:53PM BLOOD Calcium-9.5 Phos-3.5 Mg-1.8 [2181-7-16] 11:15PM BLOOD Calcium-8.6 Phos-0.9# Mg-1.6 [2181-7-17] 03:45AM BLOOD Calcium-8.7 Phos-1.0 Mg-1.6 [2181-7-16] 08:20PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.017 Micro: Blood culture [7-17]- PENDING DISCHARGE LABS [2181-7-19] 01:10PM BLOOD WBC-5.2 RBC-2.99* Hgb-8.3* Hct-26.4* MCV-88 MCH-27.8 MCHC-31.5 RDW-18.1* Plt Ct-348 [2181-7-19] 05:30AM BLOOD Glucose-127* UreaN-6 Creat-0.6 Na-137 K-4.5 Cl-106 HCO3-25 AnGap-11 [2181-7-19] 05:30AM BLOOD Calcium-9.4 Phos-2.7 Mg-1.8 Brief Hospital Course: 66 yo F w/ PMH of diabetes and history of DKA who presented in DKA and was originally admitted to the ICU and was #Diabetic Ketoacidosis-Patient meets criteria for DKA with glucose >200 with anion gap of 28 and kenonuria,she did not have a blood gas but with the gap and low bicarb it is clearly a metabolic acidosis. Most likely trigger was medication non-adherence in the setting of nausea, vomiting, and poor PO intake since receiving her last dose of chemo approximately 3 weeks prior. She had not been administering her full dose of Lantus and missed some doses of humalog because she was not eating well. She had no obvious signs or symptoms of infection: chest x-ray was negative for consolidation, urinalysis was negative, blood cultures were no growth to date after 3 days at time of discharge. EKG showed now signs of myocardial ischemia. She reports a previous hospitalization with ICU stay for DKA in [2-/2181] with unclear precipitant ([Name (NI) 10540] vs. wound seroma). She was started on insulin drip and [Last Name (un) ] was consulted. She was transitioned off of the insulin drip during her first night and was switched back to her home regimen with a more aggressive sliding scale. She was discharged on 15U lantus in the morning, a sliding scale, and has follow-up with [Last Name (un) ] as an outpatient. #Gastric cancer- patient is s/p surgical resection and now s/p 3 cycles of chemotherapy. She continues to be followed by her oncologist. As a result of chemo, she has had persistent nausea, vomiting, and poor PO intake. She gets weekly IV fluid infusions, and will continue upon discharge. #Hypertension- Normotensive during this admission on home verapamil, metoprolol, valsartan. Furosemide was held given poor PO intake and intermittent mild orthostasis. Defer to PCP whether to restart this medication. #Hyperlipidemia-continued home crestor #Anxiety-Continued home cymbalta & zolpidem #Slowed mentation / speech- patient had slowed mentation on admission. She has a history of multiple ED visits for concern of her slowed speech/aphasia and has been admitted to neurology previously. She was last seen [2181-7-14] by an inpatient neurologist, who diagnosed her with complicated migraines. Her TSH was checked during this admission and was found to be 4.1. She is followed by neurology as an outpatient. Her case manager reported two unprovoked falls prior to admission. She was seen by inpatient PT, who recommended home PT. Had mild, asymptomatic orthostatics. TRANSITION OF CARE ISSUES - Please discuss with your PCP whether you should restart furosemide (lasix). We stopped this medication during your hospitalization because we do not want your blood pressure to drop too low while you are not eating or drinking too much. Please discuss with your PCP whether to restart this medication. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from PatientwebOMR. 1. Albuterol Inhaler [11-27] PUFF IH Q4H:PRN shortness of breath/wheezing 2. Capecitabine 500 mg PO QAM AND PM one tab by mouth in morning and two at night 3. Cyanocobalamin 1000 mcg IM/SC ONCE Duration: 1 Doses 4. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea 5. Duloxetine 60 mg PO DAILY 6. Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] 7. Furosemide 40 mg PO DAILY 8. Glargine 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 9. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety/nausea hold for sedation or rr<10 10. Metoprolol Tartrate 50 mg PO BID hold for sbp<100 or hr<60 11. Montelukast Sodium 10 mg PO DAILY 12. Omeprazole 40 mg PO DAILY 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain hold for sedation or rr<10 15. Maxalt-MLT NF (rizatriptan) 10 mg Oral 2hrs prn max 3/24hr 16. Rosuvastatin Calcium 10 mg PO DAILY 17. Valsartan 320 mg PO DAILY hold for sbp<100 or hr<60 18. Verapamil SR 180 mg PO Q24H hold for sbp<100 or hr<60 19. Zolpidem Tartrate 10 mg PO HS 20. Acetaminophen 500 mg PO Q6H:PRN pain Discharge Medications: 1. Albuterol Inhaler [11-27] PUFF IH Q4H:PRN shortness of breath/wheezing 2. Duloxetine 60 mg PO DAILY 3. Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] 4. Glargine 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety/nausea hold for sedation or rr<10 6. Metoprolol Tartrate 50 mg PO BID hold for sbp<100 or hr<60 7. Montelukast Sodium 10 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain hold for sedation or rr<10 11. Rosuvastatin Calcium 10 mg PO DAILY 12. Valsartan 320 mg PO DAILY hold for sbp<100 or hr<60 13. Acetaminophen 500 mg PO Q6H:PRN pain 14. Capecitabine 500 mg PO QAM AND PM one tab by mouth in morning and two at night 15. Cyanocobalamin 1000 mcg IM/SC ONCE Duration: 1 Doses 16. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea 17. Maxalt-MLT NF (rizatriptan) 10 mg Oral 2hrs prn max 3/24hr 18. Zolpidem Tartrate 10 mg PO HS 19. Verapamil SR 180 mg PO Q24H hold for sbp<100 or hr<60 20. Prochlorperazine 5-10 mg PO Q8H:PRN nausea RX prochlorperazine maleate 5 mg [11-27] tablet(s) by mouth every eight (8) hours Disp #30 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: PRIMARY DIAGNOSIS: Diabetic ketoacidosis SECONDARY DIAGNOSIS: gastric cancer, hypertension, hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname 50155], It was a pleasure taking care of you during your recent hospitalization. You were admitted for diabetic ketoacidosis. We gave you insulin and IV fluids, and your blood sugar went down to a healthy level. It is very important that you take your insulin as prescribed every day. Even if you do not eat and you are nauseous, you should take the long-acting insulin (lantus) once a day but hold the short-acting insulin. You will have follow-up appointments with [Last Name (un) ] to discuss how to best control your blood sugar levels. Please keep the following appointments we have made for you. Please stop taking furosemide (lasix) because we do not want your blood pressure to drop too low while you are not eating or drinking too much. Please discuss with your PCP whether to restart this medication. Followup Instructions: Name: [Last Name (LF) 14116], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 9979] Appointment: Friday [2181-7-20] 8:00am Department: [State ]When: WEDNESDAY [2181-7-25] at 9:45 AM With: [Name6 (MD) ] [Name8 (MD) 9862], MD [Telephone/Fax (1) 2205] Building: [State ] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2181-7-23] at 10:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3150], MD [Telephone/Fax (1) 11133] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2181-7-23] at 10:30 AM With: [Name6 (MD) ] [Name8 (MD) 7880], 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: HEMATOLOGY/ONCOLOGY When: MONDAY [2181-7-23] at 11:30 AM With: PADDY [Name8 (MD) ], RN [Telephone/Fax (1) 9644] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2181-7-19*]	[ "285.9", "493.20", "401.9", "362.01", "327.23", "357.2", "250.63", "250.53", "272.4", "V45.71", "V10.04", "250.13", "300.00", "286.0", "398.90", "V58.67", "V45.75", "V10.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9934, 9992	4563, 7432	365, 372	10145, 10145	3231, 4540	11172, 12701	2380, 2458		8694, 9911		10013, 10013		7458, 8671			10296, 11149									2498, 3180						3196, 3212															312, 327							400, 1939					10077, 10124				10033, 10055			10160, 10272					1961, 2254	2270, 2364
69,295	153,910	8080	Discharge summary	report	Admission Date: [2125-8-20] Discharge Date: [2125-8-29] Date of Birth: [2068-5-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1973] Chief Complaint: septic shock, RLE cellulitis Major Surgical or Invasive Procedure: central line placement History of Present Illness: 57 year old Female with a history of Hypertension and idiopathic liver disease (baseline INR 1.8 as of [2121], ALb 2.6) who presents with fevers and RLE edema/cellulitis X 3 days. Pt noted onset of LE swelling R>L starting 3 weeks ago, with acute worsening accompanied by erythema and brawniness, night sweats, and intermittant fevers and pain so excruciating that it rendered her bedridden for 3 days prior to admission. Pain was only poorly controlled with ibuprofen (600 mg every 4-6 hours for the past 3 days). She experienced RLE swelling dating back 2 years ago after Right Total-Knee-Replacement, with swelling episodically 8x/month, and prompting outpt visit for draining 2x/past year. She denies jaundice, abdominal swelling, pruritus, but notes her urine was yellower than usual. She notes [10-10] lb weight loss over past 2 months and poor appetite. She denies dysuria, hematuria, frequency or abdominal/pelvic pain. She also denies cough, sob, chest pain, orthopnea, constipation, melena, weakness, and confusion. In the ED, V.S. on admission in triage were 98.7 72 98/50 18 93% RA. Patient became acutely tachypenic with RR to 31, saturating 97% on 4L, and was febrile to 101, with BP subsequently dipping from 93/40 to 70s/30s. A central line was placed, and 4L IVF and 2u FFP for bleeding at central line site, with SBP persisting in 80s. She was started on Norepinephrine, phenylephrine drips and given 150 mcg IV fentanyl. Labs were sent and revealed an elevated Lactate ~5, 4.6, 4.5. She was given Vancomycin 1g IV, and Ampicillin-Sulbactam (unasyn) 3g IV, and Acetaminophen 500mg X2 for pain. She was initially admitted to the [Hospital Unit Name 153] for treatment of sepsis, using early goal directed therapy. IVF resuscitation with >5L LR was initiated on admission with MAP holding at 65, CVP 8. She did not require pressors during her ICU stay. Her blood cultures drawn at admission were positive for 4/4 bottles positive for group-B streptococcus bacteremia. She was initially started on broad spectrum antibiotics, including empiric coverage for MRSA with Vancomycin, and Unasyn for gram negatives and positives. She was also noted with a positive UA, and she was also treated with for the UTI. She also presented in Acute Renal Failure, which improved with hydration. Empiric vancomycin was discontinued on ICU/HD2, but restarted on ICU day 3 after fevers and persistent leukocytosis. Unasyn dosing was increased given normalization of renal function. Surveillance blood cultures were drawn and are pending. Past Medical History: Idiopathic cirhossis with hypoalbuminemia and coagulopathy (Alb 2.4; INR 1.8 as of [2121]); noted by PCP [Name Initial (PRE) 21336] [2124], and started on lasix, nadolol and spirolactone as of [7-3] Thromobocytopenia baseline Plts 90 Cholelithiasis (noted on prior CT) Chronic lymphadema of RLE >LLE s/o Right knee replacement [2121] OA HTN Left [Hospital Ward Name ] cyst s/p tubal ligation Social History: No smoking, no alcohol, no iv drug use. Pt. speaks [Location 7972] Portuguese, a little English, and understands some Spanish as well. She lives with her children and grandchildren. She still lives with her husband and has been unable to work [1-27] knee pain. Family History: No hx of autoimmune disease, RA. No hx of liver disease. Physical Exam: At time of discharge: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain, + leg pain at site of bulla NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 97.5, 136/68, 88, 20, 99% GEN: NAD Pain: [2-4] HEENT: EOMI, MMM, - OP Lesions, incteric PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CC, 2+ edema, Chronic Venous Stasis Changes, Draining Bulla on RLE bandaged NEURO: CAOx3, Non-Focal Pertinent Results: [2125-8-29] 06:10AM BLOOD WBC-10.9 RBC-3.03* Hgb-10.8* Hct-31.2* MCV-103* MCH-35.7* MCHC-34.7 RDW-16.5* Plt Ct-132* [2125-8-28] 05:40AM BLOOD WBC-12.0* RBC-3.17* Hgb-10.9* Hct-31.5* MCV-100* MCH-34.5* MCHC-34.7 RDW-16.4* Plt Ct-137* [2125-8-23] 03:37AM BLOOD WBC-13.7* RBC-3.27* Hgb-11.6* Hct-32.2* MCV-98 MCH-35.4* MCHC-36.0* RDW-17.0* Plt Ct-94* [2125-8-21] 03:25PM BLOOD WBC-28.6* RBC-3.26* Hgb-11.3* Hct-32.6* MCV-100* MCH-34.7* MCHC-34.7 RDW-17.2* Plt Ct-110* [2125-8-21] 09:16AM BLOOD WBC-32.9* RBC-3.30* Hgb-11.5* Hct-33.2* MCV-101* MCH-34.7* MCHC-34.5 RDW-16.7* Plt Ct-101* [2125-8-20] 11:51PM BLOOD WBC-35.6# RBC-3.46 Hgb-11.7* Hct-35.5* MCV-103* MCH-33.8* MCHC-32.9 RDW-17.1* Plt Ct-138* [2125-8-23] 03:37AM BLOOD Neuts-75* Bands-2 Lymphs-12* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-2* [2125-8-20] 06:00PM BLOOD Neuts-86.9* Lymphs-7.0* Monos-4.8 Eos-0.8 Baso-0.6 [2125-8-26] 06:10AM BLOOD PT-22.8* INR(PT)-2.2* [2125-8-21] 03:25PM BLOOD PT-27.2* PTT-44.0* INR(PT)-2.7* [2125-8-20] 08:15PM BLOOD PT-33.1* PTT-65.6* INR(PT)-3.5* [2125-8-21] 03:25PM BLOOD FDP->1280* [2125-8-21] 01:18AM BLOOD FDP->1280* [2125-8-20] 08:15PM BLOOD Fibrino-106* D-Dimer->[Numeric Identifier 961]* [2125-8-20] 11:52PM BLOOD ESR-20 [2125-8-29] 06:10AM BLOOD Glucose-67* UreaN-6 Creat-0.6 Na-131* K-4.4 Cl-101 HCO3-24 AnGap-10 [2125-8-20] 06:00PM BLOOD Glucose-63* UreaN-52* Creat-2.1# Na-133 K-4.7 Cl-101 HCO3-19 AnGap-18 [2125-8-20] 11:51PM BLOOD Glucose-95 UreaN-55* Creat-2.1* Na-133 K-4.3 Cl-102 HCO3-16* AnGap-19 [2125-8-20] 11:52PM BLOOD Glucose-53* UreaN-52* Creat-2.3* Na-135 K-4.1 Cl-105 HCO3-15* AnGap-19 [2125-8-21] 09:16AM BLOOD Glucose-102 UreaN-55* Creat-2.0* Na-133 K-4.5 Cl-105 HCO3-18* AnGap-15 [2125-8-21] 03:25PM BLOOD Glucose-109* UreaN-55* Creat-1.6* Na-134 K-4.2 Cl-107 HCO3-17* AnGap-14 [2125-8-27] 05:30AM BLOOD ALT-33 AST-74* AlkPhos-135* TotBili-4.8* [2125-8-23] 03:37AM BLOOD ALT-33 AST-90* LD(LDH)-326* CK(CPK)-155* AlkPhos-123* Amylase-76 TotBili-2.9* [2125-8-22] 04:56AM BLOOD ALT-35 AST-85* LD(LDH)-349* CK(CPK)-410* AlkPhos-103 Amylase-54 TotBili-3.7* [2125-8-21] 09:16AM BLOOD ALT-36 AST-90* LD(LDH)-442* CK(CPK)-800* AlkPhos-126* Amylase-50 TotBili-5.7* DirBili-2.6* IndBili-3.1 [2125-8-23] 03:37AM BLOOD Lipase-108* [2125-8-22] 04:56AM BLOOD Lipase-33 [2125-8-20] 08:15PM BLOOD Lipase-30 [2125-8-29] 06:10AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.7 [2125-8-22] 04:56AM BLOOD Albumin-2.0* Calcium-7.5* Phos-2.7 Mg-2.3 [2125-8-20] 11:51PM BLOOD TotProt-6.6 Albumin-2.5* Globuln-4.1* Calcium-7.5* Phos-4.9# Mg-1.9 [2125-8-21] 03:25PM BLOOD Hapto-41 [2125-8-20] 08:15PM BLOOD VitB12-1079 Folate-6.1 [2125-8-20] 08:15PM BLOOD Cortsol-51.1* [2125-8-20] 08:15PM BLOOD CRP-131.6* [2125-8-20] 11:51PM BLOOD PEP-POLYCLONAL IgG-[2093]* IgA-1372* IgM-380* [2125-8-25] 06:50AM BLOOD Vanco-12.0 [2125-8-22] 05:27AM BLOOD Type-ART pO2-77* pCO2-35 pH-7.39 calTCO2-22 Base XS--2 [2125-8-21] 06:54AM BLOOD Type-MIX pO2-49* pCO2-33* pH-7.30* calTCO2-17* Base XS--8 [2125-8-21] 12:59AM BLOOD Type-ART pO2-71* pCO2-30* pH-7.32* calTCO2-16* Base XS--9 [2125-8-20] 11:59PM BLOOD Type-MIX pO2-50* pCO2-34* pH-7.27* calTCO2-16* Base XS--10 [2125-8-22] 05:27AM BLOOD Lactate-1.7 [2125-8-21] 04:22PM BLOOD Lactate-3.1* [2125-8-21] 06:54AM BLOOD Lactate-5.2* [2125-8-21] 12:59AM BLOOD Lactate-5.2* [2125-8-21] 09:16AM URINE Color-LtAmb Appear-Hazy Sp [Last Name (un) ]-1.013 [2125-8-21] 09:16AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.0 Leuks-NEG [2125-8-21] 09:16AM URINE RBC-4* WBC-14* Bacteri-FEW Yeast-NONE Epi-0 [2125-8-20] 06:50PM URINE Color-Amber Appear-Hazy Sp [Last Name (un) ]-1.014 [2125-8-20] 06:50PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.0 Leuks-NEG [2125-8-20] 06:50PM URINE RBC-[6-5]* WBC->50 Bacteri-MOD Yeast-MOD Epi-0 RenalEp-0-2 [2125-8-21] 09:16AM URINE CastGr-4* CastHy-4* [2125-8-20] 06:50PM URINE CastHy-0-2 [2125-8-21] 09:16AM URINE Eos-NEGATIVE [2125-8-21] 09:16AM URINE Hours-RANDOM UreaN-556 Creat-124 Na-LESS THAN TotProt-54 Prot/Cr-0.4* [2125-8-20] 6:11 pm BLOOD CULTURE #2. FINAL REPORT [2125-8-23] Blood Culture, Routine (Final [2125-8-23]): BETA STREPTOCOCCUS GROUP B. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 28857] [2125-8-20]. Aerobic Bottle Gram Stain (Final [2125-8-21]): GRAM POSITIVE COCCI IN CHAINS. Anaerobic Bottle Gram Stain (Final [2125-8-21]): GRAM POSITIVE COCCI IN CHAINS. [2125-8-20] 6:00 pm BLOOD CULTURE #1. FINAL REPORT [2125-8-24] Blood Culture, Routine (Final [2125-8-24]): BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CLINDAMYCIN = RESISTANT AT > 2 MCG/ML. ERYTHROMYCIN = RESISTANT AT > 4 MCG/ML. AMPICILLIN SENSITIVITY REQUESTED [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Numeric Identifier 28858]) [2125-8-24]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B \| AMPICILLIN------------<=0.12 S CLINDAMYCIN----------- R ERYTHROMYCIN---------- R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final [2125-8-21]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2125-8-21] AT 7:45AM. GRAM POSITIVE COCCI IN CHAINS. Anaerobic Bottle Gram Stain (Final [2125-8-21]): GRAM POSITIVE COCCI IN CHAINS. [2125-8-20] 6:50 pm URINE Site: CLEAN CATCH FINAL REPORT [2125-8-21] URINE CULTURE (Final [2125-8-21]): NO GROWTH. TTE [2125-8-29]: Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic 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: No valvular pathology or pathologic flow identified. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. CHEST (PORTABLE AP) Study Date of [2125-8-23] 4:27 AM FINDINGS: As compared to the previous examination, the right-sided central venous access line has been removed. There is no evidence of pneumothorax. Otherwise, the radiographic appearance is completely unchanged. UNILAT LOWER EXT VEINS RIGHT PORT Study Date of [2125-8-21] 11:26 AM FINDINGS: Grayscale and Doppler son[Name (NI) 1417] of the right common femoral, superficial femoral, and popliteal veins are performed. Normal flow, augmentation and compressibility are demonstrated. IMPRESSION: No evidence of deep vein thrombosis of the right lower extremity. RENAL U.S. PORT Study Date of [2125-8-21] 7:53 AM FINDINGS: The right kidney measures 12.0 cm and the left kidney measures 11.7 cm. There is no hydronephrosis, renal masses or stones. Limited views of the bladder are unremarkable. A Foley catheter is in place. IMPRESSION: No evidence of hydronephrosis. TIB/FIB (AP & LAT) SOFT TISSUE RIGHT Study Date of [2125-8-20] 9:11 PM IMPRESSION: Soft tissue edema. No subcutaneous emphysema or bony abnomality identified. CHEST PORT. LINE PLACEMENT Study Date of [2125-8-20] 8:06 PM FINDINGS: The tip of the right central venous line is in the distal SVC. There is stable cardiomegaly. The lungs are clear. There is no pneumothorax. Brief Hospital Course: 1. Septic Shock secondary to Strep Group-B bacteremia due to Leg Cellulitis: - Complete Amoxicillin - Afebrile x72 hours at time of discharge - ID agreed with longer course of Amoxicillin - Echocardiogram did not demonstrate evidence of a vegetation - Wound Care consultation - Surgical consultation was obtained with PRS 2. Acute renal failure on CKD Stage II: - Assumed to be Pre-renal secondary to hypoperfusion related to sepsis (Creatinine baseline 1.6, admission 3.2). - Hepatorenal syndrome was entertained given hx of cirhossis, but was considered unlikely as it resolved with fluids. - Given hx of NSAID use, consider AIN, but Urine Eos were negative. ATn was considered but Urine sediment was negative for rbc casts. - Renal ultrasound was negative for hydronephrosis. - Lasix diuresis was started HOD2, and spironolactone per home regimen was restarted HOD3. 3. Idiopathic Cirrhosis, Hepatitis NOS, Coagulopathy NOS - Liver dysfunction with associated thrombocytopenia, cholestatic transminitis, hypoalbuminemia (baseline Alb 2.6 now 2.4, baseline INR 1.8, peaked at 3.5) - Presumed some element of shock liver due to hypoperfusion on top of of idiopathic cirhossis. - Patient was to see hepatology clinic [2125-8-28], which was rescheduled as below - flu with hepatology as outpatient for w/u of Wilson's Disease, primary biliary cirhossis or primary sclerosing cholangitis or autoimmune hepatitis. 4. nongap and gap mixed metabolic acidosis: - Anion gap acidosis with elevated lactate in the setting of infection and malnutrtion and simultaneous non gap acidosis could reflect early renal failure. - Resolved at time of discharge 5. Benign Hypertension - Patient normotensive at time of discharge - Would restart nadolol if becomes hypertensive 6. Drug Rash The patient may have had a drug rash ot Vancomycin, versus idiopathic rash. Eosinophil count was never elevated. Code: full health care proxy: pt, daughter [Numeric Identifier 28859] Medications on Admission: FUROSEMIDE [LASIX] - 80 mg [Hospital1 ] NADOLOL - 40 mg qd SPIRONOLACTONE - 50 mg qd [T.E.D. SEQUNT COMPRESS DEVICE] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection [Hospital1 ] (2 times a day). 5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 9. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q8H (every 8 hours) for 10 days. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) 1495] [Doctor Last Name 122] Discharge Diagnosis: Cellulitis - Leg Bactremia Septicemia Discharge Condition: Good Discharge Instructions: Return to the hospital with fever, chills, nausea, vomiting, worsening pain in your legs. You need to protect your legs from trauma, and cuts as this makes you vulnerable to further infections. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD Phone:[Telephone/Fax (1) 7976] Date/Time:[2125-10-3] 2:15 Your appointment with the Liver Clinic was cancelled due to your being in the hospital. It has been rescheduled as below: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 3688] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2125-9-19] 2:30	[ "584.9", "287.5", "682.6", "715.90", "571.5", "286.9", "E930.8", "276.2", "573.3", "693.0", "995.92", "599.0", "V58.61", "782.4", "403.90", "785.52", "V43.65", "585.2", "714.0", "038.0", "276.1", "457.1" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	16009, 16100	12979, 14951	344, 368	16181, 16187	4615, 12956	16430, 16879	3692, 3750		15122, 15986		16121, 16160		14977, 15099			16211, 16407									4331, 4596																					276, 306							396, 2948																	2970, 3389	3405, 3676
26,434	198,355	18537	Discharge summary	report	Admission Date: [2197-12-17] Discharge Date: [2197-12-19] Date of Birth: [2162-7-17] Sex: M Service: ACOVE Medicine Firm HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old man with a history of FAP status post total proctocolectomy, who was recently found to have an ampullary adenoma incidentally as part of a workup of pancreatitis. He had an ERCP with polypectomy and pancreatic stent on the week prior to admission. The following day he developed some dark tarry stools. His bowel movements the following day were normal, but then the melenic stools returned on the two days prior to admission. He developed dizziness and lightheadedness the day of admission and that led him to the Emergency Department. His hematocrit was found to have dropped from 44 to 15.3, and he was admitted to the Fenard ICU. The patient did complain of periumbilical abdominal pain radiating to his right lower quadrant, which had been improving since initially starting the day after the ERCP. PAST MEDICAL HISTORY: 1. Familial adenomatous polyposis status post total proctocolectomy with ileal pouch and anal anastomosis in [2187]. 2. Ampullary adenoma status post ERCP resection. 3. History of pancreatitis. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Levaquin after the ERCP. 2. Hydrocodone prn. 3. Aciphex. 4. Celebrex. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient smokes one pack per day for about four years. He has occasional alcohol use. He lives with his family. He works as a plumber. FAMILY HISTORY: Notable for a mother who has FAP and history of ampullary carcinoma status post Whipple. PHYSICAL EXAMINATION: On exam, patient's temperature was 99.7, pulse 116, blood pressure 123/68, respiratory rate 16, sating at 100% on room air. In general, he was alert and oriented times three. He was pale, but comfortable appearing in no acute distress. Head and neck examination was unremarkable. Sclerae were anicteric. His mucosal membranes were moist. Cardiac examination: He was tachycardic with a normal S1, S2, no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. Abdomen was soft, had periumbilical and epigastric tenderness without rebound or guarding. His rectal was heme positive with melenic stool per the Emergency Room examination. Extremities have no clubbing, cyanosis, or edema. His white count was 9.4, 73% polys, 24% lymphocytes, hematocrit was 15.3 down from 44 prior to admission. Chem-7 was notable for a sodium of 136, potassium 3.3, chloride 102, bicarb 27, BUN 16, creatinine 0.9. His LFTs were normal. His lipase was 75, amylase 89. He had an abdominal CT performed that showed the pancreatic stent was situated in the uncinate process of the pancreas instead of the head and body; but otherwise was unremarkable. SUMMARY OF HOSPITAL COURSE: Patient was admitted to the Fenard ICU and given total of 4 units of packed red blood cells. His hematocrit increased appropriately to 26.5 after those transfusions. On the second day of admission, the patient was hemodynamically stable without any further evidence of upper GI bleed, and he was ready for transfer to the floor. In addition, he had an ERCP performed that showed no evidence of active bleed and they removed the pancreatic stent. The procedure went without any complications. While he was on the floor, the patient had no further evidence of melenic stools, and in-fact had light colored stools instead. His hematocrit was stable over the course of his admission, and he was discharged home. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home. DISCHARGE MEDICATIONS: 1. Iron 325 q.d. 2. Aciphex home dose. 3. Colace and Senna prn while taking iron. FOLLOW-UP PLANS: Patient will follow up with Dr. [Last Name (STitle) 50933], gastroenterologist in six months. He will see his primary care doctor for laboratory tests in the next 7-10 days. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5613], M.D. [MD Number(2) 5614] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2197-12-19] 17:40 T: [2197-12-20] 07:50 JOB#: [Job Number 50934]	[ "996.79", "E879.8", "276.8", "996.59", "577.0", "458.0", "285.1" ]	icd9cm	[ [ [] ] ]	[ "51.10", "97.56" ]	icd9pcs	[ [ [] ] ]							1588, 1678		3686, 3769				1304, 1416																						2890, 3605		1701, 2861					3787, 4240											179, 1019																	1041, 1278	1433, 1571	3630, 3663
30,469	133,322	32941	Discharge summary	report	Admission Date: [2156-1-14] Discharge Date: [2156-1-20] Date of Birth: [2092-5-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2736] Chief Complaint: Anterior STEMI Major Surgical or Invasive Procedure: Coronary catheterization [2156-1-16] History of Present Illness: 63 M with CAD s/p MI 2 years ago with RCA stent. Presented to [Hospital3 35813] Center in [State 792]on [2156-1-13] with acute respiratory distress and hypotension. An ECG showed sinus tach with RBBB and Qs in II, III, and aVF with STE v1-v5. CXR showed pulmonary edema. He was taken to the cath lab where he found to have 3vd with left main disease. An IABP was placed. He was seen by cardiac surgery emergently and admitted to the ICU. . Labs notable for peak CK 8591, with CK-MB of 436 and Trop I 359 (nl 0-0.03; >0.5 MI) on [2156-1-13] at 22:08. Also of note, WBC 24 and glucose 400, but without acidosis or an elevated anion gap. He was started on Zosyn and insulin gtt. Past Medical History: DM2 CAD, s/p MI 2 yr ago with RCA stent Social History: Lives with girlfriend of 25 years. Active smoker, [2-22] packs/week. No known EtOH. Family History: NC Physical Exam: VS: T 100.3, BP 69/49, HR 93, O2 100% on AC 450x14/0.5/5.0 Gen: Asian male, intubated & sedated. HEENT: NCAT. Sclera anicteric. PERRL. ETT in place. Neck: Supple. Left subclav sheath w/ Swann cathether. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Coarse ventilated breath sounds. Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: Bilat feet cool, but without edema. Right femoral sheath intact with IABP. bilat DP & PT pulses dopplerable. Pertinent Results: Cardiac Catheterization: 1. Initial angiography revealed a 70% proximal rca in-stent restenosis and a 90% focal rca stenosis. Right dominant circulation. The LM had a 50% tubular lesion. The ostial and proximal Lad had an 80% stenosis before tapering down to a small diffusely diseased vessel. The Lcx was a very small but free of significant disease. 2. Limited hemodynamics revealed a central aortic prssure of 100/60 with 1:1 iabp support and dopamine as the patient entered the lab in cardiogenic shock. 3. Successful PTCA and stenting of the proximal rca with a 3x18mm vision stent and of the mid rca with a 3x30mm driver stent which were post dilated to 3.0mm. Successful ptca and stenting of the proximal lad with a 2.25x18mm mini vision stent. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. . . Echocardiogram The left atrium is normal in size. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with anteroseptal/apical akinesis and inferoseptal hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . . Brief Hospital Course: This is a 63 year old gentleman who was transferred to the [Hospital1 18] after sustaining a large anterior STEMI. He underwent cardiac catheterization on [2156-1-15] during which three stents were successfully placed. His hospital course was complicated by cardiogenic shock requiring an intra-aortic balloon pump and a dopamine drip; and respiratory failure of unknown etiology for which the patient was intubated on transfer. He was successfully weaned off of the IABP and dopamine drip, and extubated on [2161-1-17]. Over the next 2 days he developed significant pulmonary edema requiring CPAP, lasix drip, and pressor support with dobutamine and milrinone. On [2155-1-20], he went into pulseless ventricular tachycardia for which a code blue was called. The patient was coded for 29 minutes without resuscitation, and was pronounced dead at 7:49 PM on [2156-1-20]. . . Active issues during his hospitalization were as follows: 1. CAD/Ischemia: Past medical history of known CAD with a prior MI s/p RCA stent. On this admission, he presented with a large anterior STEMI and two-vessel disease on cardiac catheterization where Mid RCA 90% lesion, proximal RCA in-stent [18]% re-stenosis, and 80% proximal LAD lesion were stented. The patient was treated with a high-dose statin, aspirin, plavix, and a heparin gtt. His heparin gtt was discontinued on [1-20] as he was guaiac positive and on multiple blood thinners. We were holding captopril and beta blocker for low BP . 2. Cardiogenic shock: His hospital course was complicated by cardiogenic shock, requiring IABP and dopamine gtt for pressure support. Echocardiogram on [1-15] showing EF 35% with anteroseptal and apical akinesis and inferoseptal hypokinesis. He was weaned off of pressors and IABP on [1-17], but developed new pulmonary edema requiring high flow mask with FiO2 of 1.00 on [2155-1-20]. We treated him with a lasix drip and CPAP, and attempted to improve forward flow with dobutamine and milrinone. Just prior to his death, we prepared to re-insert his PA catheter to further delineate his shock profile. . 3. Atrial fibrillation: The patient had atrial fibrillation with intermittent RVR, which initially responded well to an amiodarone load. He was transitioned to a po regimen of amiodarone 400mg po qday and monitored on telemetry. . 4. DM: Managed with insulin gtt . 5. Fever & leukocytosis: unclear source. Was being treated for presumed PNA at OSH, though CXR did not clearly show an infiltrate here, though difficult to visualize in setting of pulmonary edema. Aspiration PNA was also on the differential as the patient is not fully able to protect his airway and was s/p extubation. His UA was positive and urine cultures were pending. Blood and sputum cultures were negative. Line infection unlikely as he had fever and white count on presentation. His PA catheter was pulled and the tip cultured. His stool was sent for C. diff toxin. We continued with vancomycin and zosyn for broad coverage as his clinical status was tenuous. . 6. Respiratory failure: S/p extubation on [1-18], since then with a respiratory alkalosis and hypoxemia on ABG, which as responded to high flow oxygen mask initially, and then required CPAP. His CXR was c/w pulmonary edema. We attempted to treat this with CPAP, lasix gtt, and dobutamine/milrinone to improve forward flow. . 7. Thrombocytopenia: Improved with removal of IABP, likely caused by shearing effect. HIT work-up sent, but with low suspicion. Blood smear wnl. . Medications on Admission: Zosyn 3.375 Q6h Dopamine gtt Heparin gtt Insulin gtt Nitro gtt Propofol gtt Lasix gtt Levophed gtt Atrovent Q6h Albuterol A6h Colace 100 [Hospital1 ] Tylenol prn Discharge Medications: Patient deceased Discharge Disposition: Expired Discharge Diagnosis: Patient deceased Discharge Condition: Patient deceased Discharge Instructions: Patient deceased Followup Instructions: Patient deceased	[ "410.11", "250.00", "287.5", "427.41", "414.01", "507.0", "518.81", "996.72", "780.6", "427.1", "412", "E878.1", "785.51", "428.0", "427.31" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.41", "96.6", "36.06", "00.47", "97.44", "96.04", "00.66", "00.17", "96.72" ]	icd9pcs	[ [ [] ] ]	7327, 7336	3515, 7069	331, 373	7396, 7414	1883, 2636	7479, 7498	1280, 1284		7286, 7304		7357, 7375		7095, 7263		2653, 3492	7438, 7456									1299, 1864																					276, 293							401, 1094																	1116, 1158	1174, 1264
44,597	178,672	34440	Discharge summary	report	Admission Date: [2132-4-2] Discharge Date: [2132-4-9] Date of Birth: [2050-9-26] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 32612] Chief Complaint: Ampullary mass Major Surgical or Invasive Procedure: [2132-4-2]: 1. Diagnostic laparoscopy. 2. Exploratory laparotomy. 3. Lysis of adhesions. 4. Pylorus-preserving pancreaticoduodenectomy with harvest of pedicled omental flap for protection of pancreatic and duodenal anastomoses. 5. Placement of gold fiducials for possible postoperative CyberKnife therapy. History of Present Illness: Mr. [Known lastname 449] is a very nice 81-year-old gentleman with newly diagnosed ampullary adenocarcinoma. Mr. [Known lastname 449] presented approximately a year ago with right-sided abdominal pain. He was referred for endoscopy and found to have adenomatous polyps. Most of these were resected endoscopically. On [2132-3-6], he underwent a repeat upper endoscopy. This demonstrated recurrent adenomas. Biopsy this time showed poorly differentiated adenocarcinoma. He continues to have persistent abdominal pain and anorexia. He states he has lost 35 pounds over the last year. He did have a CT scan done today which demonstrated large mass lesion in the second portion of the duodenum. The patient was evaluated by Dr. [Last Name (STitle) ] in her [Hospital 79163] clinic and after discussion with the patient, he was scheduled for elective Whipple resection on [2132-4-2]. Past Medical History: TIA Afib BPH CHF . PSH CCY Social History: smokes 1 ppd, 60 PY hx, occa etoh, no drugs, worked as engineer w/ GE, lives w/ 44 yo son Family History: non contributory Physical Exam: On Discharge: VS: 98.1, 60, 110/56, 14, 98% RA GEN: Very thin man in no acute distress CV: Irregularly irregular rate and rhythm PULM: CTAB ABD: Midline abdominal incision opent to air and c/d/i, old RLQ JP site with occlusive dressing and c/d/i. EXTR: Warm, no c/c/e Pertinent Results: [2132-4-6] 07:38AM BLOOD WBC-8.9 RBC-3.54* Hgb-10.9* Hct-30.6* MCV-87 MCH-30.9 MCHC-35.7* RDW-14.0 Plt Ct-201 [2132-4-8] 01:00PM BLOOD PT-11.3 INR(PT)-1.0 [2132-4-6] 07:38AM BLOOD Glucose-87 UreaN-12 Creat-0.9 Na-140 K-3.6 Cl-104 HCO3-32 AnGap-8 [2132-4-6] 07:38AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.6 Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 79164],[Known firstname 1569] [2050-9-26] 81 Male [Numeric Identifier 79165] [Numeric Identifier 79166] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/mtd SPECIMEN SUBMITTED: WHIPPLE SPECIMEN. Procedure date Tissue received Report Date Diagnosed by [2132-4-2] [2132-4-2] [2132-4-7] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/mn???????????? Previous biopsies: [Numeric Identifier 79167] GI BX'S (2 JARS) [-1/3358] GI BX'S (2 JARS) DIAGNOSIS: Whipple resection, pylorus-sparing pancreaticoduodenectomy (A-AC): 1. Invasive adenocarcinoma of the periampullary duodenum, poorly differentiated, arising from an adenomatous precursor lesion with high grade dysplasia, with invasion into subserosal adipose tissue (pT3); lymphovascular and perineural invasion is present; see synoptic report. 2. Seven of thirteen lymph nodes with involvement by adenocarcinoma ([8-8]- pN2). 3. Extrahepatic bile duct segment and ampulla, within normal limits. 4. Pancreatic parenchyma with focal changes of low grade intraepithelial neoplasia (PanIn-1), focal dilation of pancreatic ducts, and squamatization of duct epithelium. Small Intestine: Segmental Resection, Pancreaticoduodenectomy (Whipple Resection) Synopsis AJCC/UICC TNM, 7th edition Protocol web posting date: [2129-10-27] MACROSCOPIC Specimen Type: Duodenum. Other organs Received: Head of pancreas, Ampulla, Common bile duct. Tumor Site: Duodenum. Tumor configuration: Infiltrative. Tumor Size: Greatest dimension: 4.2 cm. MICROSCOPIC Macroscopic Tumor Perforation: Not identified. Histologic Type: Adenocarcinoma (not otherwise characterized). Histologic Grade: G3: Poorly differentiated. EXTENT OF INVASION Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into the subserosa or into the nonperitonealized perimuscular tissue (mesentery or retroperitoneum) with extension 2 cm or less. Regional Lymph Nodes (pN): pN2: Metastasis in 4 or more regional lymph nodes. Lymph Nodes Number examined: 13. Number involved: 7. Distant metastasis: pMX: Cannot be assessed. MARGINS Segmental Resection or Pancreaticoduodenectomy (Whipple) Proximal Margin: Uninvolved by invasive carcinoma. Distal Margin: Uninvolved by invasive carcinoma. Circumferential (Radial) or Mesenteric Margin : Uninvolved by invasive carcinoma (tumor present 1 mm from margin; see Slide N). Pancreaticoduodenectomy (Whipple) Bile Duct Margin: Margin uninvolved by invasive carcinoma. Pancreatic Margin: Margin uninvolved by invasive carcinoma. Lymphovascular Invasion: Present Perineural Invasion: Present Additional Pathologic Findings: Adenoma(s). Comments: Adenomatous precursor of the duodenum is present in multiple sections, but is shown best on Slide K. No dysplastic precursor is found within the ampullary region itself, arguing against the tumor origin from this site. Clinical: Ampullary mass. [2132-4-9] 06:20AM BLOOD PT-13.9* INR(PT)-1.3* Brief Hospital Course: The patient with ampullary mass was admitted to the Surgical Oncology Service on [2132-4-2] for elective Whipple procedure. On [2132-4-2] , the patient underwent pylorus-preserving pancreaticoduodenectomy and placement of gold fiducials for possible postoperative CyberKnife therapy, which went well without complication (reader referred to the Operative Note for details). Inraoperatively patient was transfused with 2 units of RBC for low HCT, he was extubated post operatively and transferred in ICU for observation. The patient was hemodynamically stable. In ICU patient was hypotensive with low urine output, which was treated with fluid boluses. On POD # 2, patient was transferred on the floor in stable condition. The [Hospital 228] hospital course was uneventful and followed the Whipple Clinical Pathway without deviation. Post-operative pain was initially well controlled with epidural catheter and Dilaudid PCA, which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD#2, and the foley catheter discontinued at midnight of POD# 3. The patient subsequently voided without problem. The patient was started on sips of clears on POD# 3, which was progressively advanced as tolerated to a regular diet by POD# 5. JP amylase was sent in the evening of POD# 5; the JP was discontinued on POD#7 as the amylase level were low and output continue to decrease. Patient was started on home dose of Coumadin on POD # 6, and he was bridged with SC Lovenox prior discharge as his INR was subtherapeutic. Patient will continue on SC Lovenox and Coumadin until his INR reach therapeutic level, INR will be motinored by [Hospital ] Hospital [Hospital 197] Clinic as outpatient. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. At the time of discharge on [2132-4-9], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: coumadin (held since [2-/2049], on lovenox bridge prior to OR), alendronate 70' qweek, amiodarone 200', lisinopril 2.5', methimazole 7.5', metoprolol 12.5', simvastatin 20', Discharge Medications: 1. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day for 2 weeks. Disp:56 Tablet(s) Refills:0 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 4. methimazole 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:5 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please follow up with [Hospital 197] clinic on [2132-4-10] at 11:30 to check INR level. 11. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 12. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous [Hospital1 ] (2 times a day). Disp:10 injection Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Locally advanced ampullary adenocarcinoma 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 continue to follow up with [Hospital 197] clinic as outpatient to adjust you Coumadin doses. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [6-5] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical 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: Department: SURGICAL SPECIALTIES When: TUESDAY [2132-4-15] at 3:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 79168], MD [Telephone/Fax (1) 274] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Please follow up with Dr. [Name (NI) 70277] (PCP) in [2-29] weeks after discharge. . [Hospital 197] Clinic. Thursday [4-10] at 11:30 am. Completed by:[2132-4-9*]	[ "427.31", "458.29", "V58.61", "152.0", "600.00", "272.4", "196.2", "305.1", "276.2", "568.0", "242.90", "496", "585.9", "733.00", "403.90", "197.6", "197.8" ]	icd9cm	[ [ [] ] ]	[ "54.21", "54.59", "52.7" ]	icd9pcs	[ [ [] ] ]	9734, 9783	5715, 8272	317, 629	9869, 9869	2061, 5692	11230, 11741	1740, 1758		8501, 9711		9804, 9848		8298, 8478			10020, 10702							10717, 11207		1773, 1773															1787, 2042						263, 279							657, 1565												9884, 9996					1587, 1616	1632, 1724
10,653	179,565	29656	Discharge summary	report	Admission Date: [2116-3-8] Discharge Date: [2116-3-26] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Infected Pacemaker Major Surgical or Invasive Procedure: Screw-in pacer wire placement ([2116-3-12]) PICC line placement ([2116-3-13]) TEE Removal of pacemaker History of Present Illness: Patient is an 86 year old female patient with PMHx significant for mechanical aortic valve, CHB s/p PM that was complicated by large hematoma requiring evacuation who presents from OSH after found to have abscess at previous hematoma site. . Patient was recently discharged from [Hospital1 18] during which she was found to be in complete heart block. Patient had pacemaker placed however developed large chest hematoma in setting of being anticoagulated for mechanical valve. Patient required 9 units of PRBC and had hematoma evacuated. . She was discharged to nursing home on [2-13] and then was found to have infected PM with abscess at previous hematoma site. At NH her incision under her clavicle began to open and start draining while she was having temps of 104. At OSH, she had a WBC of [Numeric Identifier 71077] (69% PMNs, 17% Bands) pacemaker was removed by local surgeon and patient was started on vanc and gent (per an ID consult). She continues to spike temperatures and prelimanary wound and blood cultures at OSH are growing gram + cocci in clusters. Patient was also found to be tachycardic with HR ranging from 114-140s. She was transferred to [Hospital1 18] for further management. Past Medical History: CAD s/p 2-vessel CABG [2104] CHB s/p PM complicated by large hematoma and evacuation s/p [First Name8 (NamePattern2) ] [Initials (NamePattern4) 1525] [Last Name (NamePattern4) 1291] in [2104] for AS CHF HTN Diabetes Hypothyroidism Dementia, mild-moderate s/p appy s/p TAH Social History: Recently living in nursing home after previous discharge from [Hospital1 18] non-smoker non-drinker Family History: unable to obatin from patient due to dementia Physical Exam: T 99.2 BP 123/55 HR 77 RR 20 Sat 95% on 5L nc Gen: moaning, NAD HEENT: OP clear, no scleral icterus Neck: no carotid bruits, prominent a-waves , JVP 7cm Chest: 5cm x 3cm x 1.5cm incision on left upper chest extending into pectoral muscle tissue without any frank drainage or erythema; lungs with bibasilar rales CV: irregular, II/VI systolic murmur across precordium with mechanical S2 Abd: mildly distended, nontender, soft, normal bowel sounds, no HSM Extr: 2+ DP pulses, no edema, cool Neuro: alert, conversant, oriented to self only Pertinent Results: TTE ([2116-3-11]): There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. A mechanical aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. No masses or vegetations are seen on the aortic valve but cannot be excluded. Significant aortic regurgitation is present, but cannot be quantified. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is mild mitral stenosis (area 1.5-2.0cm2). 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 mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Labs: [2116-3-8] 01:51AM BLOOD WBC-28.0# RBC-3.53 Hgb-10.8* Hct-31.3* MCV-89 MCH-30.6 MCHC-34.5 RDW-17.0* Plt Ct-271 [2116-3-24] 03:41AM BLOOD WBC-11.2* RBC-3.26* Hgb-10.2* Hct-29.8* MCV-92 MCH-31.2 MCHC-34.1 RDW-16.5* Plt Ct-352 [2116-3-8] 01:51AM BLOOD Neuts-75* Bands-15* Lymphs-2* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2116-3-21] 01:11PM BLOOD Neuts-92.9* Bands-0 Lymphs-4.2* Monos-2.9 Eos-0.1 Baso-0 [2116-3-24] 03:41AM BLOOD Plt Ct-352 [2116-3-24] 03:41AM BLOOD PT-80.0* PTT-52.8* INR(PT)-10.5* [2116-3-8] 01:51AM BLOOD PT-22.2* PTT-39.7* INR(PT)-2.2* [2116-3-24] 09:00AM BLOOD FDP-10-40 [2116-3-24] 09:00AM BLOOD Fibrino-410* D-Dimer-[2125]* [2116-3-21] 01:11PM BLOOD Ret Aut-4.3* [2116-3-24] 03:41AM BLOOD Glucose-165* UreaN-24* Creat-2.1* Na-133 K-3.5 Cl-104 HCO3-17* AnGap-16 [2116-3-8] 01:51AM BLOOD Glucose-190* UreaN-22* Creat-0.8 Na-139 K-4.0 Cl-105 HCO3-23 AnGap-15 [2116-3-21] 01:11PM BLOOD LD(LDH)-336* CK(CPK)-126 [2116-3-23] 02:33AM BLOOD TSH-6.0* [2116-3-23] 02:33AM BLOOD T4-2.9* T3-53* [2116-3-23] 02:56AM BLOOD Type-ART Temp-37.7 pO2-76* pCO2-30* pH-7.39 calTCO2-19* Base XS--5 . [3-15] CT Head FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect, hydrocephalus, or shift of normally midline structures. There remain large areas of periventricular white matter hypodensity consistent with chronic small vessel infarction. A right thalamic lacune is again seen. There is a fluid level in the sphenoid sinus. The soft tissues are unchanged. IMPRESSION: No evidence of intracranial hemorrhage or mass effect. . [3-20] TTE Conclusions: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic prosthesis appears well seated, with normal leaflet/disc motion. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. No mass or vegetation is seen on the mitral valve. Mild to moderate ([1-21]+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2116-3-20] there is no significant change. . [3-23] CT Head FINDINGS: The study is significantly motion degraded at the lower and mid levels. Allowing for this deficiency, no acute intracranial hemorrhage is appreciated. There is diffuse cerebral periventricular white matter hypodensity consistent with chronic small vessel infarction. Chronic lacunar infarcts in the left basal ganglia and right thalamus are stable. No evidence to suggest acute major vascular territorial infarction is seen. Sphenoid sinus air- fluid level is noted. Carotid vascular calcification is seen. IMPRESSION: Motion limited study; allowing for this limitation, no acute intracranial hemorrhage seen. Sphenoid sinus air-fluid level (are there symptoms of sinusitis?). . [3-24] CT Head FINDINGS: As was the case yesterday, a number of the images are degraded by patient motion. Allowing for this deficiency, there is no definite interval change identified. Once again, there is a chronic lacunar infarct noted within the right thalamic region, as well as more generalized bilateral cerebral periventricular white matter hypodensity, consistent with chronic small vessel infarction. There is no sign for the presence of an intracranial hemorrhage. There is heavy atherosclerotic calcification of the distal vertebral arteries and cavernous carotid arteries. The surrounding osseous and soft tissue structures are remarkable for redemonstration of the sphenoid sinus air-fluid level. As was stated yesterday, the finding suggests possible acute sinusitis but requires clinical correlation, as sinus drainage could be impeded by the presence of a nasogastric tube. CONCLUSION: No intracranial hemorrhage. Brief Hospital Course: Assessment/Plan: 86 yo woman with abscess surrounding pacemaker site, s/p surgical pacemaker removal and in NSR, but had a 9 second period of asystole, treated with temporary external pacer and plan for permenant pacer once course of Abx completed. Her pacer infection seemed to be resolving but on [3-20] she had another TEE to eval for endocarditis. Her mental status never seemed to improve after that and her po intake was very poor. On [3-21], she had a hypotensive episode that required pressors and intubation. It appeared to have been from [Month (only) ] po and inability to mount a tachycardic response [2-21] heart block. She was quickly weaned off pressors and off the vent but her mental status never improved. CT scans did not show an acute intracranial event. Her daughter then made the decision to make her CMO, which was consistent with the patient's stated wishes. She passed away two days later. . Hospital course complicated by: . ## Wound abscess/bacteremia: Wound grew VRE and MRSA . ## Hematoma: recurred at pacer site, s/p 1uPRBC's with appropriate hct increase, but no further bleeding. - U/S of area just showed a small cystic structure which we did not aspirated . ## Delerium: Continues with waxing and [Doctor Last Name 688] mental status. Likely related to infection, pacer, hematoma, hospitalization, underlying dementia. Head CT without bleed [3-15], [3-23], [3-24]. Became acutely hypotensive on [3-21] requiring intubation and has not recovered mental status after that. Unclear etiology but likely multifactorial and from episodes of hypotension. . ## Valves: s/p St. [Male First Name (un) 1525] aortic valve placement in [2104]; also has moderate MS (valve area 1.0-1.5cm^2), [1-21]+ MR, 2+ TR on recent TTE - TTE and TEE were negative for vegetations - INR intermittently high and then low so was on heparin gtt off and on with fluctuating doses of coumadin . ## Rhythm: history of recent CHB - due to episode of 9 second asystole, EP screwed in pacer wires on [3-12] with external device. - telemetry - resumed beta blockade now that pacer is in place . ## Coronaries: s/p 2-v CABG at OSH in [2104] (anatomy unknown) - cont aspirin, statin; continue beta-blockade . ## Pump: diastolic CHF with LVEF of 70-75% on [1-/2116] TTE; - cont home dose of PO Lasix . ## HTN - resumed beta blockade now that pacer wires in place - on Lisinopril 80 - hydral added on [3-19] . ## Hyperlipidemia - atorvastatin per outpatient dose . ## Dementia - held psychotropics given altered mental status . ## Hypothyroidism - cont thyroid replacement . ## DM2 - hold sulfonylurea; cover with RISS . ## COPD - cont Spiriva; prn ipratropium nebs . ## FEN: now with NGT [2-21] po getting tube feeds - cardiac/purreed diet, encourage pos - trend lytes; replete prn . ## Prophylaxis - bowel regimen; on heparin gtt . ## Code: DNR/DNI /CMO. - appreciate palliative care consult . ## Access: L PICC placed by IR . Medications on Admission: Meds on transfer: Vancomycin 1gm [Hospital1 ] Gentamycin 100mg qd synthroid 0.1mg daily Protonix 40mg IV qam . Outpt meds: glyburide, metoprolol, lipitor, coumadin, lexapro, diovan, risperdal, lasix, amlodopine Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Cardiopulmary arrest 2. Sepsis 3. Infected hematoma 4. Pacemaker removal Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: None	[ "496", "426.0", "995.92", "041.04", "V09.80", "401.9", "682.2", "427.5", "V45.81", "998.59", "369.4", "348.39", "518.81", "428.30", "584.9", "V43.3", "564.00", "244.9", "998.12", "250.00", "038.11", "276.52" ]	icd9cm	[ [ [] ] ]	[ "38.93", "37.78", "96.6", "00.17", "96.71", "96.04", "88.72", "99.04" ]	icd9pcs	[ [ [] ] ]	11173, 11182	7884, 10880	279, 392	11302, 11312	2721, 7861	11364, 11372	2097, 2144		11145, 11150		11203, 11281		10906, 10906			11336, 11341									2159, 2702																					221, 241							420, 1645																	1667, 1960	1976, 2081		10924, 11122
67,348	176,811	48047	Discharge summary	report	Admission Date: [2182-6-24] Discharge Date: [2182-7-2] Date of Birth: [2103-1-20] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Cephalosporins / ciprofloxacin Attending:[First Name3 (LF) 1505] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Aortic valve replacement 25-mm Biocor apical tissue heart valve History of Present Illness: 79 year old male with moderate to severe aortic regurgitation with associated fatigue, dyspnea and neck pain was admitted preoperatively for an Aortic Valve Replacement on [2182-5-9]. He was placed on heparin drip for Coumadin washout for paroxysmal Atrial Fibrillation. Initial labs were drawn and revealed neutropenia and an elevated creatnine from baseline. Based on Mr.[Known lastname 101329] history of renal transplant, the Renal Transplant Service was consulted. His medications were reviewed and recommendations were made. His Cyclosporine and prednisone were continued. Azathioprine and Colchicine were discontinued per renal. Labs were monitored. His Creatnine drifted down to 1.5 and WBC ct=1.5 on [5-14]. The decision was made to rescreen Mr.[Known lastname 57554] for rehab with postponement of his AVR until his lab values trend towards normalizing. He returns to [Hospital1 18] today for heparin bridge preop AVR/? Asc.Ao.Replacement with normalizing lab values. Past Medical History: 1. Moderate-to-severe aortic insufficiency with dilating LV, currently be evaluated for valve replacement by cardiac surgery. 2. Recent cardiac catheterization showing no obstructive coronary artery disease, however, found to have elevated filling pressures, requiring diuresis. 3. Hypertension. 4. Kidney transplant in [2155] due to PCKD, the baseline creatinine approximately 1.6. 5. Hyperlipidemia. 6. Peripheral neuropathy. 7. Diverticulitis. 8. Pseudogout. 9. Osteoporosis. 10. Atrial fibrillation, currently on Coumadin for thromboembolic prophylaxis. Social History: Patient previously worked as an engineer for channel 5. He currently lives in a house himself. His wife passed away 9 years ago. Prior history of 3 ppd X 20 years, quitting 34 years ago. Occasional ETOH (few beers per week). No illicits. His daughters ([Name2 (NI) ] (daughter) - ([Telephone/Fax (1) 101330], [Female First Name (un) ] (daughter) [0-0-]) are very involved. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam 97.6 131/60 64AFib 18 100%RA General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM []Limitied ROM Chest: Lungs clear bilaterally []crackles right base, o/w clear Heart: RRR [x] Irregular [] Murmur [x] grade _2/6 syst__ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds [x] Extremities: Warm [x], well-perfused [x] Edema []+2 lower ext edema _____ Varicosities: None [x] Neuro: Grossly intact [x] Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 1569] [Hospital1 18] [Numeric Identifier 101331] (Complete) Done [2182-6-27] at 12:31:50 PM FINAL GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions PRE-CPB: Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. The left ventricular systolic function is globally mildly depressed, estimated EF=45%. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with focal calcifications. Trivial mitral regurgitation is seen. There is a small pericardial effusion. There is a small left pleural effusion. Dr.[Last Name (STitle) ] was notified in person of the results at time of study. POST-CPB: The patient is on no vasopressors. A bioprosthetic valve is seen in the aortic position. The valve is well seated with normally mobile leaflets. There are no apparent paravalvular leaks. There is no AI. The peak gradient across the aortic valve is 13mmHg, the mean gradient is 6mmHg with CO of 3.8L/min. The inferior and inferoseptal segments of the left ventricle appears hypoknetic. This improves with time but is still more notable than pre-bypass. Overal left ventricular systolic function remains mildly depressed, estimated EF 40-45%. The RV systolic function remains normal. The MR remains trace. Other valvular function is unchanged. The small left pleural effusion remains. There is no evidence of aortic dissection. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Name8 (MD) 17792], MD, Interpreting physician [Last Name (NamePattern4) ] [2182-6-27] 15:58 ?????? [2172] CareGroup IS. All rights reserved. [2182-7-2] 04:41AM BLOOD WBC-5.4 RBC-3.25* Hgb-9.9* Hct-30.5* MCV-94 MCH-30.5 MCHC-32.5 RDW-18.1* Plt Ct-87* [2182-7-1] 06:27AM BLOOD WBC-5.8 RBC-3.09* Hgb-9.8* Hct-29.1* MCV-94 MCH-31.6 MCHC-33.6 RDW-18.6* Plt Ct-64* [2182-6-30] 02:32AM BLOOD WBC-10.9 RBC-2.90* Hgb-9.2* Hct-27.4* MCV-95 MCH-31.6 MCHC-33.4 RDW-17.7* Plt Ct-75* [2182-7-2] 04:41AM BLOOD PT-18.8* INR(PT)-1.8* [2182-7-1] 06:27AM BLOOD PT-16.3* PTT-26.9 INR(PT)-1.5* [2182-6-30] 02:32AM BLOOD PT-14.6* PTT-26.2 INR(PT)-1.4* [2182-6-29] 01:57AM BLOOD PT-15.9* INR(PT)-1.5* [2182-6-28] 04:09AM BLOOD PT-13.4* PTT-25.5 INR(PT)-1.2* [2182-6-28] 12:10AM BLOOD PT-13.0* PTT-26.3 INR(PT)-1.2* [2182-6-27] 09:58PM BLOOD PT-13.4* PTT-26.6 INR(PT)-1.2* [2182-6-27] 06:00PM BLOOD PT-14.4* PTT-27.5 INR(PT)-1.3* [2182-6-27] 02:48PM BLOOD PT-16.5* PTT-31.9 INR(PT)-1.6* [2182-6-27] 01:17PM BLOOD PT-19.1* PTT-30.3 INR(PT)-1.8* [2182-6-27] 11:30AM BLOOD PT-14.9* PTT-45.6* INR(PT)-1.4* [2182-6-27] 04:35AM BLOOD PT-15.6* PTT-25.6 INR(PT)-1.5* [2182-7-2] 04:41AM BLOOD Glucose-87 UreaN-63* Creat-1.4* Na-137 K-3.5 Cl-97 HCO3-34* AnGap-10 [2182-7-1] 06:27AM BLOOD Glucose-141* UreaN-71* Creat-1.6* Na-136 K-3.5 Cl-96 HCO3-32 AnGap-12 [2182-6-30] 02:32AM BLOOD Glucose-113* UreaN-66* Creat-1.9* Na-134 K-3.8 Cl-94* HCO3-30 AnGap-14 Brief Hospital Course: Pre-op MSSA screen was positive and the patient was treated with Mupirocin. Additionally, on admission his INR was supratherapeutic. He was given Vitamin K and FFP. INR would trend down and on [2182-6-27] Mr.[Name14 (STitle) 101332] was taken to the operating room where he underwent Aortic valve replacement 25-mm Biocor apical tissue heart valve with Dr.[Last Name (STitle) ]. Please see operative report for surgical details. He tolerated the procedure well and was transferred to CVICU intubated and sedated for invasive monitoring. He awoke neurologically intact and extubated. He weaned off pressor support and Beta-blocker/Statin/diuresis was initiated. Renal continued to follow the patient. Coumadin was resumed for chronic AFib. 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 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Bay Point in [Hospital1 1474] in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Alendronate Sodium 70 mg PO QSUN 2. Benzonatate 100 mg PO TID:PRN cough 3. CycloSPORINE (Sandimmune) 100 mg PO DAILY 4. Diltiazem Extended-Release 120 mg PO DAILY 5. Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Lovastatin NF 20 mg Oral daily 8. Metoprolol Tartrate 75 mg PO TID 9. Furosemide 40 mg PO BID 10. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH [Hospital1 ] 11. PredniSONE 5 mg PO DAILY 12. Warfarin 2.5-3.75 mg PO DAILY 13. Aspirin EC 81 mg PO DAILY 14. Guaifenesin [4-25] mL PO Q6H:PRN cough 15. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Alendronate Sodium 70 mg PO QSUN 2. Aspirin EC 81 mg PO DAILY 3. Benzonatate 100 mg PO TID:PRN cough 4. CycloSPORINE (Sandimmune) 100 mg PO DAILY 5. Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] 6. Furosemide 40 mg PO BID 7. Metoprolol Tartrate 75 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. 8. PredniSONE 5 mg PO DAILY 9. Warfarin MD to order daily dose PO DAILY goal INR [1-18] for AFib 10. Acetaminophen 650 mg PO Q4H:PRN pain 11. Lovastatin NF 20 mg ORAL DAILY 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 13. Potassium Chloride 20 mEq PO DAILY Hold for K+ > 4.5 14. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH [Hospital1 ] 15. Guaifenesin [4-25] mL PO Q6H:PRN cough 16. Multivitamins 1 TAB PO DAILY 17. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital 27838] Rehabilitation & [Hospital ] Care Center - [Hospital1 1474] Discharge Diagnosis: Severe Aortic Insufficiency s/p Aortic valve replacement Secondary: 2. Paroxysmal atrial fibrillation. 3. Hypertension. 4. Kidney transplant in [2155] secondary to Polycystic Kidney Disease. 5. CRI with baseline creatinine of 1.2-1.4 6. Hyperlipidemia. 7. Peripheral neuropathy. 8. Diverticulitis. 9. History of pseudogout. 10. Osteopenia 11. Recent admission for dehydration and rabdomylysis 12. Recent UTI developed peripheral neuropathy from Cipro and switched to linezolid Past Surgical History: PCKD s/p renal transplant in [2155] (on immunosuppression) bilateral cataracts Inguinal hernia repair Right AV fistula in 80 which has been tied off Bronchitis Lactose intolerance BPH Bilateral rotator cuffs not repaired Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 2+ 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: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2182-7-31] 2:20 Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2182-8-28] 2:00 The Cardiac Surgery Office will call you with the following: Surgeon: Dr.[Last Name (STitle) ] # [Telephone/Fax (1) 170] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] D. [Telephone/Fax (1) 3329] in [12-17] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation Goal INR:[1-18] First draw:[2182-7-3] Needs Coumadin follow up arranged prior to DC from Rehab Completed by:[2182-7-2*]	[ "733.00", "790.92", "E878.1", "E930.8", "276.69", "255.41", "733.90", "E934.2", "272.4", "V42.0", "416.8", "V58.61", "287.5", "584.9", "585.3", "357.6", "403.90", "753.12", "600.00", "424.1", "427.31" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	10104, 10219	7166, 8430	331, 397	11000, 11228	3075, 7143	12068, 13028	2443, 2558		9191, 10081		10240, 10729		8456, 9168			11252, 12045								10752, 10979	2573, 3055																					271, 293							425, 1425																	1447, 2020	2036, 2427
17,415	154,681	44224	Discharge summary	report	Admission Date: [2114-2-24] Discharge Date: [2114-3-14] Date of Birth: [2040-11-11] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[First Name3 (LF) 2724] Chief Complaint: right leg weakness Major Surgical or Invasive Procedure: T4 vertebrectomy and instrumented fusion T1-T6 History of Present Illness: 73 yo female with ho of non-small cell CA dx [2111] with metastatic lesion to bilateral fermur and pelvid s/p radiation and chemotherapy who presents with back pain. Patient reports that she has had 3 weeks of back pain that has been gradually worse. She reports no weakness, sensory loss, paresthesias or loss of bowel or bladder function. She went to her Oncologist's office who recommended a MRI of the back. MRI showed mass at T4 resulting in vertebral body destruction and some compression of the spinal cord. She was admitted to [Hospital 1474] Hospital for pain control and patient is not a radiation candidate given prior history of radiation therapy to right lung field. She was transfered to the [Hospital1 18] Neurosurgery service for further evalaution and treatment. Past Medical History: PMHx: -Non-small cell CA (dx [7-1]) -Pathologic fracture of left hip s/p intramedullary rodding and fixing of left hip [8-31] -HTN -s/p pituatary resection -hiatal hernia Social History: Social Hx: Smoking history stopped in [2111]. Denies ETOH or drug use Family History: noncontributory Physical Exam: PHYSICAL EXAM: ON ADMISSION.. O: T: 97 BP: 138/74 HR:91 R 18 O2Sats 94% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4mm to 3mm Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Names [3-31], repeats, memory [11-29] in 5 min, repeats, reads Motor: D B T FE FF IP Q H AT [Last Name (un) 938] G R 5 5 5 5 5 4 5- 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 2 beats of clonus on right Propioception intact Left toe up/right down Rectal exam normal sphincter control nml Pertinent Results: CT/MRI:from OSH -vertebral body destruction at T4 with impingement onto spinal canal, sparing cord T-SPINE [2114-3-12] 2:55 PM IMPRESSION: Interval corpectomy and posterior thoracic spinal fusion. CHEST (PORTABLE AP) [2114-3-10] 10:24 AM IMPRESSION: Limited study. No focal consolidation is identified. The costophrenic sulci are indistinct, which may be due to small pleural effusions. CT HEAD W/ & W/O CONTRAST [2114-2-26] 5:17 PM 73 year old woman with metastatic NSSLC REASON FOR THIS EXAMINATION: assess for metastasis CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Assessment for metastasis in a 73-year-old woman with metastatic non-small-cell lung cancer. COMPARISON: No comparison is available. TECHNIQUE: Non-contrast and contrast head CT. CT OF HEAD WITHOUT AND WITH CONTRAST: No intracranial mass lesion, hydrocephalus, shift of normal midline structure, major or minor vascular territorial infarct is apparent. The density value of the brain parenchyma are within normal limits. The surrounding osseous and soft tissue structures are unremarkable. Impression: No acute intracranial pathology including no signs of metastasis. CT CHEST W/CONTRAST [2114-2-25] 4:48 PM IMPRESSION: 1. Predominantly sclerotic lesion involving the entire T4 vertebral body with destructive components compatible with osseous metastatic disease. There is also an enhancing soft tissue component within the epidural space compressing the cord in this region. Further evaluation with MRI of the thoracic spine is recommended. Please refer to CT T-spine for further details. 2. Enhancing nodular thickening of the pleura bilaterally, worse on the right is identified. Metastatic involvement cannot be excluded. 3. Sclerotic focus within the left iliac bone adjacent to the sacroiliac joint. Please correlate with prior studies or bone scan. 4. Multiple hypodense lesions within bilateral kidneys and segment IV-B of the liver, too small to characterize. 5. Coronary artery and aortic valve calcifications. 6. Small axial hiatal hernia. Cardiology Report ECG Study Date of [2114-2-25] 8:24:06 AM Sinus rhythm Modest ST-T wave changes - are nonspecific and may be within normal limits No previous tracing available for comparison Test Name Value Units Reference Range [2114-3-11] 05:50AM COMPLETE BLOOD COUNT White Blood Cells 23.3* K/uL 4.0 - 11.0 PERFORMED AT WEST STAT LAB Red Blood Cells 3.11* m/uL 4.2 - 5.4 PERFORMED AT WEST STAT LAB Hemoglobin 8.8* g/dL 12.0 - 16.0 PERFORMED AT WEST STAT LAB Hematocrit 26.6* % 36 - 48 PERFORMED AT WEST STAT LAB MCV 85 fL 82 - 98 PERFORMED AT WEST STAT LAB MCH 28.2 pg 27 - 32 PERFORMED AT WEST STAT LAB MCHC 33.1 % 31 - 35 PERFORMED AT WEST STAT LAB RDW 20.8* % 10.5 - 15.5 BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 126* K/uL 150 - 440 PERFORMED AT WEST STAT LAB Test Name Value Units Reference Range [2114-3-11] 05:50AM RENAL & GLUCOSE Glucose 105 mg/dL 70 - 105 PERFORMED AT WEST STAT LAB Urea Nitrogen 27* mg/dL 6 - 20 PERFORMED AT WEST STAT LAB Creatinine 1.2* mg/dL 0.4 - 1.1 PERFORMED AT WEST STAT LAB Sodium 143 mEq/L 133 - 145 PERFORMED AT WEST STAT LAB Potassium 4.0 mEq/L 3.3 - 5.1 PERFORMED AT WEST STAT LAB Chloride 109* mEq/L 96 - 108 PERFORMED AT WEST STAT LAB Bicarbonate 23 mEq/L 22 - 32 PERFORMED AT WEST STAT LAB Anion Gap 15 mEq/L 8 - 20 CHEMISTRY Calcium, Total 8.4 mg/dL 8.4 - 10.2 PERFORMED AT WEST STAT LAB Phosphate 3.0 mg/dL 2.7 - 4.5 PERFORMED AT WEST STAT LAB Magnesium 2.2 mg/dL 1.6 - 2.6 PERFORMED AT WEST STAT LAB Brief Hospital Course: This 73 year old white female was transferred from [Hospital 1474] hospital after MRI revealed at metestatic lesion at T4. The pt was transferred for neurosurgical eval. She was seen and evaluated by PT and deemed not safe to discharge home - A TLSO brace was ordered and fitted. The pt has been non compliant with wearing the brace after multiple education sessions. She went to OR [2114-3-7] where under general anesthesia a T 4 Costovertebrectomy and instrumented fusion T1-T6 was performed. Pt tolerated this procedure well and was transferred to TICU where she remained intubated overnight. She was extubated without difficulty on the first post op morning and transferred to the floor. Peri-operative course was complicated by delirium. She was seen and evaluated by geriatrics and placed on PRN Haldol after a 24-48 hour course of ATC haldol- her mental status improved and became A0x3. She has not needed Haldol PRN, therefore Haldol is discontinued upon discharge. Her voice is soft and this is thought to be due to screaming during the episode. She is tolerating PO intake and her 1:1 sitter has been d/c'd. PT/Ot have evaluated her and recommend course of rehab. Her incision is clean and dry and staples are to come out on [2114-3-17]. Postop xrays show good alignment and hardware positioning.. Medications on Admission: Medications prior to admission: Lexapro 10 mg po qday decadron 4 mg po q4 hours Percocet prn Ciprofloxacin (started for UTI at OSH) MOM 30 cc po prn prilosec 20 mg po qday lovenox 40 mg sc qday albuterol/atrovent prn MVI Caltrate 600 mg po qday Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for upset stomach, constipation. 2. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for abdominal distension. 3. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QAM (once a day (in the morning)). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day). 10. Oxycodone 5 mg Tablet Sig: 0.5 - 1.0 Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: metastatic lung cancer to thoracic spine post-op anemia delirium Discharge Condition: neurologically stable Discharge Instructions: ?????? Do not smoke ?????? Keep wound(s) clean and dry / No tub baths or pools for two weeks from your date of surgery ?????? If you have steri-strips in place ?????? keep dry x 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have your incision checked daily for signs of infection ?????? You may shower briefly without the collar / back brace unless instructed otherwise ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: YOUR STAPLES NEED TO BE REMOVED ON [2114-3-17] PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) 548] TO BE SEEN IN 6 WEEKS with xrays. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT Completed by:[2114-3-14]	[ "553.3", "293.9", "336.3", "162.9", "401.9", "198.5", "285.1" ]	icd9cm	[ [ [] ] ]	[ "81.05", "99.04", "77.91", "81.63", "77.79" ]	icd9pcs	[ [ [] ] ]	8628, 8671	6053, 7382	296, 345	8780, 8804	2454, 2948	10189, 10452	1477, 1494		7677, 8605		8692, 8759		7408, 7408			8828, 10166									1524, 1758											7440, 7654										238, 258	2977, 6030						373, 1166												1773, 2435					1188, 1369	1385, 1461
82,512	169,761	4306	Discharge summary	report	Admission Date: [2114-12-17] Discharge Date: [2114-12-28] Date of Birth: [2044-1-28] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[First Name3 (LF) 165] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Aortic valve replacement (27mm) [2114-12-19] History of Present Illness: 70 year old male with severe aortic stenosis presents with increased dyspnea on exertion x 1 week. He does report one episode of chest pain which lasted "just a second". Has baseline leg swelling but unchanged from prior. He called his cardiologist who increased his lasix to 80mg (40mg [Hospital1 ]). Patient initialy reported to [Hospital 7188] hospital. He was then transferred to [Hospital1 18] given cardiologist Dr. [Last Name (STitle) ] is here. He is now being referred to cardiac surgery for evaluation of an aortic valve replacement. Past Medical History: s/p BiV pacemaker placement in [Month (only) ] severe AS (last valve area 0.9 [2-27]) D/M s/p bilateral forefoot amps 15yrs s/p renal transplant (on immunosuppresants) Coronary artery disease status post LAD and D1 stent in [2093]. Mixed cardiomyopathy with severe global hypokinesis and ejection fraction of 25%. Mild-to-moderate aortic stenosis. Paroxysmal atrial fibrillation not anticoagulated. Hypertension. Hypercholesterolemia Moderate PA Hypertension Type 1 diabetes. Status post renal transplant, on chronic immunosuppression Peripheral vascular disease with bilateral transmetatarsal amputation. History of DVT. DM1 peripheral neuropathy Social History: The patient is divorced with a healthy 40-year-old son. [Name (NI) ] is currently living alone, reports having a good social support network. Denies smoking and endorses drinking one glass of wine per week. Denies a history of abuse. Family History: Mother died from breast cancer at age 47. Father with DM at age 70. Physical Exam: Pulse:80 Resp:18 O2 sat:95/RA B/P 117/74 Height:76" Weight:100.9 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [], crackles at the bases Heart: RRR [x] Irregular [] Murmur [x] grade IV/VI, systolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x], well healed right lower quadrant incision Extremities: Warm [x], well-perfused [] Edema [x] 1+ edema bilaterally Varicosities: None [] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: dop Left: dop PT [Name (NI) 167]: dop Left: dop Radial Right: 2+ Left: 2+ Carotid Bruit Right: none Left: none Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 18646]Portable TTE (Focused views) Done [2114-12-23] at 9:56:00 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2044-1-28] Age (years): 70 M Hgt (in): 76 BP (mm Hg): 93/45 Wgt (lb): 224 HR (bpm): 94 BSA (m2): 2.33 m2 Indication: Congestive heart failure. H/O cardiac surgery. Left ventricular function. Right ventricular function. Valvular heart disease. ICD-9 Codes: 428.0, V43.3, 424.1, 424.0 Test Information Date/Time: [2114-12-23] at 09:56 Interpret MD: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD Test Type: Portable TTE (Focused views) Son[Name (NI) 930]: Cardiology Fellow Doppler: Limited Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Suboptimal Tape #: 2012W000-0:00 Machine: Vivid [5-25] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.4 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 6.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 25% >= 55% Right Ventricle - Diastolic Diameter: 4.6 cm <= 2.1 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm TR Gradient (+ RA = PASP): 34 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Moderate-severe global left ventricular hypokinesis. RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall hypokinesis. Abnormal septal motion/position. AORTIC VALVE: Aortic valve not well seen. Bioprosthetic aortic valve prosthesis (AVR). No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Tricuspid valve not well visualized. TR present - cannot be quantified. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The rhythm appears to be atrial fibrillation. The rhythm appears to be A-V paced. The patient has runs of a supraventricular tachycardia. Emergency study performed by the cardiology fellow the patient. Left pleural effusion. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated with moderate to severe global left ventricular hypokinesis (LVEF = 25%). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position. A well-seated bioprosthetic aortic valve prosthesis is present. The gradients could not be assessed. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate mitral annular calcification (vs. annuloplasty ring). Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Tricuspid regurgitation is present but cannot be quantified. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Well seated aortic valve bioprosthesis without aortic regurgitation.. Biventricular cavity enlargement with biventricular hypokinesis c/w diffuse process. Compared with the prior study (images reviewed) of [2114-12-22], biventricular systolic function is slightly improved and the estimated PA systolic pressure is higher. [2114-12-28] 04:32AM BLOOD WBC-22.0* RBC-3.26* Hgb-9.1* Hct-27.9* MCV-86 MCH-27.8 MCHC-32.4 RDW-16.2* Plt Ct-27* [2114-12-28] 04:32AM BLOOD PT-46.9* PTT-49.4* INR(PT)-4.6* [2114-12-28] 04:32AM BLOOD Glucose-145* UreaN-86* Creat-3.2* Na-129* K-5.6* Cl-93* HCO3-19* AnGap-23* Brief Hospital Course: On [12-17] Mr. [Known lastname 1683] was admitted for pre-hydration for a planned cardiac catheterization prior to a planned mitral valve replacement. He underwent a pre-operative work-up. His cardiac catheterization revealed no significant coronary disease. On [2114-12-19] he underwent an aortic valve replacement with a St. [Male First Name (un) 923] tissue valve. This procedure was performed by Dr. [Last Name (STitle) ]. Please see the operative note for details. He tolerated this procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He extubated sucessfully. On post-operative day three he experienced rapid atrial fibrillation with hemodynamic instability. He was cardioverted unsuccessfully multiple times. He also experienced ventricular tachycardia and was defibrillated sucessfully. Multiple pressors were required and an intra-aortic balloon pump was placed to support hemodynamics. He developed multi-system organ failure. The attending surgeon, Dr. [Last Name (STitle) ], spoke with the patient's brother and proxy regarding his poor prognosis. After deliberation amongst the family, it was decided to withdraw care. He was made comfort measures only and expired in the presence of his family at 1809 and was pronounced by Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 18647]. The family declined a post-mortem examination. Medications on Admission: Cyclosporine 50mg [Hospital1 ] Flonase 50mcg,2 puff daily lasix 40mg daily, recently increased to 40 [Hospital1 ] gabapentin 800 1 qAM, 1 a4pm. 3 tabs qhs. lantus ISS Metolazone 2.5mg three times a week metop succ 50 midodrine 15mg [Hospital1 ] cellcept 500mg [Hospital1 ] Oxycodone-acetaminophen 5-325, 1-2 tabs q 6hr prns pravastatin 40mg prednisone 5mg quinine 324mg testosterone 75mg asa 81 calcitriol 0.25mcg glucoten Multivitamin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: severe aortic stenosis Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2114-12-28]	[ "428.0", "401.9", "486", "707.14", "785.51", "583.81", "285.1", "E878.0", "416.8", "414.01", "996.81", "276.2", "425.4", "443.9", "V12.51", "327.23", "272.0", "276.7", "995.92", "427.5", "V70.7", "V49.73", "427.31", "V45.82", "511.9", "V45.01", "276.1", "518.81", "427.1", "250.41", "287.5", "038.9", "427.41", "428.22", "424.1", "584.5" ]	icd9cm	[ [ [] ] ]	[ "39.95", "37.23", "39.61", "89.64", "35.21", "34.91", "99.60", "88.56", "99.62", "96.71", "38.95", "37.61", "96.6" ]	icd9pcs	[ [ [] ] ]	9148, 9157	7172, 8617	283, 334	9224, 9234	2721, 7149	9287, 9415	1880, 1951		9119, 9125		9178, 9203		8643, 9096			9258, 9264									1966, 2702																					236, 245							362, 925																	947, 1608	1624, 1864
14,342	199,394	23961	Discharge summary	report	Admission Date: [2183-5-12] Discharge Date: [2183-6-11] Date of Birth: [2108-6-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: NSTEMI, Hypercarbic respiratory distress, Hemoptysis, 3VD Major Surgical or Invasive Procedure: Diagnostic cardiac catheterization and PEA arrest Intra aortic balloon pump Central venous catheter placement Arterial line placement Peripheral intravenous central catheter placement Endotracheal intubation and ventilation Operative tracheostomy Percutaneous gastrostomy Bronchoscopy and lavage Esophagogastroduodenoscopy Push enteroscopy Colonoscopy Nuclear medicine bleeding scan Angiographic embolization of colonic arteriovenous malformation History of Present Illness: 74M with history of HTN, sarcoid and emphysema who presented to OSH with chest pain and "indigestion." Course at OSH notable for NSTEMI and transferred to [Hospital1 18] for cardiac evaluation. Onset of CP started on Saturday [5-10]. Reports two months of "indigestion" which responded to TUMS. This time, he ate out at Friendly's but not relieved by TUMS. Constant mild ache in the left chest without radiation. At its worst, associated SOB, nausea and dry heaves. History of chronic non-productive cough which was increased on admission. Went to covering PCP who recommended increased steroids, antitiotics. Attempted to take the medications. However, 4PM on Sunday [5-11], he developed dry heaves so went to an [Hospital3 934] Hospital ED. Labs noted for positive cardiac enzymes. Transferred to [Hospital1 18] for cardiac cath. Started on heparin, integrilin. On the day of transfer to [Hospital1 18], the patient was noted to be tachypneic; VS: BP 147/87, P=114, RR=28, with 02 sat of 78-88%. ABG: 7.26/88/70 on 100%. Of note, patient at ABG at OSH which was 7.34/64/176. He also had coughed up bloody sputum (300 cc). He was transferred to the CCU for urgent intubation prior to cath. For intubation, received etomidate, sucs, and started on propofol for sedation. Noted to have decreased SBP to 40-50s. Improvement of pressures with levophed, fluids, and off propofol. In cath, noted to have 50% distal LMCA (mod calcified), mild total occlusion LAD, heavily calcified D1 total occ, LCX (mild av [Doctor Last Name ] 60-70%, distal AV groove occlusion, major OM2 mid 90%, OM1/ramus 80%), RCA severely calcified, diffuse plaquing. PCWP 15, PA (54/28 mean 39). Pt dropped SBP to 40 with minimal pulse pressure A and PA tracings. CPR and epinephrine initiated and pressures returned with support of dopamine and norepinephrine. Pt noted to have blood in ETT and pt auto-PEEPed, having to be removed from vent transiently. IABP placed at 1:3. Transferred to CCU. Had bronchoscopy performed which showed no endobronchial lesions, bronchomalasia, and some bilateral hemoptysis L>R. Past Medical History: COPD- >er 10 yrs. Baseline FEV1 590 cc at best. VC-1.36 L. Saroid, involving lungs-per Dr. [Last Name (un) 61037] issue O2 at home-1.5L constantly h/o pneumothorax HTN Depression Social History: Married with two children. Tobacco: 2 ppd x 25 years, quit 35 years ago. No EtOH. Family History: Non-contributory Physical Exam: VS: 98.7 80 136/51 100% TM Gen: sitting in chair, no acute distress on trach collar HEENT: PERRL, EOMI, OM moist CV: S1, S2, RRR, no MRG Lung: bibasilar rales, otherwise clear w/ occ. rhonchi Abd: +BS, soft, nt, nd. Ext: Cool, DP 2+ b/l. Groin without bruits. Neuro: A+OX3, moving all four extremities, strength and sensation grossly intact. Pertinent Results: Cardiac catheterization [2183-5-12]- 1. Coronary angiography of this right dominant system revealed severe three vessel coronary artery disease. The left main coronary artery had a distal 50% stenosis with moderate calcification. The LAD had a mid vessel total occlusion with a heavily calcified D1 total occlusion and faint distal filling. The LCX had a 60 to 70% stenosis of the AV groove vessel with a distal total occlusion. The OM2 had a mid vessel 90% stenosis and the OM1 had an 80% stenosis at its origin. The RCA was severely calcified throughout (though the presence of previously placed stents could not be excluded) with a 60% stenosis proximally, 50% stenosis in the mid vessel, and diffuse disease in the PDA and RPL up to 80%. 2. Resting hemodynamics revealed minimally elevated right sided filling pressures (mean RA pressure was 9 mm Hg and RVEDP was 11 mm Hg). Pulmonary artery pressures were moderately elevated (PA pressure was 50/28 mm Hg). Left sided filling pressures were minimally elevated (mean PCW pressure was 15 mm Hg). Central arterial pressure was normal (on vasopressors) (aortic pressure was 97/66 mm Hg). Cardiac index was normal (at 3.3 L/min/m2). 3. Multiple attempts at crossing the aortic valve were made including with a straight wire. The calcified aortic valve was not able to crossed and thus left ventricular pressures and left ventriculography were not performed. 4. Before the case as well as during, the patient had copious frothy and blood secretions suctioned from his endotrachael tube. During one episode of suctioning, the patient was noted to have a significant drop in his systemic pressures to the 40s systolic with no palpable pulse. CPR was initiated and his pressures promptly improved with administration of epinephrine. The patient required varying amounts of levophed and dopamine. At one point, his pressure was noted to drop into the 80s systolic and he was removed from mechanical ventilation transiently with a large gush of expelled air and a prompt improvement in his blood pressure (suggestive of significant auto-PEEP). A stat echocardiogram was performed and revealed depressed myocardial function, a thickened aortic valve, and a mean aortic valve gradient of 20 mm Hg. No aortic insufficieny or significant pericardial effusion was noted. Cardiac surgery was consulted emergently. 2 units of PRBCs were transfused. An IABP was placed though there was no systolic unloading secondary to the patient's tachycardia. 5. Post cardiac arrest, the patient had moderately elevated pulmonary artery pressures (PA pressure was 62/38 mm Hg). Left sided filling pressures were moderately to severely elevated (mean PCW pressure was 28/30 mm Hg). Cardiac index remained normal, albeit lower than before the code (at 2.5 L/min/m2). FINAL DIAGNOSIS: 1. Severe three vessel and branch coronary artery disease. 2. Moderate pulmonary hypertension. 3. Moderately to severely elevated left sided filling pressures post cardiac arrest. ____________________________________________________ Echo [2183-5-12]- 1. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed. 2. Right ventricular systolic function appears depressed. 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are mildly thickened. 5. There is a tiny to small pericardial effusion, mostly over the right ventricle. ECHO Study Date of [2183-6-9] The left ventricular cavity size is normal. Overall left ventricular systolic function is probably moderately depressed; ejection fraction difficult to assess due to the presence of bigeminy (EF ?35%). Right ventricular chamber size is normal. Right ventricular systolic function is probably mildly depressedl. There is at least mild aortic valve stenosis. Mild to moderate ([1-26]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. Compared with the prior study (tape reviewed) of [2183-5-12], the studies are technically suboptimal for comparison. Left ventricular systolic function may be similar but cannot be adequatley compared give differences in heart rate and rhythm between the 2 studies. GI BLEEDING STUDY [2183-6-4] Blood flow images show no areas of abnormal tracer accumulation. Delayed blood pool images for 90 minutes obtained immediately after injection of tracer show no areas of abnormal tracer accumulation. Delayed blood pool images obtained six hours after injection of tracer show accumulation of tracer in the right colon and hepatic flexure, with subsequent progression of tracer into the transverse colon. MESENTERIC [2183-6-4] 5:13 PM 1. Angiographic demonstration of an area of angiodysplasia in the ascending colon, just inferior to the hepatic flexure. 2. Two vasa recta supplying this lesion were successfully embolized with microcoils, with good immediate arteriographic result. __________________________________________________ Labs on admission: [2183-5-12] 02:40AM BLOOD WBC-19.1* RBC-4.13* Hgb-12.8* Hct-37.9* MCV-92 MCH-30.9 MCHC-33.6 RDW-13.0 Plt Ct-287 [2183-5-12] 02:40AM BLOOD Neuts-95.6* Bands-0 Lymphs-1.6* Monos-2.3 Eos-0.4 Baso-0.1 [2183-5-12] 02:40AM BLOOD PT-17.2* PTT-150* INR(PT)-1.9 [2183-5-12] 02:40AM BLOOD Glucose-151* UreaN-14 Creat-1.0 Na-130* K-4.4 Cl-92* HCO3-32* AnGap-10 [2183-5-12] 02:40AM BLOOD Calcium-9.5 Phos-4.3 Mg-1.8 [2183-5-12] 01:44PM BLOOD Glucose-159* Lactate-1.9 ________________________________ Cardiac Labs: [2183-5-12] 02:40AM BLOOD CK-MB-125* MB Indx-19.3* [2183-5-12] 02:40AM BLOOD CK(CPK)-647* [2183-5-12] 02:45AM BLOOD cTropnT-0.70* [2183-5-12] 08:09AM BLOOD CK(CPK)-790* [2183-5-12] 08:09AM BLOOD CK-MB-140* MB Indx-17.7* cTropnT-1.08* [2183-5-12] 08:35PM BLOOD CK(CPK)-428* [2183-5-12] 08:35PM BLOOD CK-MB-37* MB Indx-8.6* [2183-5-13] 09:50AM BLOOD ALT-29 AST-72* CK(CPK)-354* [2183-5-13] 09:50AM BLOOD CK-MB-17* MB Indx-4.8 cTropnT-2.03* [2183-5-14] 11:20PM BLOOD CK(CPK)-225* [2183-5-13] 09:50AM BLOOD CK-MB-17* MB Indx-4.8 cTropnT-2.03* Brief Hospital Course: 75M with COPD, stable sarcoid, here with NSTEMI complicated by PEA arrest in cath lab, hypercarbic respiratory failure, H flu and MRSA pneumonia, colonic AVM bleed, 1. Cardiac a. Ischemia: PT with NSTEMI at OSH. This was likely in the setting of superimposed PNA on COPD. With NSTEMI as well as pt got anticoagulated, he bled further (bronchiectasis)leading to a bigger stress as well as PEA and coded. Catheterization showed 3VD and initially it was thought that pt needed high risk intervention vs. CABG. Cardiac surgery was consulted in the cath lab and at that point as pt was intubated, had just had PEA arrest and was hemoptysizing, they deferred. Reconsulted cardiac surgery given stabilization a few days later but given high comorbidities it was decided that risk outweighed the benefit. PCI was considered but when pt stabilized a little more, it was days out and it was thought that he was stable at that time from a cardiac standpoint. Pt was initially on heparin and Integrilin that was d/d/cd secondary to hemoptysis. He was continued on ASA, Plavix, and Statin. Peak enzymes were: CK 793, CK-MB 145, [5-12] trop 2.03 [5-13]. Plavix was d/cd on HD #11 as pt was GIB (see below) and trach was planned. Additionally, pt was started on ACEi and BB a few days in to hospitalization, but these were d/cd when he was hypotensive again and GIB (See below). Ultimately, as patient's blood pressure improved following resolution of multiple infections, patient was able begin medical managment of coronary artery disease with lisinopril and metoprolol as well as continuing atorvastatin and aspirin. Clopidogrel (Plavix) was discontinued given GI bleed and no stent placed during catherization. Irrespective, following catherization, patient had no further episodes of myocardial ischemia or angina. Patient was to followup with cardiology at [Hospital1 18]. b. Pump/Hypotension: Pt had initially been unable to maintain pressures without supportive care. CI normal on cath but decreased after arrest. He was on Levophed and dopamine after catheterization and these were able to be weaned off successfully. He was also on an IABP to help CO/CI which was successfully removed without complications a few days in to hospitalization. On HD #11, pt had hypotension requiring re-starting Levophed to maintain MAPs, which were d/cd later that day. Pt had a swan placed on admission to the CCU which was pulled after one week. Indeed, patient was found to be adrenally insufficient, likely secondary to long-standing corticosteroid treatment for sarcoidosis and COPD, and required a brief high dose hydrocortisone pulse which immediately improved hypotension. Although throughout hospitalization, patient had several episodes of CHF exacerbation/flash pulmonary edema, at the time of discharge, patient was euvolemic. Following clinical stabilization, echocardiography was repeated, which, although a poor study given ventricular bigeminy, revealed an EF of 35% and mild to moderate ([1-26]+) mitral regurgitation. The left ventricular inflow pattern suggested impaired relaxation. Mild pulmonary artery systolic hypertension was identified. Further consideration of intracardiac defibrillator was to be decided following discharge and stabilization. c. Rhythm: Pt with PEA in cardiac cath lab & resuscitated. He was tachycardic in the 140s at admission, likely due to fever, sepsis , and low stroke volume. His heart rate improved to the 60s-80s. Over the course of hospitalization, however, patient had three episodes of NSVT without further episodes of cardiac arrest. In addition, patient had intermittent episodes of ventricular bigeminy without degeneration of rhythm or hemodynamic compromise. Following hemodynamic stabilization with resolution of infections, patient was uptitrated on metoprolol given unrevascularized CAD without issues. 2. Pulm: Pt was intubated secondary to hypercarbic resp failure in likely setting of MI, ? sepsis/infection, and long standing severe COPD. Of note, sarcoidosis was felt to be stable throughout this hospitalization. a. Vent: During coronary catheterization, patient was found to have severe intrinsic PEEP, likely contributing to both hemodynamic and respiratory compromise around the time of the PEA arrest. PIPs were high (upper 30s) suggestive of airway resistance. Question of if pt met criteria for ARDS though could not exclude a cardiac cause of b/l pulmonary infiltrates completes and ARDSNET protocol ventilation was administered. At the end of the first week of hospitalization, sedation was weaned successfully, and patient was initiated on daily pressure support trials. On hospital day 18, tracheostomy was operatively placed by thoracic surgery (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) - however, required replacement next day when trach cuff was perforated following placement. Following tracheostomy placment, patient was quickly weaned to minimal pressure support and initiated on daily trach collar trials and successfully fitted for Passey-Muir valve. Of note, patient continued to require intermittent pressure support and/or assist control ventilation secondary to fatigue at the time of discharge. b. COPD: O2 dependent at baseline. Although not active during this hospitalization, likely contributed to patient's difficulty weaning from ventilator. c. Infection/Bacteremia.- Initially, pt with increased WBC/bandemia/febrile 103 . He was double covered for gram (-) w/Zosyn, Levaquin, and vancomycin but tapered to Levaquin alone when sputum grew out H. flu. BCX from cath lab grew coag neg staph but only one bottle (so thought to be contaminant). On HD #11, pt had hypotension to 80s systolic. He was placed back on AC, and Levophed transiently which was easily weaned off. He also had an increase in sputum production and was pan-cultured. At that point, a ventilator associated pneumonia was high on the differential. We added back vanco & Zosyn (had been on at admission) and switched levo to cipro for better gram (-)/pseudomonal coverage. Chest CT that day showed LLL PNA & bilat atelectasis & small pleural effusions (?aspiration). +Mediastinal LN enlargement. Course was further complicated by development of MRSA ventilator associated pneumonia which was treated with vancomycin for a full two week course. However, at the end of that course, patient again was febrile with a transient hypotensive episode, and patient was started on linezolid 600BID for an additional seven day course. Following that initial febrile episode, patient was afebrile and normotensive for the remaining hospital course. Patient completed linezolid course the day prior to discharge. d. Sarcoidosis- Inactive during this hospitalization, however, bronchoscopy revealed a left lower lobe endobronchial nodule on the day prior to discharge. e. Hemoptysis- On admission following cardiac catheterization, patient had episode of hemoptysis while on integrillin and heparin. Therefore, anticoagulation was discontinued given risk of bleeding, at which point hemoptysis resolved. 3. GI Bleed: Pt transfused 15 units pRBCs during this hospitalization. HD [10-6]. He had multiple episode of frank melena with blood clots. CT abd/pelvis (done for some bruising on flanks & Hct not bumping appropriately) was negative for RP bleed. Initial upper endoscopy and tagged RBC study were negative on HD #11. As patient continued to have frank melena intermittently, three additional nuclear medicine bleeding studies were performed, and patient underwent colonoscopy as well as push enteroscopy; the last bleeding study revealed a source in the hepatic flexure of the colon. Patient was successfully embolized angiographically at an AVM identified by interventional radiology consultants. 4. Nutrition: Following intubation, patient was intermittently given tube feeds and/or TPN for nutrition. PEG was placed at bedside on the day prior to discharge, as patient failed speech and swallow evaluation two days prior discharge. 6. Psych- Continued on outpatient dose of paxil - no issues. 7. Renal: Patient initially had acute renal failure, with creatinine max of 1.7. However, as this resolved following hemodynamic stabilization, ARF was felt to be due to ATN. At the time of discharge, renal function had completely normalized without any issues. At the time of discharge, with the exception of unrevascularized CAD all major acute issues had been resolved. Patient was able to ambulate with a walker on trach collar with assistance, was hemodynamically stable, and had no further febrile episodes. Medications on Admission: Prednisone 5 mg qday Lasix 40 mg qday Proscar 5 mg qday Pravachol 20 mg qday Colchicine 0.6 mg qday Cardura 0.6 mg qday KDUR 20 mg qday Paxil 20 mg qday Vanceril 42 mcg 2 puffs qid Fosamax Voltaren L eye drops Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Diclofenac Sodium 0.1 % Drops Sig: One (1) drop Ophthalmic once a day: one drop to left eye. Disp:1 month supply Refills:2 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: 2-6 Puffs Inhalation Q4H (every 4 hours). Disp:2 inhalers Refills:2 8. Albuterol 90 mcg/Actuation Aerosol Sig: 4-8 Puffs Inhalation Q4H (every 4 hours). Disp:2 inhalers Refills:2 9. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:2 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 11. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 12. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:15 Tablet(s) Refills:2 13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain for 7 days. Disp:21 Tablet(s) Refills:0 14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:900 mg Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Non ST elevation myocardial infarction Hypercarbic respiratory failure Bacterial Sepsis Chronic obstructive pulmonary disease Sarcoidosis Adrenal Insufficiency Pulseless electrical activity cardiac arrest Haemophilus influenzae pneumonia Ventilator associated Methicillin resistant S aureus Pneumonia Gastrointestinal bleed (colon at hepatic flexure) - arterial venous malformation Discharge Condition: Fair - Able to ambulate with walker on trach collar. Discharge Instructions: Continue taking your medications as directed. If you have chest pain not relieved with nitroglycerin, call 911 or come to the emergency room. If you have a high fever (>101F), call your doctor. Followup with your new cardiologist, Dr. [Last Name (STitle) ] [Telephone/Fax (1) 5003] [7-3] at [Hospital3 ]. Call [Telephone/Fax (1) 612] for pre-registration to see your new pulmonologist Dr. [First Name (STitle) ] as early as possible, then follow up on [7-17] at [Hospital3 ]. Followup Instructions: Unrevascularized coronary artery three vessel disease Left lower lobe endobronchial nodule Embolized gastrointestinal AV-malformation in hepatic flexure Followup with Cardiology: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 10548] Date/Time:[2183-7-3] 2:30 Followup with Pulmonary: Provider: [Name10 (NameIs) 1571] BREATHING TESTS Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 612] Date/Time:[2183-7-17] 9:15 Provider: [Name10 (NameIs) 1571] EXAM ROOM IS (NO CHARGE) Where: IS (NO CHARGE) Date/Time:[2183-7-17] 9:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 612] Date/Time:[2183-7-17] 9:30	[ "135", "518.81", "410.71", "401.9", "416.8", "995.92", "428.0", "569.85", "482.41", "519.02", "519.1", "414.01", "038.9", "255.4", "V58.65", "482.2", "496", "V09.0", "427.5" ]	icd9cm	[ [ [] ] ]	[ "99.20", "99.15", "33.24", "96.6", "00.13", "31.1", "97.23", "39.79", "37.61", "45.28", "88.56", "33.21", "45.13", "45.23", "37.23", "00.17" ]	icd9pcs	[ [ [] ] ]	20486, 20558	9940, 18582	372, 821	20984, 21038	3679, 6493	21598, 22532	3284, 3302		18843, 20463		20579, 20963		18608, 18820		6510, 8793	21062, 21575									3317, 3660																					275, 334							849, 2963										8807, 9917							2985, 3169	3185, 3268
15,856	171,592	21382	Discharge summary	report	Admission Date: [2106-9-14] Discharge Date: [2106-9-19] Date of Birth: [2054-2-21] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male with PFO and severe MR followed by serial echocardiograms for several years. The last echocardiogram in [2-11] showed worsening MR, and he was referred for surgery. The patient currently denies any chest pain or pressure, but does admits to minor shortness of breath with climbing hills and trace swelling or edema in the hands and feet at times, otherwise he is asymptomatic. Cardiac catheterization on [2106-8-3] showed an EF of 58 percent, 4 plus MR, and a 99 percent mid RCA occlusion, which was successfully stented. His last echocardiogram in [2-11] showed an EF of 60 percent, severe MR [First Name (Titles) 151] [Last Name (Titles) 12223], posteriorly split mild TR, PFO, and mild aortic atheroma. PAST MEDICAL HISTORY: Significant for MR, hypertension, psoriasis, esophageal stricture, status post dilatation two years ago, and colon polyp removal one-and-a-half years ago. ALLERGIES: HE IS ALLERGIC TO ASPIRIN, WHICH GIVES HIM BRUISING. MEDICATIONS: He is taking Plavix 75 mg once a day, aspirin 325 mg once a day, Lipitor 40 mg once a day, Hyzaar 100/25 mg once a day, Norvasc 10 mg once day, Prilosec 20 mg once a day, and Lopressor 12.5 mg once a day. SOCIAL HISTORY: He drinks two glasses of wine a day. He denies any tobacco history. He has a positive family history of coronary artery disease in his father, who died at the age of 52 from an MI. PHYSICAL EXAMINATION: His physical examination on [2106-9-14] was as follows: Heart rate of 52, blood pressure 130/88, respirations 20, saturating at 98 percent on room air. He was in no acute distress, alert and oriented x3. His carotid arteries revealed no bruits. His heart was regular rate and rhythm with a 3/6 systolic ejection murmur. His lungs were clear to auscultation bilaterally. His abdomen was soft and nontender with bowel sounds. His extremities were well perfused. There was no clubbing, cyanosis, or edema. LABORATORY DATA: The patient's labs were as follows: His UA was negative. His white blood count was 7.7, hematocrit 40.1, platelets 138,000. Sodium 141, potassium 3.6, chloride 101. Bicarbonate 29, BUN 19, creatinine 0.8, glucose 90. PT 12.2, PTT 27, INR of 0.9. ALT 28, AST 16, total bilirubin 0.6, alkaline phosphatase 51, amylase 116, and albumin 4.6. His EKG on [2106-9-14] showed sinus rhythm at 71. These labs were taken from [2106-9-13]. His chest x-ray showed mild cardiomegaly without evidence of any acute cardiopulmonary process. His catheterization report and echocardiogram were already stated. HOSPITAL COURSE: The [Hospital 228] hospital course is as follows: The patient had a [Hospital 56486] hospital course from [2106-9-14]. The patient went into the operating room and underwent mitral valve repair with a 32-mm [Doctor Last Name 405] annuloplasty ring from the surgeon, Dr. [First Name (STitle) ] [Last Name (Prefixes) ]. Cardiopulmonary bypass time was 79 minutes, cross-clamp time was 57 minutes. The patient underwent the procedure without any complications. He was transferred to the cardiac surgery Recovery Unit in stable condition on propofol 200 mcg/kg/minute, epinephrine 0.01 mg/kg/minute, and Neo- Synephrine at 0.2 mg/kg/minute. His mean arterial pressure was 73, CVP of 2, diastolic of 6, PA mean of 13. On postoperative day one, the patient was successfully extubated. His physical examination was unremarkable. His white blood cell count was 16.5, hematocrit 30.1. He was currently on meal of two. He was off nitro. He was off epinephrine. His chest tubes put out 380. The plan for today was to wean the patient off of his Neo-Synephrine, discontinue his Swan, and discontinue his chest tubes. The patient was also seen by physical therapy on postoperative day one. On postoperative day two, the patient was transferred to the Telemetry Unit, Far 2, Rithout any problems. On postoperative day three, the patient's epicardial pacing wires were discharged, and he was hemodynamically stable. His physical examination was unremarkable. He was encouraged to get out of bed and do physical therapy. Lasix was started at 20 mg 2 times a day and Lopressor 12.5 mg twice a day. His sternal dressing was clean, dry, and intact. On [2106-9-18], which is postoperative day four, the patient was in stable condition. His physical examination was unremarkable. The patient received a unit of packed red blood cells overnight from yesterday and his hematocrit revealed that it was 22.8; today his hematocrit is 27. The patient is feeling good with no other issues at this time. On [2106-9-19], the patient was in stable condition and discharged to home on [2106-9-19]. His sternal dressing was clean, dry, and intact; and no other physical examination findings were remarkable. The patient was discharged to home with services on [2106-9-19] in stable condition. DISCHARGE DIAGNOSIS: His discharge diagnosis is as follows: Status post mitral valve repair. DISCHARGE MEDICATIONS: His discharge medications are as follows: Plavix 75 mg 1 p.o. q.d., atorvastatin 20 mg 1 p.o. q.d., ferrous sulfate 325 mg 1 tablet p.o. q.d., ascorbic acid 500 mg 1 tablet p.o. b.i.d., hydromorphone 2 mg 1 tablet p.o. q.4 h., metoprolol 25 mg 1 p.o. b.i.d., and Prilosec 20 mg 1 p.o. q.d. FO[Last Name (STitle) ]: He was recommended to follow up with Dr. [Last Name (STitle) 56487] in two-to-three weeks. He was also recommended to follow up with Dr. [Last Name (STitle) 19419] in two-to-three weeks and Dr. [Last Name (Prefixes) ] in two-to-three weeks. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) 11830] MEDQUIST36 D: [2106-9-20] 15:13:03 T: [2106-9-21] 00:56:51 Job#: [Job Number 56488]	[ "V45.82", "745.5", "414.01", "424.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "99.04", "35.12", "39.61" ]	icd9pcs	[ [ [] ] ]									5228, 6062		5131, 5204			2780, 5109																							1619, 2762																165, 930																	953, 1395	1412, 1596
21,153	179,473	15295	Discharge summary	report	Admission Date: [2109-12-16] Discharge Date: [2109-12-28] Date of Birth: [2057-3-3] Sex: M Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old male with liver cirrhosis secondary to hepatitis C and alcohol abuse. He presented to [Hospital1 69] on [2109-12-16] for a living related liver transplant from his son, [Name (NI) 44475] [Name (NI) 44476]. The complications and risks of procedure were discussed in full with the patient prior to the surgery. PAST MEDICAL HISTORY: 1. Chronic hepatitis C cirrhosis. 2. Heavy alcohol use. 3. Herpes. 4. Status post tonsillectomy. 5. Status post thyroid cyst resection. 6. Status post appendectomy. MEDICATIONS ON ADMISSION: 1. Prevacid 30 mg p.o. b.i.d. 2. Famvir 25 mg p.o. b.i.d. 3. Aldactone 50 mg p.o. q.d. 4. Nadolol 20 mg p.o. q.d. 5. Glucosamine one tablet p.o. q.d. 6. Multivitamin. 7. Escitalopram 10 mg p.o. q.d. 8. Migraine medication prn. ALLERGIES: He has no known drug allergies. PHYSICAL EXAMINATION: Temperature 98.0, blood pressure 127/68, pulse 66, respiratory rate 16, and satting 97% on room air. The patient is generally icteric in no acute distress. There are numerous spider nevi present. Head, eyes, ears, nose, and throat: Normocephalic, atraumatic. External ocular movements intact. Neck is without lymphadenopathy or thyromegaly. There is no JVD. Chest was clear to auscultation. Heart sounds were regular, rate, and rhythm. His abdomen was soft, nontender. There is no hepatosplenomegaly appreciated. His extremities: Pulses were 2+ bilaterally, no bruits were appreciated. There is no clubbing, cyanosis, or edema noted. LABORATORIES ON ADMISSION: WBC was 5.3, hematocrit 42.0, platelets 75. INR was 1.7. PT was 16.2. Sodium was 138, potassium 4.3, chloride 103, bicarb 30, BUN 6, creatinine 0.7, glucose 91. His AST is 91, ALT 58, alkaline phosphatase 127, total bilirubin is 3.6. Albumin was 3.0. BRIEF SUMMARY OF HOSPITAL COURSE: Patient is a 52-year-old gentleman with liver cirrhosis secondary to chronic hepatitis C and long history of alcohol use, who presented to [Hospital1 1444] on [2109-12-16] for living related liver transplant from his son. The patient was preoped in the usual standard fashion. Procedure went without any complications. The estimated blood loss from the procedure was around 2200 cc. The patient did receive a variety of intraoperative fluids including blood products. The patient was taken to the ICU for close monitoring postoperatively. A postoperative day one Duplex ultrasound of the liver revealed a patent artery and vein. He again received variable blood products including red blood cells for a hematocrit as low as 27.4 and six packs of platelets x3 for a platelet count of 85 as well as a FFP for an elevated INR. In the ICU, the patient was diuresed and weaned to extubation. He was on a variety of antihypertensives. He received a short course of perioperative Unasyn. In addition, there was a short period of time where he was on an insulin drip as well as a hydrogen chloride drip for a bicarb of 36. These were eventually stopped. Patient was extubated on postoperative day four. Another Duplex ultrasound was repeated, which was normal. Arterial and venous wave forms were normal. There was no biliary ductal dilatation. The liver function tests continued to trend downward. On postoperative day five, the patient was transferred to the floor. Around that period, the patient had a very brief episode of some mild confusion. This eventually resolved. For immunosuppressant medication, the patient received during the hospital course a total of two doses of Simulect. He was started on cyclosporin on postoperative day one. He additionally was on a short Solu-Medrol taper and eventually was placed on p.o. prednisone. His diet was slowly advanced, which he has tolerated. A postoperative T tube study was done on postoperative day 10, which showed a size discrepancy, a question of a stenosis at the common bile duct at the biliary anastomosis. It was thought to continue with the T tube open to gravity. JP had been discontinued at this point. A future ERCP will eventually be discussed with the patient in clinic. It was thought that the patient was stable for discharge on postoperative day 12 with follow-up appointments with Dr. [Last Name (STitle) ] at the [Hospital 1326] Clinic. CONDITION ON DISCHARGE: Home with VNA services. DISCHARGE STATUS: Stable. DISCHARGE MEDICATIONS: 1. Cyclosporin 350 mg p.o. b.i.d. 2. CellCept 1 gram p.o. b.i.d. 3. Prednisone 20 mg p.o. q.d. 4. Valcyte 450 mg p.o. b.i.d. 5. Fluconazole 400 mg p.o. q.d. 6. Bactrim DS one tablet p.o. q.d. 7. Alprazolam 0.5 mg p.o. q.h.s. 8. Citalopram 20 mg p.o. q.d. 9. Clonidine 0.3 mg p.o. b.i.d. 10. Hydralazine 25 mg p.o. t.i.d. 11. Insulin-sliding scale. 12. Pantoprazole 40 mg p.o. q.d. 13. Colace 100 mg p.o. b.i.d. 14. Silvadene 1% cream applied t.i.d. to the arm and abdomen where the patient experienced some tape burns. 15. Percocet 1-2 tablets p.o. q.4-6h. prn pain. DISCHARGE INSTRUCTIONS: Patient additionally is to have triweekly laboratories which include CBC, Chem-10, coags including PT, PTT, and INR, liver function tests, amylase, lipase, albumin. He is additionally to have cyclosporin levels drawn before the a.m. cyclosporin dose. Patient is to have VNA services for laboratories, nursing, for wound care, for T tube management and teaching, and to assist with medications and compliance as well as insulin administration and blood sugar checking. FOLLOW-UP PLANS: Patient is to followup with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at the Transplant Center, telephone number [Telephone/Fax (1) 673] on [1-4] at 2 p.m. He additionally, is to followup with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2110-1-6] at 12:40 p.m. SERVICES: He is to be discharged with VNA services as described. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,PH.D.[MD Number(3) 12276] Dictated By:[Last Name (NamePattern1) 28937] MEDQUIST36 D: [2109-12-27] 20:57 T: [2109-12-31] 08:48 JOB#: [Job Number 44477]	[ "790.6", "572.3", "070.54", "789.5", "572.2", "263.9", "571.2", "401.9", "303.93" ]	icd9cm	[ [ [] ] ]	[ "38.93", "50.59", "87.54" ]	icd9pcs	[ [ [] ] ]									4556, 5124				744, 1017			5149, 5620																			2008, 4455		1040, 1701					5638, 6322											177, 530										1716, 1979							552, 718		4480, 4533
65,164	126,778	54947	Discharge summary	report	Admission Date: [2168-5-9] Discharge Date: [2168-5-28] Date of Birth: [2095-2-5] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3326] Chief Complaint: transfer from VA for second opinion Major Surgical or Invasive Procedure: tracheostomy History of Present Illness: 73M with h/o PMR, ILD with home O2 of 4-6L and on chronic steroids, OSA and DM2 presented to WX VA on [2168-4-18] with increased DOE, increased O2 req of 7-9L, productive cough with green sputum x3 days after recent head cold. Prior to this, pt had baseline exercise tolerance of 50-100 steps, but now has declined to only about 8 steps. Also endorsed orthopnea and low grade fever. In the hospital, initially satting mid 90s on 7L nasal cannula; - pt was empirically started on ceftriaxone and azithromycin for CAP, - was given IVF for iatrogenic [Last Name (un) ] [12-31] to diuresis, - desaturation to low 60s on max flow HFNC and bipap, - requiring emergent intubation on [4-20] and transfer to ICU, where pt had worsenening GGOs on CT, initiation of vancomycin for [12-2] GPCs, cefepime for broadened coverage, bactrim for PCP coverage and solumedrol burst. - Pt tolerated pressure control better than ARDS net ventilation. - Pt briefly required levofed - Pt tolerated tube feeds since [4-22] - Pt stopped vanco and azithromycin - Had high glucan>400 so continued on bactrim for concern of PCP, [Name10 (NameIs) ] bactrim switched to atovaquone for hyperkalemia. - Pt spiked to 100.6 on [5-3] and pan cultured including c diff which were all negative. - Pt's vent settings on transfer were pressure of 15/12 FIO2 50% for sats in mid to low 90s. - Family requested second opinion re: whether he will ever get off vent. On arrival to the MICU, patient's VS. 98.4 96/59 77 97% on PS [9-9] 50% FIO2. He does not awaken to voice or touch. Review of systems: (+) Per HPI (-) Unable to obtain b/c of intubation Past Medical History: Prostate Cancer s/p XRT and hormone Rx PMR Hypertension Morbid Obesity Type II DM OSA - did not tolerate CPAP Interstitial lung disease (UIP/IPF) but no definitive diagnosis as never had bronch/bx. Social History: Smoked until [2145] 90pkyrs, former EtOH use, No IVDU, retired Family History: No CAD, no DM, No cancers Physical Exam: VS P 84 BP 122/75 96% General trached, on CPAP, arousable, tracking, withdraws to pain HEENT PERRL, nose clear, MMM, no lesions oral pharynx Chest Decreased breath sounds B/L at bases, +rhonchi in RUL CV irregularly/irregular rhythm, normal S1/S2, no MRG Abd obese, +bowel sounds, soft, NT, ND GU foley in Extr trace b/l lower extremity edema Peripheral Vascular: R picc line Pertinent Results: [2168-5-9] 08:35PM GLUCOSE-96 UREA N-44* CREAT-0.9 SODIUM-145 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-30 ANION GAP-12 [2168-5-9] 08:35PM estGFR-Using this [2168-5-9] 08:35PM ALT(SGPT)-87* AST(SGOT)-39 ALK PHOS-67 TOT BILI-0.6 [2168-5-9] 08:35PM CALCIUM-8.8 PHOSPHATE-4.5 MAGNESIUM-2.5 [2168-5-9] 08:35PM WBC-7.7 RBC-3.30* HGB-9.7* HCT-30.0* MCV-91 MCH-29.4 MCHC-32.3 RDW-15.9* [2168-5-9] 08:35PM PLT COUNT-226 [2168-5-9] 08:35PM PT-14.0* PTT-27.6 INR(PT)-1.3* [2168-5-9] 08:25PM TYPE-ART RATES-/28 PEEP-12 O2-50 PO2-97 PCO2-46* PH-7.44 TOTAL CO2-32* BASE XS-5 INTUBATED-INTUBATED CT CHEST [2168-5-10] IMPRESSION: 1. Interval improvement in degree of acute-to-subacute patchy ground-glass opacification with accompanying septal thickening with intervening normal areas of lung on a background of unchanged to slightly progressed subpleural interstitial abnormality with traction bronchiectasis, but no discrete honeycombing. In total this pattern is suspicious for acute interstitial pneumonia on a background of interstitial lung disease. PCP infection superimposed on chronic interstitial lung disease is an alternate consideration. It is unlikely to reflect pulmonary edema or bacterial infection. 2. Interval decrease in degree of lymphadenopathy in the mediastinum and hila which is likely reactive for the ongoing interstitial process. 3. Enlarged ascending aorta to 4.8 cm. 4. Nasogastric tube tents the stomach and could be withdrawn by approximately 1 cm. EEG This is an abnormal continuous ICU monitoring study due to diffuse background slowing and attenuation with intermittent brief runs of frontal intermittent rhythmic delta activity (FIRDA). These findings are indicative of moderate to severe diffuse cerebral dysfunction of non-specific etiology. No epileptiform discharges or electrographic seizures are present. Note is made of an irregularly irregular rapid cardiac rhythm and occasional wide complex premature cardiac beats. CT chest [2168-5-18] IMPRESSION: 1. Interval development of moderate bibasilar right greater than left likely atelectasis with otherwise little change in the degree of interstitial abnormality presumed to reflect acute exacerbation of chronic interstitial lung disease. 2. Unchanged Ascending aortic dilatation 3. Decreased mediastinal adenopathy. CTA head [2168-5-18] IMPRESSION: 1. No evidence of acute vascular territorial ischemia, though no dedicated perfusion sequence was requested or performed. 2. No flow-limiting stenosis, significant mural irregularity, aneurysm larger than 2 mm, or dissection of the cranial vessels. 3. Complete opacification of the mastoid air cells and middle ear cavities, and aerosolized secretions in the sphenoid air cell, likley related to prolonged intubation and supine positioning. CXR [2168-5-21] Comparison is made with prior studies from [5-17] and 20th. The appearance of the cardiomediastinum is unchanged. Cardiomegaly is moderate. Mediastinal lymphadenopathy is better seen in prior CT from [5-18]. Tracheostomy tube is in a standard position. Right PICC tip is difficult to evaluate, can be followed to the lower SVC. There is no pneumothorax. Bibasilar opacities, larger on the left side are unchanged, likely atelectasis. Patient has known chronic interstitial lung disease, superimposed there is increasing diffuse density of the interstitial markings. This suggests again exacerbation of the chronic interstitial lung disease, less likely edema. [2168-5-21] MRI of head with contrast IMPRESSION: 1. There is no evidence of acute or subacute intracranial process, specifically no diffusion abnormalities are demonstrated to indicate acute ischemic event. 2. Possible lacunar ischemic change versus prominent perivascular space noted of the right basal ganglia, unchanged since the prior head CT. Slightly prominent ventricles and sulci, possibly age-related and indicating mild cortical volume loss. 3. Unchanged bilateral opacities noted of the mastoid air cells, likely related with prolonged intubation. micro: [2168-5-17] Urine >100K GNR [2168-5-18] Urine Legionalla Antigen negative [2168-5-20] Stool Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. [2168-5-17] Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. STAPHYLOCOCCUS EPIDERMIDIS \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S Brief Hospital Course: 73 yo M with ILD, OSA, presents from VA for second opinion on tracheostomy after 3 weeks of mechanical ventilation 2/2 acute on chronic hypoxic respiratory failure from pneumonia in the setting of rapidly progressing interstitial lung disease. # Respiratory Failure - At VA pt initially presented with symptoms consistent with viral URI, but given severe underlying ILD, he rapidly decompensated requiring mechanical ventilation. Pt was treated for bacterial pneumonia, PCP [Name Initial (PRE) 1064] (given he is on chronic steroids) and was aggressively diuresed at the VA, but still ventilator dependent on admission to [Hospital1 18]. Pt also received pulse dose of steroids at VA with slight radiological improvement in disease state. Pt had numerous barriers to extubation on presentation including high PEEP requirements, over-sedation and lack of resolution of his disease state. A family meeting occurred and it was agreed that pt would need tracheostomy given prolonged intubation and oversedation. A tracheostomy was performed without complication. He remained ventilator dependent alternating between PSV and CMV ventilation, requiring high cuff pressures likely due to anatomical dilatation of the trachea. Patient was placed on Cefepime for [Hospital1 16630] (MDR Klebsiella sensitive to Meropenem/cefepime). Several episodes of emesis complicated the patients respiratory status on [2168-5-26]. Soon after vomiting he desated and required 60% FiO2. To prevent further episodes of emesis his tube feed rates were decreased and he was given PRN Zofran. He has not experienced any further emesis. On [5-27] minor adjustments were made to PEEP settings and his FiO2 was lowered by to 50%. # Altered Mental Status: On admission, pt was intubated and heavily sedated on propofol with RASS neg [1-1]. Reportedly, pt's mental status was normal prior to intubation at VA. As per VA discharge summary, there was no reason for pt to have experienced an anoxic injury throughout hospital course. However, during VA course, pt had been weaned off propofol and was "awake but not alert" on [2168-5-8]. On admission to [Hospital1 18], pt was heavily sedated. Neurology was consulted and felt that initial exam was consistent with global encephalopathy secondary to being chronically sedated on fentanyl, versed and propofol in a person with a large body habitus. TSH was unremarkable. A CT brain was performed on admission that was unrevealing and on [2168-5-18] a CTA head was performed which was also unremarkable. 72 hrs of continuous EEG monitoring was done and did not show any epileptiform activity but did show moderate to severe diffuse cerebral dysfunction of non-specific etiology. After tracheostomy, pt was weaned off of sedation and started on haldol IV TID. He slowly became less agitated, but remained minimally interactive on examinations. Mild improvement noted [5-23] with localizing tactile stimuli and tracking staff across room. An MRI was performed that revealed no acute/subacute intracranial process, potential evidence small vessel disease. The patient has been intermittently responsive since [2168-5-24] responding to some simple commands such as finger squeezing and occasional head nodding yes/no. His prolonged period of unresponsiveness could be due to patient having a large volume of distribution (large body habitus), with sedatives now wearing off. # [Name (NI) 16630] - Pt was spiking fevers earlier in hospital course, now has normal BP. Diffuse infiltrates on repeat CT, in addition to worsening basilar atelectasis. Sputum growing MDR Klebsiella sensitive to [Last Name (un) 2830] and cefepime. Will give cefepime 1g q12 for 2 weeks. Concerns about aspiration after episodes of emesis on [5-26]. The pateint will need to continue cefepime until [6-2] and vancomycin until [2168-5-30]. # BACTEREMIA - Staph. epidermidis grown on [2168-5-17] in 1 of 2 bottles. Will need 2 week course of IV Vancomycin which was started on [2168-5-17] and should be complete on [2168-5-30]. Blood culture from [5-19] revealed no growth. \ # Polymyalgia rheumatica - Pt was treated with methylprednisolone x3 days at VA. Was previously treated with prednisone 15mg PO daily, but was never given PCP [Name Initial (PRE) ]. On admission his CRP and ESR were markedly elevated, and we were concerned for possible flare of PMR. He was continued on home dose steroids of 15mg daily. #Atrial fibrillation - On admission to [Hospital1 18], pt was not being actively anticoagulated for his known afib. Despite persistent afib, his rates remained normal without AV nodal blockade. He was initially started on heparin drip for anticoagulation prior to tracheostomy placement. After trach, he was started on coumadin for anticoagulation. Transition Issues: - The pateint will need to continue cefepime until [6-2] and vancomycin until [2168-5-30]. - A repeat EEG should be performed for the patient's altered mental status. Medications on Admission: Doxazosin mesylate 4mg daily Hydrochlorothiazide 25mg Per VA Hydroxychloroquine 200mg [Hospital1 ] Levothyroxine 0.3mg Lisinopril 20mg daily Metformin 1000 [Hospital1 ] Niacin 750 Pioglitazone 30 daily Prednisone 10mg daily Prednisone 5mg QID Simvastatin 40mg daily Discharge Medications: 1. levothyroxine 300 mcg Tablet Sig: One (1) Tablet PO once a day. 2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 3. niacin 750 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 4. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day. 5. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 10. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 11. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO once a day. 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) PO BID (2 times a day) as needed for constipation. 16. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 17. cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q12H (every 12 hours) for 5 days: continue until [6-2]. 18. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 2 days: continue until [2168-5-30]. 19. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day: hold if SBP <110. 20. doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day: hold if SBP <110. 21. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: hold if SBP <110. 22. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Altered Mental Status Altered Respiratory pattern Ventilator Associated Pneumonia ACUTE RESPIRATORY FAILURE ILD ANEMIA BACTEREMIA Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname ] was admitted to hospital for respiratory distress thought to be related to your interstitial lung disease. You were placed on a ventilator and subsquently tracheostomy. You also developed a pneumonia and were treated with antibiotics. You are being discharged to a ventilator facility. Followup Instructions: please contact your primary care doctor for follow up after you leave the facility.	[ "515", "E939.4", "278.01", "V15.82", "482.0", "V58.61", "V09.81", "785.52", "276.8", "486", "E935.2", "518.0", "185", "427.31", "995.92", "349.82", "E938.3", "V46.2", "V85.39", "787.91", "V46.11", "401.9", "V58.65", "038.19", "725", "250.00", "278.03", "997.31", "518.84" ]	icd9cm	[ [ [] ] ]	[ "43.11", "96.6", "33.23", "31.1", "96.72", "38.97", "38.91" ]	icd9pcs	[ [ [] ] ]	15077, 15149	7687, 9423	338, 352	15325, 15325	2840, 7167	15799, 15885	2357, 2384		13070, 15054		15170, 15304		12771, 13047			15460, 15776									2399, 2821					7211, 7664														1982, 2035		263, 300							380, 1963												15340, 15436					2057, 2257	2273, 2341
15,209	191,888	17049	Discharge summary	report	Admission Date: [2128-12-24] Discharge Date: [2129-1-4] Date of Birth: [2069-6-19] Sex: F Service: Green Surgery HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old female with multiple medical problems including paraplegia, chronic obstructive pulmonary disease, sacral decubitus ulcer, enterovaginal fistula status post diverting colostomy with [Doctor Last Name 3379] pouch. The patient noted stool from small defects in the midline incision site from the diverting colostomy on the a.m. of presentation to [Hospital1 346]. She denied nausea, vomiting, and diarrhea. She reported a fever three days prior to presentation, but had no fever since. She noted some mild discomfort at the ostomy site. She denied urinary symptoms. Of note, the patient chronically has a Foley. She denied changes in her diet. PAST MEDICAL HISTORY: 1. Status post diverting colostomy with [Doctor Last Name 3379] pouch. 2. PEG tube for supplemental feeding. 3. Coronary artery disease. 4. Status post myocardial infarction. 5. Hypertension. 6. Chronic obstructive pulmonary disease with home oxygen dependence. 7. Paraplegia from T8-9 epidural abscess following laminectomy in [2127]. 8. Sacral decubitus ulcer with osteomyelitis and VAC dressing. 9. Enterocutaneous fistula. 10. Chronic Foley catheter. 11. History of polycythemia [Doctor First Name ]. 12. Heparin-induced thrombocytopenia with HIT antibodies. 13. Possible seizure disorder. 14. History of cerebrovascular accident. 15. Aneurysm in the external carotid artery area and right middle cerebral artery. ALLERGIES: 1. Heparin. 2. Baclofen. MEDICATIONS: 1. Meropenem 1 gram IV q.8h. 2. Percocet. 3. Albuterol. 4. Fluticasone. 5. Ipratropium bromide. 6. Salmeterol. 7. Zinc. 8. Dilantin 100 t.i.d. 9. Metoprolol 25 b.i.d. 10. Gabapentin 400 t.i.d. 11. Pepcid 300 q.d. 12. Vitamin C. 13. Multivitamin. 14. Aspirin 81 mg a day. PHYSICAL EXAMINATION: The patient's vital signs on admission were significant for a temperature of 98.1, a heart rate of 92, a blood pressure of 107/62, respiratory rate of 18, and an oxygen saturation of 95% with nasal cannula rate not specified. The patient was in no acute distress. She was alert and oriented times three. Her heart was in regular sinus rhythm. Her lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, and nondistended. The left lower quadrant ostomy site was viable and pink. There was stool visibly leaking out of a small defect in the midline incision. The defect was found to be from the ostomy to the subcutaneous tissue with no defect found in the fascia. Of note, there was also a PEG in place in the right upper quadrant. Examination of the buttocks revealed a large deep sacral decubitus ulcer that was clean. There was no visible bone exposure. STUDIES: CBC on admission was significant for a white blood cell count of 12,100 with 76% neutrophils. Hematocrit was 30.2%, platelet count was 834,000. Chemistry was remarkable for a sodium of 132, potassium of 5.2, a chloride of 93, bicarbonate level of 32, a BUN level of 18, and a creatinine of 0.3. Her glucose was 88. Her coagulation studies were unremarkable. CT of the abdomen and pelvis: Was significant for a small fluid collection in the subcutaneous fat adjacent to the new colostomy site. There was small gas and fluid tract extending from the peritoneal origin of the colostomy to the midline skin surface. There were no intraperitoneal fluid collections. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the hospital in preparation for surgery to repair the enterocutaneous fistula. The patient was given a bowel preparation on the day of admission. She was then taken to the OR. The colon had become ischemic between the fascia and skin level and stool had tracted subcutanesouly. There was no intra-abdominal fistula. The colostomy was resited. The patient's postoperative course was complicated by tachycardia on postoperative days one and two. As a result, the metoprolol was increased to 7.5 mg IV q.6, on postoperative day #2, hospital day #4. Patient also developed some erythema around the stoma site on hospital day two, postoperative day four, and was started on Kefzol 1 gram IV q.8 in addition to the meropenem she was already receiving for treatment of her sacral decubitus ulcer. In the evening of postoperative day #2, hospital day #4, the patient became acutely short of breath with a desaturation to 85%. Her heart rate had elevated above her baseline sinus tachycardia to approximately 129. On physical exam, the patient was wheezy throughout with crackles. A stat portable chest x-ray suggested pulmonary edema consistent with congestive heart failure. Blood gas on the floor was consistent with respiratory acidosis. As a result, the patient was given 20 of IV Lasix. She was transferred to the care of the Intensive Care Unit. Because of concern for her chronic obstructive pulmonary disease as a component of her respiratory dysfunction, her Lopressor was discontinued. She was started on diltiazem for control of tachycardia. She diuresed well with lasix and her dyspnia resolved. On hospital day #5, a decision was made to discontinue Dilantin because the patient did not have a clear diagnosis of seizure disorder. Previous seizure had been in the setting of sepsis and patient had no seizures in the past year on subtherapeutic antiepileptic medications. On hospital day #6, postoperative day #4, the patient was discharged from the Intensive Care Unit to the [Hospital Ward Name 121] 2 unit. On hospital day #7, postoperative day #5, the patient began to have gas in the ostomy bag. As a result, the patient was advanced to a full-liquid diet. On hospital day #8, postoperative day #6, the patient was advanced to a house diet. The patient was given nutritional supplementation and consultation with the Nutrition service. On hospital day #9, postoperative day #7, the patient was found to be persistently tachycardic. As a result, her dose of diltiazem was increased from 30 mg p.o. q.d. to 60 mg p.o. q.d. Her nebulizer doses were also decreased in an effort to control tachycardia. This was found to improve her heart rate. On hospital day #11, postoperative day #9, the patient began to have softl brown liquidy material from the ostomy. As a result, the patient was discharged on hospital day #12, postoperative day #10. DISCHARGE DIAGNOSES: 1. Enterocutaneous fistula. 2. Status post colostomy resiting. 3. Chronic obstructive pulmonary disease. 4. Paraplegia. 5. Coronary artery disease. 6. Hypertension. 7. Status post cerebrovascular accident. 8. History of cerebral aneurysm. 9. Heparin-induced thrombocytopenia history. 10. Enterovaginal fistula. 11. Question of a seizure disorder. 12. Congestive heart failure. 13. Cellulitis. 14. Percutaneous gastrostomy tube for supplemental feeding. DISCHARGE MEDICATIONS: 1. Salmeterol. 2. Acetaminophen. 3. Fluticasone propionate. 4. Gabapentin 400 mg q.8h. 5. Docusate sodium p.o. b.i.d. 6. Albuterol. 7. Diltiazem 60 q.i.d. 8. Famotidine 20 mg b.i.d. 9. Ipratropium bromide. 10. Meropenem. 11. Dilaudid. 12. The patient had VAC dressing. FOLLOWUP: The patient was to followup with Dr. [Last Name (STitle) ] in [12-24] weeks as well as with Dr. [Last Name (STitle) ] on the Thursday following discharge. The patient had [Last Name (STitle) 269] care for ostomy care as well as physical therapy. CONDITION ON DISCHARGE: Patient was discharged home in stable condition on a regular diet with supplemental feeding. The patient was paraplegic, nonambulatory, Foley catheterized, and using home oxygen therapy. The patient was always mentating clearly. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 28129], M.D. [MD Number(1) ] Dictated By:[Last Name (NamePattern1) 47939] MEDQUIST36 D: [2129-2-21] 21:20 T: [2129-2-24] 04:32 JOB#: [Job Number 47940] (cclist)	[ "785.0", "707.0", "428.0", "998.6", "276.2", "518.5", "569.69", "496", "599.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "46.43" ]	icd9pcs	[ [ [] ] ]								6497, 6951	6974, 7519																										3562, 6476		1955, 3533																171, 857																	879, 1932		7544, 8061
21,043	139,988	43552	Discharge summary	report	Admission Date: [2182-3-28] Discharge Date: [2182-4-8] Date of Birth: [2136-12-27] Sex: M Service: DENTAL Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 93695] Chief Complaint: facial assualt Major Surgical or Invasive Procedure: ORIF right mandibular fracture History of Present Illness: 45 y/o male with HIV on HAART (last CD4 235; 12%; VL 84 copies) and HCV (not on therapy) followed by [Doctor Last Name ] in [Hospital ] clinic. Pt with hx extensive facial fractures post assault in [2178]. Readmitted through ED [3-28] [1-25] acute right mandibular fracture. Past Medical History: HIV, dx [2164], found on general screening, he is homosexual, been on HAART since diagnosis, had PCP pneumonia once HCV: not treated Fungal infection on face and anus CAD s/p 2 MIs Neuropathy ? Infection of aorta [2177] - s/p surgery to remove a portion of aorta Social History: moved to [Location (un) 86] recently, living with sister, no working on disability, homosexual. +tobacco, denies ETOH Family History: [Name (NI) 93696], Brother - DM, Mother - got hep C from blood transfusion and died of cirrhosis Physical Exam: GA: in pain HEENT: PERRLA, EOMI, swelling right mandible, tender to palp, ma CV: RRR no m/r/g Lungs CTA bilat abd: soft NT ND +BS Extrem: no c/c/e or deformities, no c spine tenderness Neuro: CN 2-12 intact Pertinent Results: [2182-3-28] 06:07AM WBC-6.6 RBC-2.96* HGB-11.2* HCT-32.0* MCV-108* MCH-37.7* MCHC-35.0 RDW-15.3 [2182-3-28] 06:07AM GLUCOSE-85 UREA N-24* CREAT-1.2 SODIUM-137 POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-20* ANION GAP-14 CT max/facial: IMPRESSION: 1) Acute comminuted right mandibular fracture involving the body and angle, likely traversing the inferior alveolar nerve canal. 2) Several old facial fractures, s/p repair, as above. 3) Chronic sinus disease, as above. 4) Opacified right mastoid tip, without evidence of fracture Pathology: . Bone, "from infected hardware," maxilla right (A): Fragment of lamellar bone with mild interstitial fibrosis. No acute osteomyelitis. II. Bone fragment, "mandibular fracture site," right (B): Fragment of bone with focal acute osteomyelitis. Special stains including AFB, GMS, PAS and Gram stains for bacteria, mycobacterium and fungi are negative with appropriate controls. III. Node (C): The specimen is being reviewed by Hematopathology. Results will be reported as an addendum. IV. Infected hardware: Gross examination only Brief Hospital Course: Mr. [Known lastname 21006] is a 45 yo male with HIV, Hep C, and prior facial trauma who was admitted to Dr.[Name (NI) 93697] service on [2182-3-28] s/p facial assault with a right communited mandibular fracture. He was preoperatively screened per protocol and was brought to the OR on [3-28] for a ORIF right mandible. During the operative, he was found to have infected hardware status post ORIF in [2178] of right maxilla which was removed, and surgical debridement. Cultures sent to rule out osteomyelitis of the maxilla. Please see the operative note for specific details. Mandible fracture: Post-operatively the patient had significant facial swelling and anesthesia felt that he needed to remain nasally intubated for airway protection. He was monitored in the ICU and antibiotics were started for his right maxillary infection. POD 2 his facial swelling decreased significantly, his oral wires were cut by Dr. [Last Name (STitle) ] and he was successfully extubated. He was continued on liquid pain medication and a purreed diet without complications. Prior to discharge, he had a repeat Panorex, his diet was advanced to a regular diet, and he was discharged home with trauma clinic follow up with DR. [First Name (STitle) ] in 5 days and for suture removal at that time. Osteomyelitis: The bone from his right mandible showed acute osteomyelitis on pathology. He was started on antibiotics including IV Vancomycin. His blood cultures remained negative. Special stains including AFB, GMS, PAS and Gram stains for bacteria, mycobacterium and fungi are negative with appropriate controls. A swab from the hadrware did grow PREVOTELLA. ID was closely following the patient and agreed that at the time of discharge he could go home on oral Moxifloxacin for 6 weeks and that Dr. [Last Name (STitle) 9404] would follow him closely in [Hospital ] clinic. Sinusitis: The patient was seen by ENT who recommended antibiotics, nasal sprays and follow up with them in 1 month. HIV: The patient was continued on his home HIV medications and will follow up with Dr. [Last Name (STitle) 9404] as an outpatient. Social: While on the floor, the patient left the hospital without alerting the nurses. He would always return but it was not clear why he was leaving. His PICC line was removed and he was discharged without IV access. We had close contact with his sister. [Name (NI) ] was discharged home with his sisters and will be staying with her for a few days. He will have visiting nursing for assistance with medications. Medications on Admission: Acyclovir 800", ASA 81', Bactrim DS', Lamivudine 300', Neurontin 600", PRevacid 30', Trazadone 50'qhs, Vicodin, Zerit 40", Zoloft 100", ZXyprexa 10qhs Discharge Medications: 1. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day for 6 weeks. Disp:42 Tablet(s) Refills:0 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Stavudine 20 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 6. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day). Disp:1350 ML(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary: 1. Right comminuted fracture of mandible angle. 2. Infected hardware status post ORIF in [2178] of right maxilla, removal of hardware, surgical debridement and cultures confirming osteomyelitis of the maxilla. 3. Sinusitis Secondary: HIV- CD4 count 235 ([3-19]), HCV, CAD- MI x 2, h/o PCP, h/o Perirectal abscess Discharge Condition: stable Discharge Instructions: A visiting nurse will come to help give you your medications. We have started you on antibiotics that you must take for the infection in your facial bones. Keep your stitches clean and dry. Resume all your medications from home. Please get a saline nasal spray at any drug store and use it in both nostrils three times a day. Call your doctor or go to ED for: -fever>102 -chest pain or shortness of breath -or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [First Name (STitle) ] this Friday for your jaw please call [Telephone/Fax (1) 85595] to make the appointment. Please follow up with Dr [Last Name (STitle) 9404], the ID doctor, on [4-16] at 11am. Please follow up with the Ear, Nose, and Throat doctors [Last Name (NamePattern4) ] 3 weeks-call Dr.[Name (NI) 37917] office to make the appointment ([Telephone/Fax (1) 26106] [First Name11 (Name Pattern1) 6811] [Last Name (NamePattern4) 93698] MD, DDS, PHD[MD Number(3) 93699]	[ "305.00", "473.8", "305.1", "V54.01", "042", "802.25", "285.9", "996.67", "V18.0", "E960.0", "070.70", "526.4" ]	icd9cm	[ [ [] ] ]	[ "76.2", "76.97", "38.93", "96.04", "76.76", "96.71", "93.90", "99.21", "96.6" ]	icd9pcs	[ [ [] ] ]	6194, 6245	2586, 5159	329, 362	6629, 6638	1480, 2563	7128, 7701	1136, 1238		5360, 6171		6266, 6608		5185, 5337			6662, 7105									1253, 1461																					275, 291							390, 686																	708, 980	996, 1120
63,482	196,259	53832+59553	Discharge summary	report+addendum	Admission Date: [2162-3-16] Discharge Date: [2162-3-21] Date of Birth: [2081-3-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 443] Chief Complaint: Pericardial Effusion Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: 80 year old man with a history of CAD s/p stent to LAD in [2157] with recent admission for in-stent rethrombosis (STEMI) with successful PTCA who is sent from an outside hospital with new pericardial effusion and acute anemia. . The patient was recently discharged on [3-11] for revascularization and thrombectomy after in-stent rethrombosis of LAD cypher stent placed in [2157] in setting of holding plavix for a knee replacement. . He was discharged on aspirin, plavix, metoprolol, captopril, atorvastatin, and warfarin with a lovenox bridge (the patient was found to have apical akinesis and was at high risk of clot formation). He had been doing well until [3-15] when he noted the onset of sharp left sided pleuritic chest pain and shortness of breath. THis improved after administration of aspirin. He was subsequently admitted to [Hospital3 3765], where echocardiogram revealed pericardial effusion with concern for hemopericardium. He was given 1mg of vitamin K, ASA and Plavix were continued. There was concern for acute blood loss given a hematocrit of 22.8, and he was subsequently transfused 1u pRBC. Vitals on transfer: 97.6, 18, 67, 92/61, 96% 3L . Of note, the patient was noted to have an acute anemia prior to his STEMI while at rehab for his knee replacement. He had an endoscopy showing gastritis at that time, with eventual stabilization of his hematocrit. . On arrival to the floor, patient reports feeling continued pleuritic chest pain, but otherwise has no complaints including no pre-syncope, syncope, shortness of breath. He also has no f/c/s, cough, or swelling. He has not noticed any blood in his stool. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: LAD cypher stent in [2157] at [Hospital1 2025] In stent restenosis [2162-3-4] (off of plavix for knee surgery), with PTCA and aspiration thrombectomy with restoration of TIMI 3 flow distally 3. OTHER PAST MEDICAL HISTORY: roator cuff tear left wrist fracture Osteoarthritis s/p left total knee replacement and left continuous femoral nerve block gout pseudophakia Social History: Retired electrical engineer for [Doctor Last Name ] in [Location (un) ]. He lives in [Location 3068] with his wife-[Name (NI) ]- [Telephone/Fax (1) 110437]. 2 children- mark and [Doctor First Name ] - Tobacco history: never Family History: History of CAD (brother also has stents). Physical Exam: Admission: VS: 98.5 113/72 69 97% 2L GENERAL: NAD, laying in bed speaking in full sentences HEENT: PERRL, EOMI, JVD. CARDIAC: distant heart sounds with RRR. LUNGS: Clear anteriorly ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm and well perfused. No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge: VS: 98.5, 109/69, 88, 18, 96% on RA i/o 2540/965 in 24hrs, 100/300+inc GENERAL: NAD, laying in bed speaking in full sentences, AAOx3 HEENT: No JVD. CARDIAC: RRR. LUNGS: Few bibasilar crackles ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm and well perfused. No c/c/e. No femoral bruits. +healing TKR scar. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission- [2162-3-16] 08:07PM BLOOD WBC-11.0# RBC-2.83* Hgb-8.1* Hct-25.0* MCV-89 MCH-28.6 MCHC-32.4 RDW-14.0 Plt Ct-464* [2162-3-16] 08:07PM BLOOD PT-34.1* PTT-35.9 INR(PT)-3.3* [2162-3-16] 08:07PM BLOOD Glucose-113* UreaN-23* Creat-1.0 Na-130* K-3.9 Cl-93* HCO3-24 AnGap-17 [2162-3-16] 08:07PM BLOOD ALT-69* AST-42* AlkPhos-141* TotBili-1.3 [2162-3-16] 08:07PM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2 [2162-3-20] 11:35AM BLOOD Lactate-1.7 [2162-3-20] 06:54PM BLOOD Lactate-1.1 [2162-3-20] 11:35AM BLOOD freeCa-1.04* Discharge- [2162-3-21] 07:25AM BLOOD WBC-14.7* RBC-3.59* Hgb-10.2* Hct-31.9* MCV-89 MCH-28.3 MCHC-31.9 RDW-13.9 Plt Ct-353 [2162-3-21] 07:25AM BLOOD PT-16.2* PTT-30.8 INR(PT)-1.5* [2162-3-21] 07:25AM BLOOD Glucose-111* UreaN-13 Creat-0.8 Na-136 K-4.7 Cl-101 HCO3-24 AnGap-16 [2162-3-19] 07:40AM BLOOD ALT-59* AST-48* AlkPhos-123 TotBili-1.0 [2162-3-21] 07:25AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 Pericardial Fluid- [2162-3-17] 01:45PM OTHER BODY FLUID WBC-900* Hct,Fl-20.0* Polys-54* Lymphs-31* Monos-15* [2162-3-17] 01:45PM OTHER BODY FLUID TotProt-4.5 LD(LDH)-1361 Amylase-15 Albumin-2.6 Mircobiology- -[2162-3-17] 1:45 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [2162-3-17]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2162-3-20]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [2162-3-18]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. -[2162-3-17] 1:45 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES. Fluid Culture in Bottles (Preliminary): NO GROWTH. -[2162-3-20] Blood Culture, Routine-PENDING-Prelim no growth to date -[2162-3-20] Blood Culture, Routine-PENDING-Prelim no growth to date -[2162-3-20] URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML. -[2165-3-19] Legionella Urinary Antigen (Final [2162-3-21]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. PERICARDIAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS. Echocardiographs -Portable TTE ([2162-3-16] at 7:46:05 PM) There is moderate regional left ventricular systolic dysfunction with at least mid to distal anterior/anteroseptal hypokinesis. A ventricular septal defect cannot be excluded. Right ventricular chamber size and free wall motion are normal. There is a moderate to large sized pericardial effusion. No right ventricular diastolic collapse is seen. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Moderate to large circumferential pericardial effusion. Evidence of early tamponade physiology. There are echo dense elements within the effusion and fibrous strands causing loculation. There is approximately 2cm of fluid over the anterior right ventricle during diastole, suggesting that a sub-xiphoid approach would be safe. Moderate regional LV systolic dysfunction consistent with LAD infarction. A ventricular septal rupture cannot be excluded on the basis of this study. -Portable TTE ([2162-3-17] at 2:56:00 PM) There is moderate regional left ventricular systolic dysfunction with hypokinesis of the mid to distal anterior wall and anterior septum. There is abnormal septal motion/position. There is a trivial/physiologic pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2161-3-16], the pericardial effusion has been tapped. Tamponade physiology is not present. There is a septal bounce seen, which is often seen after tap and is probably due to mild effusive-constrictive physiology. -Portable TTE ([2162-3-18] at 8:38:30 AM) There is mild regional left ventricular systolic dysfunction with septal hypokinesis. The remaining segments contract normally (LVEF = 40%). Right ventricular chamber size is normal. with borderline normal free wall function. There is abnormal septal motion/position. There is no aortic valve stenosis. No aortic regurgitation is seen. There is a very small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. The echo findings are suggestive but not diagnostic of pericardial constriction. IMPRESSION: Very small residual echodense pericardial effusion with suggestion of constrictive physiology (by 2D echo only). Studies- -CHEST (PA & LAT):[2162-3-20] Moderate left and small right pleural effusions with adjacent basilar atelectasis, most substantial in the left lower lobe. Co-existing pneumonia cannot be excluded in the appropriate clinical setting. Brief Hospital Course: 80 yo M with h/o CAD s/p stent to LAD in [2157] with recent admission for STEMI (in-stent rethrombosis) with successful PTCA who was sent from an outside hospital with new pericardial effusion and acute anemia. . # Hemorrhagic pericardial effusion: The etiology was felt to likely post-STEMI in the setting of an elevated INR (pt was on anticoagulation therapy for apical akinesis, as below). He received 5 units of fresh frozen plasma and underwent a pericardiocentesis, during which 1050 mL was removed. The drain was removed the following day when it was noted to be no longer draining fluid and a repeat TTE did not show evidence of persistent effusion. He remained hemodynamically stable throughout his hospital stay. He is not to be discharged on anticoagulation beyond his dual-antiplatelet therapy for his CAD. . # Acute anemia: This was likely secondary to known gastritis given heme positive stools. His hematocrit remained stable following the transfusions he received on admission. He is to follow up with GI as an outpatient. He was also started on a PPI during this admission. . # Apical Akinesis: Noted on his previous admission following his STEMI and he was started on warfarin for ppx. As above, he presented with a hemorrhagic pericardial effusion in the setting on an elevated INR (3.3 on admission). The risks and benefits of continued anticoagulation were discussed and the patient is not to be discharged on warfarin. He is to continue his plavix and increased aspirin dose. . # CAD: The patient is s/p PTCA and thrombectomy to open LAD stent re-thrombosis. He was continued on his plavix and his aspirin dose was increased from 81 mg daily to 325 mg daily. He was also continued on atorvastatin and metoprolol, although labile BPs led to a dose reduction of metoprolol. His lisinopril was also held given labile BPs. It should be restarted as an outpatient if his BP tolerates. . # Acute on Chronic systolic CHF: The patient's previous echo showed a LVEF of 40%. Repeat echo's following pericardiocentesis revealed a stable EF with very small residual echodense pericardial effusion and then suggestion of constrictive physiology (by 2D echo only). He was diuresed as tolerated and appeared euvolemic upon discharge. He is to follow up with cardiology after discharge. . # Altered mental status, acute confusional state c/w delirium. Pt was noted have a new leukocytosis and was felt to be more somnolent by his wife on [2162-3-20]. A general infectious work up revealed a UA c/w urinary tract infection (multiple WBCs with bacteria noted). His CXR revealed a left sided pleural effusion, thought to be secondary to his recent STEMI. Although intrathoracic infection could not be officially ruled out, it was felt that given the patient's lack of s/sx c/w PNA, this was not the source of his infection. He was started on levofloxacin to cover both a pulmonary and urinary source and when his prelim urine culture grew gram negative rods, he was transitioned to bactrim x7 day course for a complicated UTI. The patient also reported loose stools and was started on empiric flagyl, but this was discontinued when the patient did not have additional diarrhea the following day. . ======================================= TRANSITIONS OF CARE ======================================= 1. Pericardial effusion - Pending studies include: final anaerobic culture (prelim no growth to date), final acid fast culture (AFB smear negative), and final fungal culture (prelim no growth to date). 2. Blood pressure medication changes - decrease of metoprolol dose and lisinopril held given labile BPs in the hospital. Can be restarted as tolerated. 3. Other studies pending upon discharge: Blood cultures, sent [2162-3-20], prelim no growth to date. Urine culture, sent [2162-3-20], prelim gram negative rods (>100,000 colonies). Medications on Admission: 1. clopidogrel 75 mg Tablet, 1 Tablet PO DAILY 2. aspirin 81 mg Tablet, 1 Tablet PO DAILY 3. atorvastatin 80 mg Tablet, 1 Tablet PO DAILY 4. metoprolol succinate 50 mg Tablet, 1 Tablet PO DAILY 5. lisinopril 10 mg Tablet, 1 Tablet PO DAILY 6. warfarin 2.5 mg Tablet, 2 Tablet PO at bedtime 7. docusate sodium 100 mg, 1 Capsule PO BID 8. sertraline 100 mg Tablet, 1 Tablet PO once a day. 9. ferrous gluconate 325 mg (36 mg iron) Tablet, 1 Tablet PO BID 10. Dulcolax 5 mg Tablet, 1 Tablet PO daily prn for constipation. 11. Ambien 5 mg Tablet, 1 Tablet PO at bedtime. Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 9. 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 10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 3765] Hospice Program Discharge Diagnosis: Primary: -Pericardial effusion Secondary: -Urinary tract infection -Coronary artery disease -Coagulopathy -Chronic systolic congestive heart failure 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 Mr. [Known lastname 110438], It was a pleasure taking part in your care during this hospitalization. You were admitted because fluid had built up around your heart and you were experiencing chest pain. The fluid was drained and your pain improved. Your blood was also very thin, and you were given medications to reverse this. This likely contributed to the fluid you had around your heart. We found that you were anemic. This may be due to inflammation in your GI tract and you should be sure to follow up with a gastroenterologist. An appointment has been made for you and is listed below. You also developed a urinary tract infection and are being treated with antibiotics. We hope you continue to feel well. Please make the following changes to your medications: -START: Bactrim 1 tablet twice daily x6 days (this is the antibiotic for your urinary tract infection -START: Pantoprazole 40 mg daily (this is to decrease acid in your stomach) -DECREASE: Metoprolol to 25 mg daily -INCREASE: Aspirin to 325 mg daily -STOP: Lisinopril unless otherwise directed -STOP: Warfarin Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] B. Location: [Hospital ] MEDICAL Address: [Location (un) 21638], [Location (un) ],[Numeric Identifier 21639] Phone: [Telephone/Fax (1) 21640] Appointment: Tuesday [2162-3-23] 2:30pm Department: CARDIAC SERVICES When: WEDNESDAY [2162-4-7] at 2:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [2162-4-13] at 2:00 PM With: [First Name8 (NamePattern2) 4503] [Last Name (NamePattern1) 4504], 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 Name: [Known lastname 18091],[Known firstname 5654] Unit No: [Numeric Identifier 18092] Admission Date: [2162-3-16] Discharge Date: [2162-3-21] Date of Birth: [2081-3-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3780] Addendum: After discharge, sensitivities on urine culture came back as follows. Patient was discharged on bactrim, to which this organism is sensitive. URINE CULTURE (Final [2162-3-22]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Discharge Disposition: Home With Service Facility: [Hospital3 13985] Hospice Program [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3782] MD [MD Number(2) 3783] Completed by:[2162-3-22]	[ "599.0", "272.4", "286.9", "535.50", "428.23", "V43.65", "423.3", "410.72", "V45.82", "414.01", "274.9", "428.0", "423.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "37.0" ]	icd9pcs	[ [ [] ] ]	17895, 18120	8669, 12382	324, 344	14514, 14514	3804, 5197	15818, 17872	2987, 3031		13166, 14230		14341, 14493		12574, 13143			14697, 15455									3046, 3785		2288, 2531		5362, 5362			5395, 5698											15484, 15795			264, 286				5728, 8646		12398, 12548	372, 2172											5233, 5329	14529, 14673		2562, 2705			2194, 2268	2721, 2971
42,851	129,529	38426	Discharge summary	report	Admission Date: [2124-1-21] Discharge Date: [2124-1-29] Date of Birth: [2042-7-4] Sex: M Service: SURGERY Allergies: Keflex Attending:[First Name3 (LF) 371] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: [2124-1-21] Upper EGD [2124-1-25] Exploratory laparotomy and resection of small bowel tumor. History of Present Illness: 81M with hx CAD s/p PCI in [6-/2123] presented [1-14] to OSH with complaints of chest pain for several weeks, also was having melena, admitted to MICU in setting of GI bleed complicated by demand ischemia, now transfered to [Hospital1 18] for further management of persistent proximal small bowel bleed. . At OSH, patient ruled in for NSTEMI with ST depressions on ECG and peak trop of 0.35 in setting of GI bleed with initial Hct of 17. He was transfused 9u pRBCs with improvement in chest pain symptoms. ECHO showed no wall motion abnormalities. EGD was performed [1-16] which showed hiatal hernia and gastritis but did not show any source of active bleeding in esophagus and stomach. After remained stable ~30 for a couple of days after transfusion, patient was transfered to floor on [1-18], at which time diet was slowly advanced. Overnight after transfer to the floor, patient had another episode of small volume melena and Hct drop to 25.4, after which he was transfused another 2u PRBCs to which Hct did not respond; post-transfusion Hct was 25.6. He was also given continuous IVFs overnight for unknown total amount. A tagged RBC bleeding scan was done yesterday, showing bleeding in proximal small bowel in LUQ. Gastroenterology at OSH feels that safest intervention would be embolization. . This morning aspirin and plavix are being held; aspirin had been initially decreased to 81mg on admission. Atenolol is also being held since this morning. Patient is transferred to [Hospital1 18] for further management of proximal small bowel bleed. No further report of melena since last night. Of note, at OSH, patient also had renal insufficiency with BUN/Cr of 65/1.5 on [1-15] decreased to 40/1.2 this morning. Baseline creatinine is 1.2, per report. . Of note, wife is currently hospitalized at [Hospital6 10353] for metastatic breast cancer, likely will need to go home with hospice. Daughter is also involved with both parents. Patient was diagnosed with a small bowel tumor, which is likely the cause of the bleeding. He underwent resection of this tumor and portion of small bowel on [2124-1-25]. After this his diet was advanced, which he tolered,pain was controlled, and bleeding resolved. Past Medical History: 2 vessel CAD - s/p PCI with DES in LCx and OM in [6-/2123] at [Hospital1 18] Bladder Cancer s/p resection [5-/2123] HTN HLD BPH s/p TURP Depression s/p appendectomy Social History: Wife just died of metastatic breast cancer during this admission - Tobacco: never - Alcohol: 6-8 beers a week - Illicits: None Family History: Cardiac disease. Brother died of melanoma Physical Exam: Temp 98.5 BP 134/68 P52 R 18 O2 sat 96% on RA General: Alert, oriented, no acute distress HEENT: Sclera pale, 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. well healed LLQ inscision GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS: [2124-1-21] 11:05PM HCT-31.3* [2124-1-21] 06:23PM PT-13.9* PTT-21.0* INR(PT)-1.2* [2124-1-21] 06:22PM HCT-29.7* [2124-1-21] 01:22PM GLUCOSE-118* UREA N-40* CREAT-1.2 SODIUM-143 POTASSIUM-4.1 CHLORIDE-113* TOTAL CO2-21* ANION GAP-13 [2124-1-21] 01:22PM CK(CPK)-151 [2124-1-21] 01:22PM CK-MB-4 cTropnT-0.32* [2124-1-21] 01:22PM CALCIUM-8.0* PHOSPHATE-3.8 MAGNESIUM-1.8 [2124-1-21] 01:22PM WBC-6.8 RBC-2.98* HGB-8.8* HCT-25.4# MCV-85 MCH-29.6 MCHC-34.8 RDW-16.4 [2124-1-21] 01:22PM PLT COUNT-158 [2124-1-21] CT angio : No active extravasation was identified, specifically in the area of concern. Bleeding scan: Accumulation in LUQ suggesting proximal small bowel source [2124-1-23] CT Abd/pelvis : 1. Radiopaque, post-procedural clips and material seen in the duodenum and jejunum. No evidence of jejunal mass at the clips. 2. Multiple bilateral renal and a single liver hypoattenuating lesion likely representing simple cysts. 3. Hypoattenuating pancreatic head and pancreatic uncinate process lesions likely representing IPMNs or cysts. MRCP may provide better characterization if clinically indicated. 4. Moderate atherosclerotic calcification of the abdominal aorta with a small anterior penetrating ulcer at the infrarenal aorta. 5. Diverticulosis without diverticulitis. [2124-1-24] Jejunal mass mucosal biopsy: Fragments of adenoma with cytological features suggestive of high grade dysplasia and focally prominent cautery artifact, see note. Brief Hospital Course: # GIB: Transferred from OSH where he presented with GIB and HCT drop to 17. s/p 11 units of PRBCs at OSH. Transferred to [Hospital1 18] as he has received his care here. rapidly enlarging clot in proximal jejunum on enteroscopy with clip placement by GI. Atenolol, plavix and ASA were held. IR performed angiography but no embolization as site as they did not see did not see extravasation of contrast even at the area of the clip so they are hesitant to do an embolization. Pt was placed on IV PPI, received 4U PRBCs. Consulted vascular surgery who did not think they would operate on him unless he has active bleeding with hemodynamic compromise. On [1-24], GI again took the patient for endoscopy, at which point he was also transferred to the floor. He was found to have a small bowel tumor by push enteroscopy. He underwent exploratory laporotomy and small bowel resection for this tumor on [2124-1-25]. Subsequently his diet was advanced,which he tolerated, and had good bowel function. His pain was well controlled on PO medications, and he was ambulating without difficulty. He is now stable for discharge home. Due to the surgery we are holding his plavix. We have asked him to restart plavix on wednesday [2124-2-2]. . # [Last Name (un) ]: Reportedly at baseline. Resolved. Continued maintenance fluids and avoided nephrotoxins. . # CAD: Noted to have NSTEMI with peak troponin of 0.35 at OSH. s/p DES to LCX and LAD in 06/[2123]. At [Hospital1 18], he has not had chest pain and trending down troponin with no rise in CK. . # HTN: Atenolol held in the setting of GIB Medications on Admission: Home medications: aspirin 325mg daily plavix 75mg daily ramipiril 5mg QD Paxil 20mg QD Lipitor 10mg Daily Vitamin B 12 1000mcg monthly INJ atenolol 100mg QD Chlorthalidone 25mg PO daily Medications on transfer from OSH: Atenolol (held) ASA (Held) Plavix (held) Tylenol PRN Morphine PRN Nitroglycerine PRN Zofran PRN Lipitor 10 mg qd morphine MTVI Paxil 20mg Protonix 40mg [Hospital1 ] Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: start [2124-2-1]. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Small bowel tumor Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented to the outside hospital with complaints of chest pain for several weeks and dark stools indicating bleeding from your gut. Your chest pain was thought to be due to low blood volume causing your heart to work too much and it resolved with increasing your blood volume. . You were transferred to [Hospital1 69] for further evaluation of the bleed from you gut. You were found to have an intestinal bleed from a small bowel tumor. You underwent surgical resection of this tumor. YOUR PLAVIX WAS BEING HELD FOR SURGERY. YOU SHOULD RESTART TAKING PLAVIX ON WEDNESDAY [2124-2-2]. Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in 2 weeks. Call Dr. [Last Name (STitle) 39408] for a follow up appointment within the next week. Completed by:[2124-1-29]	[ "V10.51", "414.01", "152.8", "285.1", "578.1", "401.9", "V45.82", "412" ]	icd9cm	[ [ [] ] ]	[ "44.43", "45.16", "88.47", "45.62", "45.91", "45.13", "54.4" ]	icd9pcs	[ [ [] ] ]	7725, 7776	5190, 6806	273, 377	7862, 7862	3636, 5167	8636, 8856	3021, 3064		7246, 7702		7797, 7841		6832, 6832			8013, 8613									3079, 3617			6850, 7223																		225, 235							405, 2658												7877, 7989					2680, 2858	2874, 3005
18,353	169,892	52552	Discharge summary	report	Admission Date: [2162-1-6] Discharge Date: [2162-1-12] Date of Birth: [2101-6-19] Sex: M Service: [Hospital1 139] CHIEF COMPLAINT: Chief complaint was back pain. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male with extensive vasculopathic disease who presented with the acute onset of left flank pain after using cocaine. The patient was on Lopressor at this time. The patient subsequently had [10-13] back pain radiating throughout his flank. He had accompanying hematuria as well. The patient has had this in the past and thought that this was another episode of bleeding secondary to his renal cysts. He was also on Coumadin at this time. The patient had no bright red blood per rectum. He had no nausea, vomiting, or hematemesis. He was found to have a retroperitoneal bleed on an abdominal computed tomography. PAST MEDICAL HISTORY: (His past medical history otherwise included) 1. End-stage renal disease with hemodialysis on Monday, Wednesday, and Friday. 2. Diabetes mellitus. 3. Peripheral vascular disease. 4. Coronary artery disease; status post myocardial infarction in [2155] and a non-Q-wave myocardial infarction in [2160]. 5. The patient also has mild pulmonary hypertension. 6. Renal cysts. 7. Hepatitis C virus with a viral load of 600,000. 8. Peptic ulcer disease. 9. Nephrolithiasis. 10. Hypothyroidism. 11. Pancreatitis. 12. Dilated cardiomyopathy with an ejection fraction of 20% in [2157]. 13. Obstructive sleep apnea (with CPAP). MEDICATIONS ON ADMISSION: (The patient's medications on admission included) 1. Prilosec 20 mg p.o. q.d. 2. Norvasc 2.5 mg p.o. q.d. 3. Lopressor 50 mg p.o. b.i.d. 4. Digoxin 0.25 mg p.o. q.o.d. 5. Insulin 70/30 12 units subcutaneous q.a.m. and 2 units subcutaneous q.p.m. 6. Regular insulin sliding-scale. 7. Captopril 25 mg p.o. t.i.d. 8. Coumadin 5 mg p.o. q.d. 9. Epogen. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Social history included a one pack per day tobacco use and occasional recreational cocaine use. The patient is a retired fire fighter. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission included vital signs with a temperature of 100.3, blood pressure was 150/80, heart rate was 96, respiratory rate was 20, oxygen saturation was 96% on 2 liters. General appearance revealed a tired-appearing male in no apparent distress. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, rubs, or gallops; distant. Pulmonary examination revealed clear to auscultation bilaterally. The abdomen revealed positive bowel sounds, soft, nondistended, and obese. Tenderness in the left flank. Extremities revealed trace edema bilaterally. No cyanosis or clubbing. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission included a white blood cell count of 14.5, hemoglobin was 10.7, hematocrit was 31, and platelets were 190. Chemistry-7 revealed sodium was 132, potassium was 4.8, chloride was 97, bicarbonate was 24, blood urea nitrogen was 47, creatinine was 8.2, and blood glucose was 215. Calcium was 9.1, phosphate was 8.4, and magnesium was 2. RADIOLOGY/IMAGING: A computed tomography performed on [2162-1-5] showed a large left perinephric hematoma which dissected into the retroperitoneum. It was unchanged from the previous computed tomography and was measured at 9.6 cm. There was no extravasation of contrast, and no new hematoma. HOSPITAL COURSE: The patient came into [Hospital1 190] and underwent a chemoembolization of the left kidney by Interventional Radiology because he was not considered to be a good surgical candidate. The patient tolerated this procedure well to increase in the size of his hematoma by computed tomography scan. While in the Medical Intensive Care Unit, the patient had a 12-beat run of ventricular tachycardia on [2162-1-4]; for which he was put on labetalol. Electrophysiology was consulted regarding an implantable cardioverter-defibrillator placement; however, it was determined that the patient had no need for a defibrillator at that time. The event appeared to be triggered. Therefore, the patient was transferred from the Medical Intensive Care Unit to the floor and was monitored for several days. This was mainly because he received significant amounts of benzodiazepines and Haldol while in the Medical Intensive Care Unit and subsequently had an altered mental status. The patient recovered over a few days and was seen by Occupational Therapy and Physical Therapy and was judged to be clear for discharge to home. MEDICATIONS ON DISCHARGE: Given the above, and the above-described course, the patient was discharged to home with changes in his medication regimen. He was continued on Prilosec 20 mg p.o. q.d., albuterol inhaler 2 puffs q.4-6h. as needed, Atrovent inhaler 2 puffs q.4-6h. as needed. He was switched from Lopressor and captopril to labetalol 250 mg p.o. t.i.d. He was continued on digoxin 0.125 mg p.o. q.o.d., and he was continued on his previous insulin regimen. Otherwise, the Coumadin was discontinued. Epogen was administered during dialysis, and the patient was additionally put on an aggressive bowel regimen including Colace, Senna, and Dulcolax. He was also given Sarna lotion, miconazole cream, and lactic acid lotion to apply to dry and infected areas (such as his feet). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up in dialysis as per his prior regimen. 2. The patient was to follow up with is primary care physician in one week. 3. The patient to follow up with Dr. [Last Name (STitle) 986] from Urology within one to two weeks. 4. The patient was also provided with a list of telephone numbers for which he could obtain help for his recreational cocaine use. The risks of his actions were discussed with him, and the patient himself felt that he did not need any additional counseling or help in discontinuing his cocaine use. [Name6 (MD) 251] [Last Name (NamePattern4) 11865], M.D. [MD Number(1) 11866] Dictated By:[Name8 (MD) 10249] MEDQUIST36 D: [2162-1-12] 20:47 T: [2162-1-16] 02:30 JOB#: [Job Number 108525]	[ "292.0", "753.19", "459.0", "585", "070.54", "276.7", "425.4", "304.21", "427.1" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.29", "88.45" ]	icd9pcs	[ [ [] ] ]												4685, 5449	1578, 1991	3534, 4658				5482, 6302																												165, 197							226, 877																	900, 1551	2008, 3516
50,827	180,375	41212	Discharge summary	report	Admission Date: [2149-2-27] Discharge Date: [2149-3-7] Date of Birth: [2063-5-5] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 618] Chief Complaint: ICH Major Surgical or Invasive Procedure: None History of Present Illness: [Known firstname ] [Known lastname 89780] is an 85 year old right handed woman on coumadin for AF. According to her husband and daughter, the patient awoke this morning and complainted of headache around 8am. She wanted a cup of coffee and her husband walked with her to the living room and he noticed that on the way, she wasn't speaking. He left her standing next to the couch as he walked into the kitchen to get her coffee. He then heard a bang and came back to find his wife face down on the floor. Their grandson lives downstairs and heard the noise as well and he came up and noticed his grandmother had a left facial droop. EMS was called and the patient was taken to [Hospital6 ] where she her entire left side apparently became weak and she became less responsive which prompted intubation. Head CT was performed and revealed a large right frontal IPH. INR was 2.0, so she was given FFP, Vit K, & profiline 7. She was loaded with Keppra and tx to [Hospital1 18] for further evaluation. The patient is unable to complete ROS. Per the family, she had no recent complaints. She may have had a slight cough a few weeks ago, but no known illness. Past Medical History: - Hypertension - Hyperlipidemia - Hypothyroidism - s/p parathyroidectomy for elevated PTH - Afib on coumadin - Known carotid disease - s/p pacemaker - s/p left partial lobectomy for lung ca ~20 years ago Social History: Married, lives with her husband. Retired office worker. Daughter's family lives a floor below them. Remote smoking hx. No alcohol or drugs Family History: Brother with CHF Multiple cancers no hx stroke Physical Exam: Neuro (off propofol): Does not open eyes spontantously. Will follow commands (wiggles toes, shows thumb with right hand, squeezes right hand and releases on command). Pupils 2mm and minimaly reactive, left pupil irregular, + corneals, EOMI. Decreased tone on the left compared to the right. Spastic right lower extremity. Hyperreflexic on the left compared to right. Bilateral upgoing toes. Withdraws right arm and both legs to noxious. No movement of the left arm. See Death note for exam once expired. Pertinent Results: CT Head [2149-3-3]: IMPRESSION: 1. No significant interval change in the size of the right frontal lobe intraparenchymal hemorrhage, right parafalcine subdural hematoma, or extent of intraventricular hemorrhage. 2. No significant change in the degree of leftward shift of normally midline structures. 3. Stable size and configuration of the ventricles bilaterally. CXR: [2149-3-4] FINDINGS: In comparison with the study of [3-3], the monitoring and support devices are essentially unchanged. There is a vague area of patchy opacification in the right upper zone that could represent an area of consolidation. Mild fullness of pulmonary vessels raises the possibility of some elevated pulmonary venous pressure Brief Hospital Course: Patient [Name (NI) 89780] is an 85 year old woman with history of a-fib on coumadin who was admitted with a large frontal hemorrhage. Her neurologic examination on admission was poor and medical management was instituted. She received mannitol for ICP control (empiric). Her examination continued to be poor throughout her stay in the ICU. The family was made aware of her status and they decided to make her CMO. She passed away on [2149-3-7]. TOD 10:15am Medications on Admission: Coumadin 6 mg daily Asa 81mg daily Sotalol AF 80 mg Twice Daily Levothyroxine 50 mcg daily Amlodipine 5 mg Tab Daily Diovan 160 mg daily at bedtime Simvastatin 40 mg daily at bedtime Digoxin 125 mcg daily at bedtime folic acid 1 mg daily Vitamin B-12 1,000 mcg daily Calcium 500 + D 2 Tablet(s) daily Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: IPH Discharge Condition: n/a Discharge Instructions: Admitted for IPH. Made CMO. Expired [2149-3-7] Followup Instructions: n/a [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2149-3-7]	[ "V10.11", "433.10", "401.9", "437.9", "V45.01", "342.92", "431", "V58.61", "277.39", "E934.2", "781.94", "244.9", "V49.86", "V66.7", "272.4", "427.31" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.72", "96.6" ]	icd9pcs	[ [ [] ] ]	4113, 4122	3268, 3734	307, 313	4170, 4176	2520, 3245	4275, 4401	1922, 1971		4086, 4090		4143, 4149		3760, 4063			4200, 4252									1986, 2501																					263, 269							341, 1520																	1542, 1748	1764, 1906
26,174	184,433	8116	Discharge summary	report	Admission Date: Discharge Date: [2139-2-15] Date of Birth: Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old male with end stage renal insufficiency and diabetes who was on hemodialysis for four years and last dialysis was two days prior to admission. The patient denied nausea, vomiting and PAST MEDICAL HISTORY: Significant for diabetes, neuropathy and retinopathy. Hemodialysis for several years. PAST SURGICAL HISTORY: Includes toe amputation, CABG times four in [2135] and left AVF and left lower extremity bypass surgery. MEDICATIONS: Home medications include Lipitor 10 mg po q d, Captopril 12.5 mg po bid, Aspirin, Insulin. ALLERGIES: Bactrim. HOSPITAL COURSE: Patient was cleared by cardiology and nephrology prior to the transplantation. Patient underwent a cadaveric renal and pancreatic transplant on [2138-2-5]. On postoperative day #1 the patient was placed in the ICU as per routine and on the following several days patient appeared to have a delayed kidney graft function and patient was continued on hemodialysis. The patient was recovering in the ICU while regaining his renal function and, patient's recovery was complicated by an acute inferior posterior MI on postoperative day #7 and patient underwent emergent catheterization which showed that his CAB graft were open and he had non-bypassable disease. Cardiac echo showed inferior posterior severe hypokinesis with ejection fraction of 35-40%, no significant pericardial effusion and at the time patient was recommended to undergo ICU management of MI and hypotension and careful volume management in view of elevated filling pressure. So patient was taken back to the surgical Intensive Care Unit undergoing management for his acute MI. On postoperative day #10 the patient, while undergoing dialysis, appeared to have a bradycardia and ventricular tachy and hypotension and patient was placed on Dobutamine. At the time patient's heart rate was in the 30's and systolic blood pressure was at 60's and Dobutamine was started and patient appeared to be critically ill at the time and on [2-14] the patient underwent another cardiac catheterization which showed unchanged patency since previous study and temporary pacemaker was placed in the right ventricular apex and due to his worsening hypotension and deteriorating condition, an intra-aortic balloon pump was placed on [2139-2-15] and on return from cath lab status post intra-aortic balloon placement, patient was noted to have heart rate of 40 and no readable blood pressure, no pulse, ACLS protocol was initiated and return of BP and heart rate capture was pacer. After approximately 15 minutes the pacer wire did not capture, BP dropped, ACLS protocol was again initiated. Once again return of BP and pulse and all drips maximized and patient's condition was discussed with the family and decision was made to proceed with comfort measures only and at that time patient was started on a Morphine drip and family does not wish to perform chemical codes if further defibrillation occurs and patient died at 6:15 on [2139-2-15]. Addendum: The patient had severe small vessel coranary disease which led to intractable MI. His allografts were functional prior to his cardiac arrest. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3598], MD [MD Number(1) 3599] Dictated By:[Name (STitle) 28933] MEDQUIST36 D: [2139-5-5] 19:13 T: [2139-5-5] 19:49 JOB#: [Job Number 28934]	[ "785.59", "427.31", "250.41", "263.9", "276.7", "428.0", "410.31", "997.1", "E878.0" ]	icd9cm	[ [ [] ] ]	[ "37.78", "37.61", "52.80", "38.91", "37.23", "55.69", "37.21", "39.95" ]	icd9pcs	[ [ [] ] ]														745, 3571										490, 727																													141, 355																	378, 466
61,138	199,498	41049	Discharge summary	report	Admission Date: [2136-5-14] Discharge Date: [2136-5-18] Date of Birth: [2054-1-7] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1943] Chief Complaint: Transfer for slow VT, hemodynamically stable Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 82 yo M with h/o CAD s/p CABG, HTN, HL, IDDM, sCHF (EF 30%) s/p ICD/pacemaker admitted to an OSH ([Hospital3 19345]) on [2136-5-10] with increasising seizure activity at his nursing home. He was transferred from the OSH to the [Hospital1 18] CCU on [2136-5-14] for evaluation of ?slow VT causing his seizures. This was ruled out by EP while he was in the CCU after pacer interrogation, and he was transferred to medicine overnight for further work-up of his seizure activity and for diuresis in the setting of a CHF exacerbation. Briefly, the patient was recently diagnosed with seizure activity and is followed by an OSH neurologist, currently on Keppra. He had multiple (at least 3) witnessed seizures at the [Hospital 582] [Hospital ] Nursing Home on [5-10], and with each seizure his post-ictal phase was noted be more prolonged. He was sent into the OSH for evaluation. There he was consulted on by nephrology for acute on chronic renal failure (2.4 on admission, baseline 1.6-1.7) and cardiology, and his outpt neurologist was to be consulted -- in the interim his keppra was kept at 500 mg PO BID on discharge to [Hospital1 18]. Cardiology was concerned he was having 'slow VT' and his PPM was therefore not set to fire because it was not above threshold and started him on an amiodarone gtt. He also may have been off of his amiodarone which was appears to have been started during his last [Hospital1 18] discharge but per the OSH cardiology note may have been stopped around the beginning of [Month (only) 116]. He was reloaded with IV amiodarone at the OSH with plan to resume oral amiodarone at 400 mg PO daily and was transferred to the [Hospital1 18] CCU for further evaluation of his 'slow VT'. Also noted to have an E. coli UTI noted at OSH. In the CCU, the patient was evaluated by EP for this question of slow VT. His pacer was interrogated and shown to have 1 episode of VT for 10 minutes but likely the tachycardia was AF w/ RVR did not explain his seizures. ICD was re-programmed by EP. He was given diuresis with IV lasix for his volume overload. Ciprofloxacin was also started for his UTI. He was called out to medicine and per report had a bed at 10 pm on [Hospital Ward Name 121] 7 but was not seen by a nightfloat resident overnight due to a misccommunication about whether the CCU was going to continue to follow the patient on the floor. He was immediately evaluated by MS IV and senior resident this morning. Per discussion with his dtr [Name (NI) 1453] (HCP), the patient has had declining quality of life since [2136-1-24] including multiple hospitalizations (one in [1-/2136] leading to [Hospital1 18] transfer in [2-/2136], another in [3-/2136], and then the most recent on [2136-5-10]) for ?syncope versus seizure. HCP and her sister and mother have been taking care of him exclusively for the past 6-8 months since his health started deteriorating. He likely has been having seizure activity since [Month (only) 956]. After his initial discharge from [Hospital1 18] in [2-/2136], he was admitted to [Hospital 5130] Rehab for one month, then to [Location (un) 582] in [Location (un) 7658] and then was at home for 9 days. He was having frequent falls at home and so was re-admitted to LGH in [2136-3-23]. He was set up with a neurologist Dr. [Last Name (STitle) 9590] at that time who believes his seizures are due to demented, atrophied brain and is more susceptible to siezures as a result. His Keppra was increased from 750 mg PO BID to 1000 mg PO BID at his [2136-4-3] outpatient neurology visit. The dtr reports that while he was at home, he was having frequent falls and his BS was 14 by EMS on this way to the hospital for the LGH [2135-3-24] admission, [in the setting of PCP changing [Name9 (PRE) 8472] 36 U QHS to Humalog 70/30 for cost improvement] so hypoglycemia may have been a contributing to his seizure activity as well. Neurologist recommended that if his seizures persisted to be seen by an epileptologist and have 24 hour EEG evaluation potentially. The patient was recently discharged to [Location (un) 582] in [Location (un) ] and was only there for a few days before the seizure activity that prompted this current admission was noted by the staff and the dtr (described as talking, lying in bed, then suddenly becoming stiff, with jerking movements of hands and legs, neck thrown back, not responsive, then after seizure was progressively more post-ictal for longer periods of time). During that admission, Dtr also reports that at one point he was transferred to the ICU and made CMO and ICD was turned off, but then he recovered and looked much better the next day, so decision was made to restart his ICD and transfer to [Hospital1 18] for futher evaluation of slow VT. Of note, dtr states father's quality of life has been deteriorating, and that he has stated in the past that he would not want to be maintained by artifical means such as breathing tubes or feeding tubes and has stated to his family that he would want 'nature to take it's course if it was his time'. His outpatient cardiologist Dr. [Last Name (STitle) 89513] did mention hospice to the family given that his CHF is end stage. The dtr is agreeable to further discussing this during this hospitalization and agreed to DNR/DNI code status this admission. On the floor the patient is sleepy but easily arousable, but AOx3 ('[Known firstname ] [Known lastname 28331]', [Hospital1 18], [2136-5-15], [Last Name (un) 2753]) but attention is waxing and [Doctor Last Name 688] and he is unable to sustain attention to answer questions. He has no memory of the seizure activity. Past Medical History: Diabetes Dyslipidemia HTN CABG x4vd in [2113] Pacemaker Left bundle branch block Atrial fibrillation Depression Chronic low back pain Anxiety BPH H/o Nephrolithiasis S/p Orchiectomy S/p Cataract extraction Social History: Lives with wife. [Name (NI) ] 2 daughters who are involved in his care. -Tobacco history: denies -ETOH: denies -Illicit drugs: denies Family History: Siblings with CAD < 55 y/o Physical Exam: VS: 96.1 110/60 70 21 93% on 4 L NC GA: elderly M, AOx3, NAD but inattentive to questions, waxing [Doctor Last Name 688], garbled speech. HEENT: PERRLA. MMM. no LAD. + JVD to earlobe. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: wheezing with crackles throughout all lung fields Abd: soft, NT, distended +BS. no g/rt. neg HSM. Extremities: wwp, 1+ edema in ankles. DPs, PTs 2+. Neuro/Psych: unable to follow commands on exam. PERRLA. Pertinent Results: Labs and Imaging Studies at [Hospital6 3105] Prior to Transfer: Creat: 2.44 (baseline 2) BUN: 54 Glc: 119 Ca/Mg/Phos: 8.6/2.1/4.1 CBC: 7.5/9.7/30.2/285 INR: 3.6 PT: 39 BNP 2119. Micro: Ucx with pan-[Last Name (un) 36] e.coli Imaging at OSH: [5-12] CXR: Stable cariomegally, persistent mild CHF [5-12] Renal u/s: No abnormalities EKG: (per report, not included in paperwork): wide complex tachycardia at 126, right bundle morphology with left axis. CBC trend: [2136-5-14] 05:22PM BLOOD WBC-9.2 RBC-3.63* Hgb-10.6* Hct-31.8* MCV-88 MCH-29.1 MCHC-33.2 RDW-14.7 Plt Ct-344 [2136-5-15] 03:48AM BLOOD WBC-6.4 RBC-3.60* Hgb-10.5* Hct-31.4* MCV-87 MCH-29.2 MCHC-33.5 RDW-14.6 Plt Ct-324 Coag: [2136-5-14] 05:22PM BLOOD PT-44.5* PTT-34.6 INR(PT)-4.6* [2136-5-15] 03:48AM BLOOD PT-57.5* PTT-34.2 INR(PT)-6.3* Chemistry: [2136-5-14] 05:22PM BLOOD Glucose-159* UreaN-55* Creat-2.2* Na-140 K-5.7* Cl-101 HCO3-28 AnGap-17 [2136-5-15] 03:48AM BLOOD Glucose-83 UreaN-50* Creat-2.0* Na-142 K-4.0 Cl-103 HCO3-29 AnGap-14 [2136-5-14] 05:22PM BLOOD Calcium-8.3* Phos-4.4 Mg-2.5 [2136-5-15] 03:48AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.5 Biomarkers [2136-5-14] 05:22PM BLOOD CK-MB-4 cTropnT-0.03* [2136-5-14] 05:22PM BLOOD CK(CPK)-123 EKG: v-paced 2D-ECHOCARDIOGRAM: [2136-2-23]: The left atrium is mildly dilated. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with severe anterior, septal and lateral hypo- to akinesis. The inferolateral segments contract normally (LVEF = 25-30%). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Moderate pulmonary hypertension CXR: TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: 82-year-old male patient with history of CHF and persistent oxygen requirement, evaluate for vascular congestion or infiltrates. FINDINGS: AP single view of the chest has been obtained with patient in sitting semi-upright position. Analysis is performed in direct comparison with the next preceding AP single view chest examination of [2136-2-25]. Permanent pacer in left anterior axillary position as before. Dual intracavitary electrode system in unchanged position including ICD electrode and right atrial electrode. Status post sternotomy and bypass surgery as before. Again noted is considerable perivascular haze in the pulmonary circulation and increasing densities on the bases suggestive of some pleural effusion. This congestive pattern has now increased in comparison with the study of [2136-2-25]. On chest examination [2136-2-22], a similar congestive pattern was noted as it exists now. IMPRESSION: Reoccurrence of more marked pulmonary congestion. Thus congestion level similar to what existed prior to permanent pacer placement on [2-25]. Hand Film (Left): HISTORY: Possible fracture after seizure. FINDINGS: No previous images. Three views show no definite fracture or dislocation. Extensive vascular calcification suggests underlying diabetes. Several lucencies are seen at the proximal and distal aspects of the middle phalanx of the third digit, of uncertain etiology, but probably no clinical significance. EEG: [2136-5-18]: Read is pending Microbiology: Urine cultures (OSH): E. coli pan-sensitive. Brief Hospital Course: 82 year old male with a past medical history of dementia, coronary artery disease status post CABG ([2113]), diabetes, hypertension, hyperlipidemia, systolic heart failure (ejection fraction 30%), status post recent ICD placement was initially admitted to the cardiac care unit for "slow ventricular tachycardia" per outside hospital report. He was then subsequently transferred to the floor where he received further work-up for his initial complaint of "seizures" at the outside hospital (OSH). # ? Slow ventricular tachycardia (VT): Patient was transferred from outside hospital ([Hospital6 3105]) for evaluation of slow VT. No documented EKG or telemetry strips faxed over with patient. His amiodarone had recently been stopped by his outpatient cardiologist. He was reloaded with IV amiodarone and transferred to [Hospital1 18]. On presentation to [Hospital1 18] patient found to be in atrial fibrillation with EKG demonstrating V pacing with no VT. The ICD was interrogated and showed one episode of VT for 10 seconds and 1 shock. Cardiology confirmed that the ICD was functional. Per EP likely that atrial fibrillation in setting of intraventricular conduction delay was misinterpreted as VT. Decision made to stop amiodorone load and transition back to daily dosing of 200mg PO daily. His heart rate was stable in the 70s on the floor and he was continued on a combined regimen of amiodarone and metoprolol. # Paraoxysmal atrial fibrilliation: Patient was on coumadin as an outpatient with INR supratherapeutic 4.6. His coumadin was held in this setting and was restarted on [5-18] at 3 mg PO daily once INR was in [1-26] range. INR was monitored daily due to patient being on Bactrim as well for UTI. Patient was continued on metoprolol for rate control. # Urinary tract infection (UTI): Urine culture at the outside hospital showed 6000 colonies of pan-sensitive E Coli. Patient was started on on bactrim for planned treatment course of 7 day course for complicated UTI ([5-14] - [5-20]) # Seizure disorder: Patient initially presented to OSH with witnessed "seizures" in his rehabilitation center. He has a history of "seizures" of unclear etiology and is on keppra 1000 [Hospital1 ] at home. There is a possibility the seizures could have been due to a hypoglycemic event in a past [3-/2136] LGH admission, although no blood sugars were checked at the times of the seizures. His outpatient Patient was seen by neurology at OSH and started on Keppra with levels as high as 1500mg PO BID. However due to acute renal failure at the OSH, the dose was decreased to 500 mg [Hospital1 ] PO BID prior to transfer. Patient was seen by neurology at [Hospital1 18] who felt that his seizures were more likely convulsive syncope, but recommended a 24 hour EEG as an outpatient, follow-up with his outpatient neurologist, and continuation of his home dose of Keppra. An 30 minute EEG was obtained and results preliminarily showed signs of encephalopathy but no seizure activity. Patient was continued on keppra 1000 [Hospital1 ] per his outpatient neurologist recommendations. # Delirium: Patient presented to [Hospital1 18] with waxing and [Doctor Last Name 688] mental status in addition to his baseline advanced dementia. On admission his speech was garbled and was lethargic although arousable. His mental status improved during the course of his hospital stay. This may be related to treatment of his urinary tract infection with Bactrim. # Coronary artery disease status post CABG: Patient was asymptomatic and ruled-out for acute coronary syndrome with negative cardiac biomarkers x2 at the [Hospital1 18]. He was continued on metoprolol. We will discontinue his home statin and aspirin as patient will be transitioning to home hospice. # Systolic heart failure (ejection fraction 30%): Patient was diuresed with IV lasix as he presented with pulmonary congestion and put out over 10 L of fluids. Patient was continued on lasix 40 mg PO daily and metoprolol. Weight was approximately 220 lbs on discharge. He was 95% on RA on discharge. [Month (only) 116] continue prn albuterol for shortness of breath. Also recommend oral morphine prn for shortness of breath. # Acute on Chronic Renal failure: On admission patient's Cr was 2.2, which was elevated from her baseline of 1.6. This was likely secondary to poor perfusion in the setting of decreased PO intake and poor forward flow. Renal ultrasound at outside hospital was negative for obstruction or hydronephrosis. Cr normalized on hospital day #2 as patient's PO intake increased. Medications were renally dosed and nephrotoxins avoided. # Hand swelling: Patient reported pain in his left hand after his seizures. It is likely due to a thrombophlebitis from an IV. Unlikely an arm DVT given patient is therapeutic on coumadin currently. A left hand x-ray demonstrated no fractures. Warm compresses and pain control were recommended. # Aspiration risk: Patient was assessed by speech and swallow who recommended: (1) a diet of regular solids and thin liquids (choosing soft options until pt has dentures in place), (2) Meds whole one at a time with thin liquids, (3) [Hospital1 ] oral care, and (4) Distant supervision with meals. # Gastroesophageal reflux: Stable. On omeprazole. # Diabetes: Stable. Patient was continued in insulin sliding scale. On discharge, patient's regimen was simplified # Depression: Stable. Continued home sertraline 25 mg QD. # Benign prostatic hypertrophy: Stabled. Continued home tamsulosin 0.4 mg qhs # Goals of care: Patient has had multiple hospitalizations since [1-/2136] with a decline in functional status after each episode. In the setting of his multiple medical problems and two end stage diseases (CHF and dementia) palliative care and the primary team initiated a discussion on the goals of care with the health care proxy (daughter [Name (NI) 1453]) and his family. The family decided that he would be most suitable in a hospice environment and confirmed his code status as DNR/DNI. Patient wishes to go back home but family was having difficulty with him falling at home and with overall care, so he was discharged back to [Location (un) 582] [Location (un) ] with palliative care. Patient's medication regimen will be simplified to maximize his quality of life. Transitional issues: Patient will be discharged to inpatient hospice. Going forward we recommend that the patient follow-up with his PCP to further simply his medications and improve quality of life. Patient should follow up with his outpatient neurologist regarding his seizures. Dr. [Last Name (STitle) 9590] should follow up the result of the EEG performed at [Hospital1 18]. Medications on Admission: acetaminophen 325 mg q6h prn albuterol nebs amiodarone 200 mg qd aspirin 81 mg qd bisacodyl 10 mg qd prn calcium 500 mg tid prn GERD clopidogrel 75 mg qd docusate 100mg [Hospital1 ] furosemide 60 mg qd Novolog Mix 70-30 40 units Subcutaneous qAM. Novolog Mix 70-30 25 units Subcutaneous at bedtime. lactulose 30mg q8 prn lisinopril 2.5 mg qd metoprolol tartrate 12.5 mg [Hospital1 ] multivitamin qd omeprazole 20 mg qd sennosides 8.6 mg [Hospital1 ] sertraline 25 mg simvastatin 40 mg qd spironolactone 12.5 mg qd tamsulosin 0.4 mg qhs warfarin 5 mg qd ativan 1 mg vitamine b12 1000 mcg vitamin d [2124] lopressor 12.5 [Hospital1 ] lasix 40 QD lisinopril 2.5 QD keppra 1000 [Hospital1 ] glipizide 2.5 QD lantus 35 QD lasix 40 if weight gain >3lbs coumadin 3 QD colace 100 [Hospital1 ] senna 2 tabs MVI 1 tab zocor 40 mg qd zoloft 25 qd asa 81 qd pepcid 20 [Hospital1 ] proscar 5 mg QD Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Lantus 100 unit/mL Solution Sig: Forty (40) U Subcutaneous once a day: 40 U at Breakfast NO INSULIN SLIDING SCALE . 13. 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. 14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days: End date = [2136-5-20]. Disp:4 Tablet(s) Refills:0 15. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 2.5 mg PO Q4H (every 4 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: Windgate Discharge Diagnosis: Primary diagnoses: Rule out seizure, rule out ventricular tachycardia, acute on chronic renal failure, delirium, advanced dementia, urinary tract infection Secondary diagnoses: Acute on Chronic Systolic Heart failure (EF 30%), benign prostatic hypertrophy, gastrointestinal reflux, coronary [Last Name (un) ] disease, paraoxysmal atrial fibrillation 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 transferred from an [Hospital6 3105] for an abnormal rhythm in your heart that was concerning for "ventricular tachycardia," which can be very dangerous. You were stabilized, and the cardiologists here examined your ICD (which is supposed to "shock" you out of these dangerous rhythms) and felt that the ICD was working properly without evidence of venticular tachycardia. The rhythm you had was likely a fast version of the underlying 'atrial fibrillation' which we are aware you have. Secondly since you initially were admitted to [Hospital1 487] for seizures, we continued the work-up here. The neurologists here felt that your symptoms were likely convulsive syncope rather than seizures. They monitored you with an EEG and recommended that you continue keppra at your current dosing. Thirdly on admission you also had fluid in your lungs, which we treated with lasix. Furthermore at [Hospital3 ], you were found to have an urinary tract infection for which you were treated with bactrim. Lastly given your multiple medical problems, we had a discussion with your family about goals of care. We decided that the best option would be hospice. You will be going back to [Location (un) 582] [Location (un) ] with a focus on palliative care. When you are discharged, please observe the following medication changes: Please STOP the following medications. -All vitamins and supplements -Lisinopril -Aspirin. -Ativan. -Glipizide. -Simvastatin. PLEASE START or CHANGE the following medications: -We increased your Lantus to 40 U at breakfast. You may discontinue your insulin sliding scale. -We added back amiodarone 200 mg by mouth daily. -We added back metoprolol 12.5 mg by mouth twice a day. -Your coumadin was reduced from 3 mg daily to 1 mg daily because of your on bactrim. Please have your inpatient MDs adjust this as necessary based on an INR check. Weigh yourself every morning, [Name6 (MD) 138] hospice RN if weight goes up more than 3 lbs. Followup Instructions: Please call your PCP and coumadin clinic for follow-up after discharge from your extended care facility. PCP is [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 89514] [Name9 (PRE) ] Clinic [Telephone/Fax (1) 89515] Outpatient [Hospital3 ], Ms. [Last Name (Titles) ], [2136] She is requesting a discharge summary faxed to [Telephone/Fax (1) 89516]. Name: [Last Name (un) ],[Name6 (MD) 89517] A MD Location: NE NEUROLOGICAL ASSOC. Address: [Location (un) ], [Hospital1 ],[Numeric Identifier 29072] Phone: [Telephone/Fax (1) 9591] Appointment: Monday [2136-6-4] 2:45pm Department: CVI [Location (un) ], [Apartment Address(1) ] When: MONDAY [2136-7-9] at 1:20 PM With: [Last Name (un) 1918] [Doctor Last Name ] [Telephone/Fax (1) 11767] Building: [Location (un) 20588] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "780.2", "584.9", "414.00", "300.4", "345.90", "041.4", "426.3", "250.00", "V45.81", "599.0", "427.31", "V49.86", "E849.7", "V45.02", "996.62", "V58.67", "451.84", "E879.8", "428.23", "437.0", "403.90", "724.2", "585.9", "428.0", "272.4", "790.92", "V58.61", "349.82", "290.41" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	20277, 20312	11092, 17468	348, 354	20711, 20711	7129, 11069	22901, 23874	6565, 6593		18824, 20254		20333, 20490		17882, 18801			20888, 22878									6608, 7110	20511, 20690															17489, 17856					264, 310							382, 6160												20726, 20864					6182, 6393	6409, 6549
587	150,352	23532+57359	Discharge summary	report+addendum	Admission Date: [2100-10-26] Discharge Date: [2100-12-1] Date of Birth: [2044-2-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8810] Chief Complaint: LUQ pain x 1 month, w/u at [Hospital6 ] Major Surgical or Invasive Procedure: CT-guided biopsy [2100-10-27] History of Present Illness: 56M w/minimal PMHx who p/w gradual onset LUQ dull pain/"pushing" x ~1 month. Some radiation to L flank, worse lying down, slightly relieved w/walking. He presented to the [Hospital3 ] system, where initial dx included constipation, treated with laxatives with no relief of pain. Currently the patient reports 7/10 intensity abdominal pain. At the VA: LDH 726, CT showed massive LAD in retrocrural nodes into upper abdomen involving celiac nodes; concerning for lymphoma. He was prepared for biopsy of the area, but was unable to complete procedure secondary to discomfort (?chest pain). He was discharged yesterday and presents to [Hospital1 18] to transfer his care to this facility. Pt states he does not want to go back to VA for any care. Pt also notes nausea, "dry heaves" ~4-5x in past 2 weeks. +anorexia, ~30 lbs unintentional wt loss over past 6 wks. +feverishness, +NS +chills. Profound fatigue and generalized weakness. constant diarrhea x 2 yrs, taking frequent "stool hardener" ?kaopectate, which he recently self-d/c'd. No current bowel problems. Past Medical History: Arthroplastic surgery on knee. No history of CAD Social History: Lives with wife and 2 daughters in [Name (NI) 86] area. He smoked 1.5 ppd x 40 years, "quit 4 days ago." Works as a letter carrier, but has taken sick for past week. Approximately 6 drinks per week. Family History: Daughter with leukemia, diagnosed [2096-11-11]. She receives care in [Hospital1 18]. No other family history of malignancy. Physical Exam: PE: VS T98.7, P72, BP 161/75, R18, SpO2 95% RA Gen: Alert, oriented male in no distress. Appears slightly older than stated age. HEENT: Pharynx clear, poor dentitions. No cervical lymphadenopathy. CV: No JVD. S1 S2 with no murmurs. Lungs clear. Chest: No lesions. Abd: Nontender over CM, no HSM by palpation or percussion. Nonobese. Guaiac negative stool per ER report. Ext: No C/C/E x4. Pertinent Results: [2100-10-26] 02:30PM GLUCOSE-84 UREA N-17 CREAT-0.8 SODIUM-141 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-28 ANION GAP-17 [2100-10-26] 02:30PM ALT(SGPT)-15 AST(SGOT)-20 CK(CPK)-52 ALK PHOS-107 AMYLASE-24 TOT BILI-0.4 [2100-10-26] 02:30PM LIPASE-16 [2100-10-26] 02:30PM CK-MB-NotDone cTropnT-<0.01 [2100-10-26] 02:30PM WBC-9.9 RBC-4.12* HGB-12.4* HCT-35.9* MCV-87 MCH-30.2 MCHC-34.7 RDW-12.5 [2100-10-26] 02:30PM PLT COUNT-302 [2101-10-27] CT abdomen: In the upper abdomen, there is a large heterogenous mass consistent with confluent adenopathy measuring up to 9.4 x 7.8 cm. It surrounds the aorta and celiac axis with tethering of the left gastric artery. A 3.1 x 1.9 cm periportal node is also seen. 1. Large heterogenous splenic mass. Heterogenous bulky retroperitoneal adenopathy surrounding the aorta and celiac artery. Areas of necrosis are seen. These findings are concerning for lymphoma. 2. Left renal exophytic cyst. Possible right renal cyst. [2101-10-27] Pathology: Overall, the findings are of a high grade, non-Hodgkin B-cell lymphoma. Given the high proliferation fraction, the differential diagnosis includes a high grade diffuse large B-cell lymphoma versus an atypical Burkitt lymphoma. Cytology: Overall, findings are of a high-grade CD10-positive B-cell lymphoma. Differential includes atypical Burkitt's vs large B-cell lymphoma. [2100-10-28] CT Chest: IMPRESSION: 1) Right hilar lymphadenopathy measuring 17 mm in diameter, as well as slight prominence other bilateral hilar nodes. In the clinical setting of lymphoma, involvement of lymphoma in the right hilar nodes is suspected. Correlative FDG PET or gallium imaging may be helpful. 2) Calcified subcarinal node, with multiple calcified granulomas, representing prior granulomatous infection. 3) Non-calcified pulmonary nodule measuring less than 5 mm in diameter, as described above, probably related to the prior granulomatous infection, however, please follow up these lesions on future CT scans. 4) Gynecomastia. 5) Interval development of small amount ascites, measuring 43 Hounsfielunits, which raises the possibility of hemoperitoneum following recent biopsy. [2100-10-28]: TTE: Conclusions: 1.The left atrium is mildly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal. 4.The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 5.The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. 6.There is no pericardial effusion. [2100-10-29]: bone marrow biopsy- Normocellular marrow for age with multiple lymphoid aggregates [2100-11-4]: CT abdomen: There has been interval decrease in the size of the splenic lesion. Previously, it measured 11.5 x 11.1 cm and now measures 10.0 x 8.6 cm. It is now more heterogeneous in appearance with low attenuation areas consistent with necrosis. Small amount of higher attenuation fluid is noted at the inferior margin of the spleen consistent with peri-splenic hematoma. The retroperitoneal mass of bulky adenopathy involving the proximal abdominal aorta and left diaphragm has also decreased in size. Previously, it measured 9.4 x 7.8 cm and now measures 7.6 x 6.6 cm. Areas of low attenuation are also seen consistent with necrosis. [2100-11-16]: Gastrointestinal mucosal biopsies, two: A. Esophagus: 1. Active esophagitis, with ulceration. 2. No viral inclusions or tumor seen. 3. Methenamine silver stain of the esophagus (slide A) is negative for fungi, with satisfactory control. . B. Duodenum: 1. Acute duodenitis, with multiple crypt abscesses and focal loss of villi. 2. No viral inclusions or tumor seen. 3. Immunostain of the duodenum (slide B) is negative for cytomegalovirus, with satisfactory control. Some reagents are not approved for diagnostic use. Note: Possible causes of the duodenal inflammation include infection and drug injury. [2100-11-18]:CT abdomen: Gallbladder is slightly prominent but demonstrates no secondary signs of cholecystitis. There is a stable appearing,predominantly hypodense lesion within the spleen measuring 8.2 x 7.0 cm. This appears unchanged in size and appearance in the interval. A large paraesophageal soft tissue mass measures 6.5 x 5.5 cm and is grossly unchanged in appearance as well. Pancreas and adrenal glands are normal in appearance [2100-11-23]: CT sinus: IMPRESSION: Minimal ethmoid sinus thickening. Evidence of prior right maxillary surgery. Otherwise, negative study. [2100-11-27]: CT abdomen:IMPRESSION 1. No evidence for splenic, perisplenic, or intra-abdominal hemorrhage. 2. Unchanged size and appearance of the splenic hypodense lesion, and peri- splenic fluid collection. 3. Unchanged soft tissue mass in the lesser sac, which is presumably a mass of matted lymph nodes. Brief Hospital Course: The patient is a 56 yo male with Burkitt's lymphoma. #Burkitt's Lymphoma - The patient presented to the [Location 1268] VA with 5-6 day history of LUQ pain and constipation. A CT scan at WR was notable for lymphadenopathy concerning for neoplastic disease. A repeat CT abdomen on admission was notable for extensive LAD, splenomegaly with a splenic lesion. On [2101-10-27], CT guided core biopsy of spleen was notable for B cell lymphoma - DLBL vs Burkitts. CT chest was done for staging which was notable for enlarged R hilum LN. He then had a baseline TTE which suggested an LVEF of >55%. A bone marrow biopsy was done which suggested T cell dominant lymphoid profile. There was a small population of CD10 co-expressing B cells; given the known history of a CD10 positive B-cell lymphoproliferative disorder, the findings are suspicious and minimal involvement of the marrow cannot be entirely excluded. He was started on IVFs with [12-23] amps of bicarb + bicarb tablets for goal urine pH >7 and allopurinol. When his urine pH was greater than 7, he was given his first dose of cytoxan 400 mg IV ([2100-10-29]). He was given anzemet/decadron prior to chemo for antinausea prophylaxis. In the pm of day 1, he was given his first dose of vincristine 2mg IV x1. The medications were separated in time because he was considered high risk for TLS because his LDH was 1100 and rising and he had Burkitts with a large tumor burden. TLS were checked q3 hours. On day 2, he was given 1600 mg cytoxan in the morning and 80 mg IV doxurubicin in the evening. His LDH increased to max 2900 on Day 2 of Modified [Last Name (un) ] protocol. He did not develop evidence of hyperkalemia, hyperphosphatemia, hyperuricemia, or hypocalcemia. His bicarbonate in his blood rose to 43, so the bicarb in his fluids was decreased. The frequency of TLS labs was decreased to q6hours. On day 3, he received IT cytarabine + hydrocortisone with no complications and 400 mg IV cytoxan with no complications. On day 4 and 5, he received 400 mg Cytoxan with no complications, hematuria, etc. On day 5, he received the second dose of IT cytarabine with hydrocortisone with no complications. Over the first few days of chemo, the patient also required intermittent doses of lasix to maintain a stable weight and limit bipedal edema. On day 7, the patient noted an increase in his LUQ pain; a repeat CT of the abdomen showed necrosing tumor decreasing in size. He received his second dose of vincristine on day 7. He tolerated the vincristine well without peripheral numbness/tingling or constipation. On day 8, the patient had continued increased LUQ pain so he was started on a morphine PCA. On day 9 he was started on IVFs with bicarb for goal urine pH >7.0. On day 10, he got Methotrexate 6 gm IV. On day 11, he started leucovorin rescue. His 24 hour MTX level was 1.87. On day 12, he was neutropenic. He spiked to 102.4 overnight so he was started on cefepime, blood cultures/urine cultures were sent which were negative. A few hours after having a fever, he started to have profuse watery diarrhea ~2L in 8 hours. Flagyl was added for possible C.Diff. Stool cultures, cdiff and CMV were sent which were negative (cdiff negative x 3). The patient was also started on ciprofloxacin for double gram negative coverage. By mid morning of day 13, the patients blood pressures had decreased to 70s-80s/40s-50s and his HR increased to 120s. He also had [12-23] episodes of projectile vomiting-nonbloody. He was also started on neupogen (per protocol) and b/c the patient was neutropenic and there was concern of typhilitis. He was given over 5 Liters NS bolus with no increase in pressures. He was then transferred to the [Hospital Unit Name 153] for further management of his hypotension. An A-line was placed and he was started on levophed once in the unit. Another 2L of NS were administered and the levophed was weaned off. CT abdomen was performed with oral contrast (through NGT b/c pt unable to tolerate contrast) due to concern for abdominal source, especially typhlitis. His CT abdomen demonstrated some mild wall thickening in the cecum. He remained febrile and vancomycin was started. He again remained febrile with negative cultures so caspofungin was started. Repeat KUBs were unremarkable, without free air. On day 14, he had coffee ground emesis overnight and guaic + stools so he was started on IV PPI. The coffe ground emesis resolved, but the patient continued to have 1-2L /day watery diarrhea (no infectious etiology had was found) so octreotide was started. The patient continued to have diarrhea with decreased po intake so TPN was started. After [12-23] days of octreotide, the patients diarrhea decreased to [4-26] episodes per day. Repeat stool studies were again negative. The patients ANC began to rise on day 17. He was no longer neutropenic by day 18 so the neupogen was stopped. The vanco and cefepime were also stopped because he was no longer febrile. Because the patient was no longer neutropenic, he was able to have an EGD which was notable for grade 1 esophagitis and diffuse nodularity of the mucosa of the duodenom. The path from the biopsies were consistent with crypt abscess from drug vs infection. CMV and fungal cultures were negative from the biopsies. It was felt that the etiology of the diarrhea was methotrexate induced. The patient was still afebrile so the caspo was stopped. Over the next few days, the patients wbc count increased despite stopping neupogen. By day 21, his wbc increased to 49. Flow was sent on the blood and it was found to not be consistent with Burkitts. In the setting of such a high wbc, there was concern for Cdiff Toxin B even though Cdiff A was negative x >3 so stool was sent for toxin B and the patient was started on po vanco in addition to flagyl. TGG was also sent to evaluate for celiac sprue. This test was also negative. A repeat abdominal CT was done which was notable for stable mass in spleen, stable paraortic lymph nodes and no thickening of wall of small bowel. The patients diarrhea began to slow down to 2-3 stools per day and his wbc trended down. On day 26, his wbc was 17.6, his t. bili was 1.7, he had only [11-21] stools per day so it was decided to start part b of modified [Last Name (un) ] protocol (IVAC). He was given 75% dose of etoposide and ara-c, 100% dose of ifosfamide in light of his elevated bilirubin. The patient was also started on mesna with the ifosfamide. Baseline cerebellar check was only notable for minimal intention tremor with finger to nose testing. The patient's cerebellar exam remained stable throughout and s/p the 4 doses of ara-c. He tolerated the 5 days of chemo well. His course was complicated only by minimal nausea decreased with anzemet and ativan. On day 8, the patient received IT MTX with no complications. His ANC on discharge was 1170. He refused 1 Unit PRBC prior to discharge. #LUQ pain - the patients pain was well controlled with PO pain meds until after his first round of chemo. The pain then increased and he required a morphine pca for pain control. The PCA was stopped in the setting of the patient's acute mental status changes while he was hypovolemic/hypotensive. When he was transferred back to 7 [Hospital Ward Name 1826], he was started on a fentanyl pca for pain control. This did not decrease his pain, so he was changed back to a morphine pca. The morphine pca gave him good relief. Prior to discharge, he was changed to ms contin and po msir for breakthrough pain. #Acute renal failure - In the setting of the patient's hypotensive episode, his creatinine increased to a max of 1.4. His BUN increased to 24. His FeNa was 1.4%. It was felt to be secondary to volume depletion (prerenal). The patient's UO remained 50-100 cc/hour. Due to concern for methotrexate toxicity (completed on [11-6]) and MTX level 0.36 on [11-8], especially in light of sepsis and potential third spacing of MTX, IV leucovrin was increased and hemodialysis was started. His methotrexate level decreased appropriately, and no further hemodialysis was required. #Hyperbilirubinemia - In the setting of the diarrhea, hypotension, the patients bilirubin also started to rise. It was mostly direct by fractionation. A ruq ultrasound was normal and had normal venous flow. The patients peak bilirubin was 8.1 with direct bili of 5.7 on day . Hepatitis A, B and C serologies were sent which were negative. The etiology of the hyperbilirubinemia was unknown, and with negative US and CT scan it was felt to be secondary to septic gallbladder (although peaked several days after the episode of hypotension occurred) vs methotrexate effect. The patient remained on actigall 600 mg [Hospital1 ] throughout the admission. His bilirubin trended down to normal on the actigall. #Altered Mental Status - On day 13, in the setting of the diffuse watery diarrhea and hypotension, the patient became lethargic. It was felt that the ativan given for his nausea and his morphine pca could be contributing to his altered mental status so both of these were held. The patients neuro exam was nonfocal during the episode. The patients lethargy resolved after stopping these meds and after aggressive hydration. #Depression - The patient has a history of several major depressive episodes. He has been hospitalized at least 2 times for "breakdowns". He was admitted on celexa 40 mg daily and wellbutrin 200 mg [Hospital1 ]. Throughout the admission, he remained down with a flat affect. His celexa dose was increased to 60 mg daily with improvement in his mood. He was also seen by psychiatry who felt that he should be maintained on celexa and wellbutrin. #FEN - The patient remained on TPN from day 17 until discharge. His electrolytes were repleted as needed. #Code - Full. Medications on Admission: Meds @ home: Wellbutrin 200 mg po bid, Celexa 40 mg po qd, Colace 100 mg po bid, MVI 1 tab po qd, Percocet 1-2 tabs q4-6h. 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. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 3. Bupropion HCl 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:180 Capsule(s) Refills:2 5. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:120 Capsule(s) Refills:2 6. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 10 days. Disp:20 Tablet(s) Refills:0 7. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. Disp:45 Tablet(s) Refills:0 8. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:0 9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for nausea. Disp:30 Tablet(s) Refills:0 10. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthru pain. Disp:24 Tablet(s) Refills:0 11. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection Q24H (every 24 hours): Please inject 480 mcg subcutaneously x 6 days. Disp:10 mL Refills:0 12. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). Disp:60 ML(s) Refills:2 13. Vancomycin HCl 250 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:28 Capsule(s) Refills:0 14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Burkitt's Lymphoma Discharge Condition: Stable Discharge Instructions: please take all medications as prescribed. If you have fevers, chills, sweats, nausea, vomiting, abdominal pain, increased diarrhea, you should call Dr.[Name (NI) 3930] office or come to the emergency department. Temperatures of 100.4 and above should be considered a fever while your white count is low. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7779], MD Where: [Hospital6 29] HEMATOLOGY/BMT Phone:[Telephone/Fax (1) 3237] Date/Time:[2100-12-2] 2:30 Name: [Known lastname 11016],[Known firstname ] Unit No: [Numeric Identifier 11017] Admission Date: [2100-10-26] Discharge Date: [2100-12-1] Date of Birth: [2044-2-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11018] Addendum: The patient was started on GCSF on [2100-11-30]. He will continue it for 8 doses per modified [Last Name (un) 11019] protocol. Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 11020] MD [Doctor First Name 11021] Completed by:[2100-12-4]	[ "995.92", "789.2", "428.0", "787.01", "305.1", "009.3", "038.9", "584.9", "289.59", "E933.1", "535.61", "275.2", "276.8", "458.9", "782.4", "293.83", "285.9", "276.5", "288.0", "200.28", "783.21", "575.9", "530.21" ]	icd9cm	[ [ [] ] ]	[ "03.31", "99.15", "38.93", "99.04", "88.47", "41.32", "99.25", "39.95", "96.07", "45.16" ]	icd9pcs	[ [ [] ] ]	20427, 20597	7417, 17249	360, 395	19316, 19324	2357, 7394	19683, 20404	1801, 1934		17422, 19225		19275, 19295		17275, 17399			19348, 19660									1949, 2338																					277, 322							423, 1493																	1515, 1565	1581, 1785
64,507	192,284	35270	Discharge summary	report	Admission Date: [2142-12-1] Discharge Date: [2142-12-2] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: HYPOTENSION, UTI Major Surgical or Invasive Procedure: None. History of Present Illness: 86 yo F, from [State 4260]. PMH of several stents and CAD, HTN, hyperlipidemia, hypothyroidism. Unsure about medications. Drove in from [State 4260] yesterday. Normally drinks 6+ glasses of water. Decreased po intake today given a wedding today. Yesterday with difficulty getting stream going, no burning. At reherasal dinner, very warm environment, ended up LOC. Does endorse N. No HA, F/Ch, sweats, pain. Initial VS 98, 55, 75-80/60, 17, 98/RA. EKG with V1 and V2 changes with ?ST changes. Given ASA 325mg po. Obtained EKG from [State 4260], revealed that they were old. Cardiology consulted and provided agreement. WBC 31.5, with band 7 and left shift. BUN:Cr appears dry. Normal Trop and lactate. Given 3L NS in ED. With improvement of hypotension to high 80s. Also given Cipro 400mg IV in ED. Afebrile throughout. Access from ED was 18g and 20g. . Upon ROS denies F/Ch, back pain, burning with urination, diarrhea, BRBPR, hematuria, cough, abdominal pain, CP, SOB, orthopnea, rash or recent antibiotic use. Past Medical History: CAD s/p MI in [6-13] with 2 stents placed (unsure of type) HTN Hyperlipidemia Hypothyroidism s/p CCY Social History: Lives in independent housing. Denies tobacco, drug or EtOH use. In town for grandaughter's wedding. Family History: Mother with unknown cancer. Father with MI. Physical Exam: 95.7, 76, 116/53, 68, 16, 100/2L NC Gen: NAD, alert and conversant HEENT: NCAT, PERRL, MMM Neck: Supple, no JVD CV: RRR without m/g/r Pulm: symmetric expansion, CTAB anteriorly, diminished BS in bases posteriorly with crackles; no wheeze or rhonchi Abd: +Active bowel tones, soft, NT, ND Ext: WWP with 1+ edema b/l Neuro: A&O x 3, CN II-XII grossly intact, moving all limbs equally Pertinent Results: WBC 31.5, Hb 10.6, HCT 31.1, Plt 210 N:79 Band:7 L:7 M:4 E:3 Bas:0 Nrbc: 9 . Na 134, K 4.7, Cl 104, HCO3 21, BUN 36, Cr 1.1, Glu 150 CK: 46 MB: Notdone Trop-T: <0.01 . PT: 12.7 PTT: 20.0 INR: 1.1 Lactate:1.0 . URINE WBC [12-27], Bact Rare, Leuk Mod, Nitr Neg . IMAGING CHEST (PORTABLE AP) Study Date of [2142-12-1] 9:05 PM Single portable AP radiograph of the chest was performed. There is no relevant prior imaging for comparison. FINDINGS: The heart is enlarged. Lungs are clear. Pulmonary vasculature is within normal limits. CHEST (PORTABLE AP) Study Date of [2142-12-2] IMPRESSION: No significant interval change with no evidence of acute cardiopulmonary disease. Brief Hospital Course: 86 yo F, with CAD, HTN, hyperlipidemia; p/w decreased uop and hypotension. . # Hypotension: Likely multifactorial. Initially could be primarily from poor po intake with continued 'water pill' dosing. BUN:Cr c/w dehydration. Also with concern for evolving sepsis with leukocytosis > 30 and bandemia. Reassuringly, lactate was not elevated. Improved on transfer with SBP > 100. Monitored uop and pressure, considered further resuscitation with CVL, but pt has refused to sign ICU consent upon admission. Treated UTI with ciprofloxacin. Followed cultures and CXR. . # UTI. Likely worsened / propogated by poor po intake and dehydration. Reports only one other UTI in the past and denies any complications. Afebrile (but mild hypothermia upon transfer), no flank pain or abdominal pain, so low suspicion for kidney infection. Followed with blood and urine cultures and treated with Cipro 250mg po Q12 x 3 days . # Hypoxia: New O2 requirement, likely [3-10] IVF. - Monitored, weaned as tolerated and resolved. Follow up CXR was unremarkable. . # Hypothermia: Likely [3-10] infection. Monitored, resolved. . # CAD s/p MI. Continued Plavix 75mg daily and ASA 81 mg daily. . # Hyperlipidemia: continued simvastatin 80mg daily upon discharge. . # Hypertension: Hypotensive upon presentation as above, which rapidly resolved with IVF and antibiotics. Restarted Carvedilol 12.5mg daily along with the rest of pt's medications as prescribed, but instructed pt to hold Lisinopril and Spironolactone until she returns home from wedding. . # Hypothyroidism: Continued Levothyroxine 75 mcg daily, once meds confirmed by family. . FEN Appears euvolemic except mild crackles at bases, continued volume resuscitation as above / repleted PRN / NPO until pressure stable . Ppx Pneumoboots, bowel regimen PRN . Code Status: DNR/DNI, confirmed on admission, states she's discussed this with her daughter . Communication: [Doctor First Name ] and [Name (NI) ] [Name (NI) 80452] (son-in-law to spend night in waiting room) Medications on Admission: ASA 81mg daily Spironolactone 25mg daily Simvastatin 80mg daily Carvedilol 12.5mg daily Plavix 75mg daily Levothyroxine 75mcg daily Omeprazole 20 mg daily Lisinopril 10mg daily Aspirin 81mg daily Discharge Medications: 1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:6 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day for 10 doses. Disp:10 Tablet(s) Refills:0 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO once a day for 10 doses. Disp:10 Tablet(s) Refills:0 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day: Do not restart until you have completed your antibiotics. 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day: Do not restart until you have completed your antibiotics. Discharge Disposition: Home Discharge Diagnosis: Primary: Urinary tract infection, low blood pressure (hypotension) Secondary: Coronary artery disease, history of hypertension, high cholesterol, hypothyroidism, history of anemia Discharge Condition: Hemodynamically stable, afebrile and improved. Discharge Instructions: You were admitted with low blood pressure and a brief loss of consciousness while in a warm room. You were found to be dehydrated and have a bladder infection. You were given IV fluids and antibiotics. Once improved, you were discharged home for further recovery. Take all medications as prescribed. Do not take your Lisinopril or your Spironolactone until you have completed you return home. You have been given prescriptions for Plavix, Carvedilol and Ciprofloxacin. Take these medications as prescribed until you get home and resume all your medications. Please follow-up with your regular physician later this week. Discuss your illness and hospitalization. You should also discuss further evaluation for your low blood counts (anemia) and low platelets (thrombocytopenia). Followup Instructions: Follow-up with your regular physician [Last Name (NamePattern4) ] [8-16] days to discuss your hospitalization, bladder infection and further evaluation of your low blood count (anemia). [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2142-12-3]	[ "780.65", "458.9", "780.2", "401.9", "V45.82", "412", "244.9", "599.0", "V45.79", "272.4", "414.01" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5977, 5983	2775, 4800	279, 287	6208, 6257	2066, 2752	7093, 7444	1603, 1648		5047, 5954		6004, 6187		4826, 5024			6281, 7070									1663, 2047																					223, 241							315, 1341																	1363, 1470	1486, 1587
9,319	123,202	44855	Discharge summary	report	Admission Date: [2102-3-13] Discharge Date: [2102-3-19] Service: UROLOGY Allergies: Toprol Xl Attending:[First Name3 (LF) 6440] Chief Complaint: Bladder and left ureter tumor, incisional hernia Major Surgical or Invasive Procedure: Left ureterectomy with bladder cuff excision, incisional herniorrhaphy History of Present Illness: 83F with bladder and left ureteral tumor identified on work-up of hematuria. Bladder biopsy last month identified papillary urothelial carcinoma, high grade, with focal lamina propria invasion. Past Medical History: 1) Afib 2) Hypertension 3) CHF (unclear if systolic, diastolic, or both; EF 60% in [12-11]) 4) DM Type II- diet controlled. 5) Thyromegaly- Noted at last clinic visit. Scheduled for outpatient scan. 6) RML/RLL PNA with parapneumonic effusion on [12-21] admission. 7) Pseudogout Social History: She lives alone but has a daughter and sons who live nearby. No hx of tobacco or EtOH. Family History: Non-contributory. Physical Exam: General: comfortable Abd: soft, non tender, non distended Incision: clean, dry, intact Foley: cranberry colored urine Pertinent Results: [2102-3-19] 07:35AM BLOOD WBC-8.5 RBC-3.06* Hgb-9.4* [Month/Day/Year ]-27.0* MCV-88 MCH-30.6 MCHC-34.7 RDW-14.4 Plt Ct-224 [2102-3-18] 06:30AM BLOOD Creat-1.7* Brief Hospital Course: Ms. [Known lastname 45417] was admitted to Dr. [Last Name (STitle) 365]??????s Urology service after undergoing left ureterectomy with bladder cuff excision and herniorraphy, transfused 6U PRBC intraoperatively. Please see dictated operative note for details. She received perioperative antibiotic prophylaxis. She was observed in the PACU overnight, extubated POD1. She was transferred to the urology floor from the PACU in stable condition. She experienced rapid atrial fibrillation POD1 that resolved with IV beta blocker and her home digoxin and oral beta blockers. Her pain was initially controlled with intravenous analgesics then oral analgesics as diet was advanced. NGT removed POD2, JP removed POD4. Diet was advanced conservatively to regular diet POD5. She was transfused an additional unit of blood POD 4 for [Last Name (STitle) ] 25, post-transfusion [Last Name (STitle) ] 27. Her major complaint has been bladder spasms, managed with levsin and ditropan. She worked with physical therapy who recommends home physical therapy. The remainder of the hospital course was relatively unremarkable. She was discharged in stable condition, ambulating, eating well, and with bladder spasm and pain control on oral analgesics. On exam, her incision was clean, dry, and intact, with no evidence of infection. Urine is cranberry colored. She was given explicit instructions to follow-up in clinic with Dr. [Last Name (STitle) 365] in 1 week, and that the urethral catheter (foley) would be removed during the follow-up appointment. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for 1 weeks. Disp:0 Tablet(s) Refills:0 2. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO 8PM (). Disp:0 Tablet(s) Refills:0 3. Atacand 16 mg Tablet Sig: One (1) Tablet PO Daily (). Disp:0 Tablet(s) Refills:0 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:0 Cap(s) Refills:0 5. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:0 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:0 Capsule, Sustained Release(s) Refills:0 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:0 Tablet(s) Refills:0 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:0 Tablet(s) Refills:0 9. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as needed for pain for 3 days: No alcohol or driving on this medication. Disp:20 Tablet(s) Refills:0 10. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual every six (6) hours as needed for bladder pain for 2 weeks: Stop 24 hours before foley is to be removed. Disp:56 Tablet, Sublingual(s) Refills:0 11. Oxybutynin Chloride 5 mg Tablet Sig: 0.5-1 Tablet PO TID (3 times a day) as needed for bladder spasm for 2 weeks: Stop 2 weeks before foley is to be removed. . Disp:42 Tablet(s) Refills:0 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation for 1 weeks: Take while on oxycodone. Stop when having regular bowel movements. Disp:20 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Left ureteral/bladder cancer, incisional hernia Discharge Condition: Stable Discharge Instructions: Do not restart coumadin until you hear from Dr. [Last Name (STitle) 365]; otherwise take your home medications as before. No vigorous physical activity for 2 weeks. Expect to see occasional blood in your urine. You may shower and bathe normally. Do not drive or drink alcohol if taking narcotic pain medication. Resume all of your home medications, but please avoid coumadin/aspirin/advil until you hear from Dr. [Last Name (STitle) 365]. Call Dr.[Name (NI) 6444] office for appointment AND if you have any questions. If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: Call Dr.[Name (NI) 6444] office for appointment on discharge ([Telephone/Fax (1) 6445]) AND if you have any questions. Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name12 (NameIs) ] INTERNAL MEDICINE (NHB) Phone:[Telephone/Fax (1) 3070] Date/Time:[2102-5-11] 10:15	[ "553.21", "285.1", "427.31", "596.8", "241.1", "250.00", "252.01", "189.2", "V45.73", "428.0", "401.9", "188.8" ]	icd9cm	[ [ [] ] ]	[ "56.42", "53.51" ]	icd9pcs	[ [ [] ] ]	4665, 4724	1360, 2916	265, 338	4816, 4825	1163, 1337	5550, 5850	991, 1010		2939, 4642		4745, 4795					4849, 5527									1025, 1144																					177, 227							366, 561																	583, 870	886, 975
13,101	174,194	46130+58882	Discharge summary	report+addendum	Service: Date: [2123-11-22] Date of Birth: [2069-5-9] Sex: M Surgeon: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] HISTORY OF THE PRESENT ILLNESS: This is a 54-year-old gentleman, who was recently discharged on the 13th of [Month (only) ] to rehabilitation with multiple medical problems, including coronary artery disease, status post [Female First Name (un) 899] in [2115], congestive heart failure with EF of 20% to 30%, status post pericardial stripping, prostatic mitral and tricuspid valve placement in [Month (only) 205], [2123] for valve dysfunction and constriction after radiation; ICD placement for nonsustained VT and low ER inducible VT. The patient was admitted recently with shortness of breath and pulmonary edema. He had respiratory distress, which was felt to be multifactorial and in part, due to MRSA pneumonia and CHF. Hospital course then was complicated by episodic hypotension requiring transient inotropic and pressor support. Hemodynamic monitoring was not possible secondary to the prosthetic tricuspid valve. Hemodynamics using showed physiology consistent with sepsis. He improved with antibiotics, and eventually he was diuresed and afterload reduced. The etiology of the infection was thought to be pneumonia. He was covered broadly. Cultures were negative except for sputum with MRSA. Pleural effusion was tapped and it was transudative with on evidence of infection. He has had a chronically low hematocrit, which is multifactorial. There was no evidence for DIC. He did have blood loss from the left femoral artery puncture site and required transfusion, bronchitic support, and blood loss anemia. On the evening of the 19th, he was found to be hypotensive with the blood pressures in the 70s and poor oxygenation. His chest x-ray showed CHF versus ARDS. He developed a fever to 101.2. He was started on Dopamine. He was sent to [Hospital1 98139] for further care. He notes increased sputum production, but no dyspnea or chest pain. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post inferior myocardial infarction [2114] complicated by left ventricular thrombus, status post left circumflex stent in [2123-4-1]. 2. Congestive heart failure. 3. Status post mitral valve and tricuspid valve prosthetic replacement [2123-8-10]. 4. AICD in [2123-4-1]. 5. History of cerebrovascular accident with residual left finger numbness. 6. History of Hodgkin lymphoma at the age of 27, status post radiation and splenectomy. 7. Hypercholesterolemia. 8. History of cervical diskectomy. 9. Tracheostomy in [2123-8-1]. 10. Gastrostomy tube placed in [2123-8-1]. 11. MRSA diagnosed in [Month (only) ], [2123], with witnessed aspiration with p.o. medications and liquids. 12. Constrictive pericarditis. 13. Iron-deficiency anemia. MEDICATIONS ON ADMISSION: 1. Ceftazidime started [10-19]. 2. Epogen. 3. Amiodarone 400 p.o.q.d. 4. Aspirin 325 p.o.q.d. 5. Iron. 6. Lasix 20 mg p.o.q.d., 20 mg IV. 7. Spironolactone. 8. Levothyroxine 200 p.o.q.d. 9. Enoxaparin 40 subcutaneously b.i.d. 10. Kayexalate. 11. Ativan. 12. Morphine p.r.n. ALLERGIES: No known drug allergies. FAMILY HISTORY: The patient's father died from colon cancer. No history of coronary artery disease. The patient is married. He used to self employed. He does not smoke or drink alcohol. He currently lives at [Hospital ] Rehabilitation Center. PHYSICAL EXAMINATION: The patient is resting comfortably in bed in no acute distress. VITAL SIGNS: Blood pressure 76/43 left arm; 97/44 right arm. Pulse 80. Saturation 94% on 100 FIO2. HEENT: Pupils equal, round, and reactive to light and accommodation. Extraocular muscles are intact; anicteric sclerae. Hearing aids are in place. Moist mucous membranes. Neck was supple without lymphadenopathy. LUNGS: Coarse sounds throughout; no wheezes or rhonchi. CARDIOVASCULAR: No jugular venous distention. Carotids normal with brisk upstrokes, regular rate and rhythm. Mechanical S1 and normal S2; no rub or gallop. ABDOMEN: Abdomen was soft, nondistended, nontender, normoactive bowel sounds. EXTREMITIES: Positive pitting of the lower extremities of thigh, pitting edema in the arm, markedly improved from previous hospitalization. There was a well healed scar of the left arm, PIC in the right arm. Dressings to both heels decubitus ulcers. Chest: Well healed scar, muscular chest-wall defect dressed. Decubitus on sacrum mildly erythematous without obvious drainage. LABORATORY DATA: Laboratory revealed the hematocrit of 23.4; platelets 453,000, white blood cell count of 9.8 with no bands; sodium 134; potassium 5.2; chloride 99; bicarbonate 26; BUN 123; creatinine 1.5; glucose 116; calcium 7.5; magnesium 3.4; phosphorus 5.6; albumin 2.5; INR 1.3; PTT 32; arterial blood gas on 90% with FIO2 with 5-cm of PEEP revealed the pO2 of 7.36, pCO2 of 49, pO2 of 56. Chest x-ray showed diffuse alveolar filling with patchy interstitial markings. The last echocardiogram revealed an EF of 25 to 35% with normal valve function; severe global left ventricular hypokinesis; mild right ventricular dilation. HOSPITAL COURSE: Mr. [Known lastname ] was treated simultaneously for infectious pneumonic process, as well as congestive heart failure. For pneumonia he had initially received Vancomycin, and the Zosyn. He was extensively evaluated by the Heart Failure Team, Dr. [Last Name (STitle) ] for management of his CHF and possible candidacy for heart transplant. He was initially tried on Milrinone, but failed secondary to hypertension. Dopamine was tried with limited success in conjunction with aggressive bolus Lasix regimen. Dopamine was discontinued and we started using a combination of afterload reduction and inotropic support. The patient did not successfully diurese to this regimen. Sputum eventually showed polys with no organisms, but grew out a fairly resistant Serratia and Klebsiella and was started on Imipenem. However, he developed a rash from the Imipenem and he was started on Bactrim. The Bactrim was ultimately discontinued. He remained on the Dopamine until [11-19]. He had been intermittently tried on Dopamine, Dobutamine, and Lasix drip with again limited success in terms of diuresis. Multiple blood transfusions were given to support hematocrit greater than 30. His renal function intermittently improved and worsened based on the degree of diuresis. There was an episode of acute renal failure during the week of [11-10], probably secondary to hypotension after failed attempt to wean Dopamine in conjunction with oncotic support in the form of packed red blood cells and Lasix. Renal function returned closer to baseline of 2. Multiple trials of trach-mask were attempted, however, the patient did not have the cardiac function to support spontaneous ventilation and eventually tired. He has been intermittently using between 10 to 20-cm of pressure support in conjunction with 5-cm to 10-cm of PEEP and an FIO2 ranging between .4 and 1. The Dopamine was eventually weaned to off on [11-29] and 21st with just Dobutamine and Lasix. The patient diuresed fairly successfully 3-4 liters over a [3-6] day period. Access had been a difficult issue secondary to extensive bleeding in the femoral region in the past. A right subclavian was attempted, but failed. Right internal jugular complicated by arterial puncture and a PICC line had been placed in the right arm, which is functioning at this point. Over the week of [11-12] to [11-19], the patient was tried on trach-mask trials. However, this in conjunction with changes in the Ativan dosing produced hallucinations and delirium. The patient was placed back on pressor support ventilation and improved significantly in terms of his mental status. ISSUE #1. Cardiovascular: The patient is status post multiple inotropic trials to improve cardiac function and diurese both left and right side fluid overload. He has been intermittently tried on milrinone, Dopamine, and dobutamine. The most successful of these regimens has been a combination of dobutamine and Lasix. The patient did not tolerate Milrinone secondary to hypotension. On Dopamine, he would intermittently diurese, but not progressively. Maintaining the patient 200 cc to 300 cc negative a day is a reasonable goal on a moderate dose of Dobutamine at 6 mcg per k per minute using a Lasix drip at 5 to 20 mg an hour. In terms of his tricuspid and mitral valve replacement, the patient was initially on Coumadin, which had been stopped, however, his INR continued to take a long to drip down secondary to poor nutrition. He had an INR of 4.2. There was moderate bleeding from the trach-site. The patient was reversed with FFP. The INR was brought down to 1.9, at which time Heparin was started. As the patient improved, he started on Coumadin with a target INR of [4-4]. The patient continues to be V-paced at 80. ISSUE #2. Pulmonary: The patient has a history of pneumonia, which in the past grew MRSA. During this admission grew Klebsiella and Serratia sensitive to Imipenem and Bactrim. The patient developed a rash to Imipenem and was started on Bactrim. The patient developed a rash to Imipenem. The patient was started on Bactrim. However, this was stopped in the setting of acute renal failure for the worry of possible interstitial nephritis. However, the patient did not seem, from the respiratory standpoint, to acquire antibiotics. Antibiotics were stopped on the 10th and 12th of [Month (only) 359]. Chest CT was performed on the [11-19] to help characterize the degree and extent of pulmonary disease. The CT was notable for consolidation and interstitial disease, which was central sparing the periphery consistent the primary pulmonary process. No significant CHF was seen in the periphery. It is possible that the amount of radiation received 20 years ago may have resulted in a primary interstitial process to whatever cardiogenic process is occurring. With aggressive diuresis in [Month (only) 359] on Dobutamine and Lasix the oxygen requirements decreased to FIO2 of .41. Ensuring a steady diuresis of 200-300 cc a day should prevent further oxygen requirements. However, it is unlikely secondary to the patient's poor cardiac function and extent of interstitial disease that he will become vent independent in the near future. ISSUE #3: Renal. The patient had sensitive renal function. Creatinine ranged from 1 to 3. He is clearly sensitive to renal perfusion and systolic blood pressure and keeping the hematocrit above 30 to maintain good oncotic pressure for renal perfusion is necessary for good renal function. His renal function was very sensitive to blood pressures below 70 to 80, causing acute renal failure with an ATN type picture. However, with improved and aggressive diuresis off the Dopamine, his renal function has improved to a baseline of 1.1. A limit to his diuresis may be reached in terms of the BUN, which has risen to the high 90s. ISSUE #4: Endocrinological: From an endocrinological standpoint he has a history of hypothyroidism; TSH has been relatively high and consistent with hypothyroidism in the setting of systemic illness. His Levothyroxine doses have been progressively increased. He is now at 200 mcg a day and will need a TSH checked in the near future., ISSUE #5: Gastrointestinal. The patient was received tube feeds through his PEG, however, due to increased agitation and abdominal distention in the absence of clear obstruction or perforation, his tube feeds were stopped in favor or TPN. As his fluid balance continues to improve, he should be able to start enteral feeding. ISSUE #6: Psychiatric. The patient was controlled primarily with Remeron and Ativan for sleep at night. When the Ativan was discontinued in conjunction with trach-mask trials, his mental status acutely decompensated in the form of hallucination and delirium. The mechanical ventilation was restarted with progressive clearing of his mental status. There was no evidence of CO2 narcosis. However, hypoxia is a significant possibility for cause of mental status changes during independent ventilation. The Remeron was discontinued. The patient responds well to Haldol, as needed. ISSUE #7. Electrolytes were followed closely. Potassium was repleted as needed, as well as magnesium. Nutrition was as above. The patient has a right peripherally inserted central catheter, which is functioning. The patient has been placed on a proton pump inhibitor and had an elevated INR for much of his hospitalization, but recently this has been reversed as described, and the patient has been Heparinized. This discharge summary will continued in a DC addendum. The patient is currently a full code. Numerous family discussions with his wife and himself were held. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Name8 (MD) 30528] MEDQUIST36 D: [2123-11-22] 14:47 T: [2123-11-22] 15:18 JOB#: [Job Number 98140] Name: [Known lastname 15655], [Known firstname 116] Unit No: [Numeric Identifier 15656] Admission Date: [2123-11-19] Discharge Date: [2123-12-6] Date of Birth: [2069-5-9] Sex: M Service: ICU ADDENDUM: Mr. [Known lastname ] continued to remain hemodynamically stable and on stable vent settings throughout the remainder of his hospital stay. His Lasix was weaned down to 60 mg [Hospital1 ] for a rising BUN to 120 and creatinine to 1.3 on the day of discharge. At this point his fluid status is felt to be slightly negative. DISPOSITION: He was discharged to rehabilitation in fair condition. DISCHARGE INSTRUCTIONS: 1. He should have strict monitoring of ins and outs and daily weights. At this time his fluid status is slightly negative. His Lasix should be adjusted for a goal positive of about 0.5 kg over the next one to two days and then aim for even fluid status. Monitor electrolytes, BUN, and creatinine twice weekly until stable on stable Lasix dose. 2. Check TSH in two weeks and adjust levothyroxine dose as needed. 3. Monitor hematocrit intermittently, especially if he continues to have intermittent hemoptysis or bleeding elsewhere. Transfuse as needed for a goal hematocrit of greater than 30. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg po q day. 2. Lansoprazole 30 mg po q day. 3. Levothyroxine 300 mcg po q day. 4. Captopril 18.75 mg po tid. 5. Lasix 60 mg IV bid, titrate to fluid status as above. 6. Lovenox 40 mg subcutaneous [Hospital1 ]. 7. Celexa 10 mg po q day. 8. Combivent eight puffs qid. 9. Epogen 5,000 units q Monday, Wednesday, and Friday. 10. Reglan 10 mg po tid. 11. Nepro tube feeds 40 cc/hr. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Pneumonia. 3. Hemoptysis. 4. Hypothyroidism. 5. Depression. 6. Coronary artery disease. 7. Status post mitral valve replacement and tricuspid valve replacement. 8. Status post automatic implantable cardioverter - defibrillator placement. 9. Status post tracheostomy. 10. Status post PEG. 11. Methicillin - resistant Staphylococcus aureus colonization. 12. Status post pericardial stripping for constrictive pericarditis. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3662] Dictated By:[Name8 (MD) 15657] MEDQUIST36 D: [2123-12-30] 11:57 T: [2123-12-30] 13:58 JOB#: [Job Number 15658]	[ "584.9", "201.90", "428.0", "038.9", "482.83", "518.81", "482.0", "292.81", "707.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "99.15", "38.93", "96.6" ]	icd9pcs	[ [ [] ] ]							3455, 14621	15700, 16423	15269, 15679				3112, 3438			14645, 15246																																																						2257, 3086
18,233	163,848	6338	Discharge summary	report	Admission Date: [2136-2-21] Discharge Date: [2136-2-25] Date of Birth: [2063-6-17] Sex: M Service: MEDICINE Allergies: Compazine / Phenergan / Percocet Attending:[First Name3 (LF) 4891] Chief Complaint: Shortness of breath, altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 72 yo man with h/o esophageal CA, COPD, multiple aspiration PNA in the past, currently NPO with g-tube who lives with family and presents with cough and difficulty breathing since this morning, associated with sore throat, nasal congestion. Per his family, he was also noted to be somnolent this morning and not at his mental baseline. They feel that he has been weaker than usual over the last 2-3 days. In the ED, initial vs were: T 101.6, P 128, BP 90/63, R 30, O2 93% on RA. He initially triggered for tachycardia, fever, and hypotension, and he was given 1L of NS. He had a CXR, which showed likely PNA in the left lung base, as well as abnormal densities in the right apex concerning for mass lesion. He was given Levoquin and Ceftriaxone for PNA. His EKG showed sinus tachycardia. His VS at the time of admission were P 120, SBP 110, R 30, O2 96% on 2L. On the floor, he notes continued difficulty breathing, although he is on his home oxygen regimen. Per his daughters, he is more alert than earlier today, but is still "slower" than his mental baseline. Review of systems: (+) Per HPI; family notes bilateral foot swelling/pain x 5 days, now resolved (-) Denies fever, chills (although he has been taking tylenol for bilateral foot pain). Denies headache, visual changes. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: COPD on 3L home O2 (increased to 4L for exertion), never intubated for exacerbation Pulmonary HTN Diastolic CHF (echo [1-30] EF>55%) CAD Esophageal adenocarcinoma diagnosed in [8-/2131], status post 5FU and Cisplatin, s/p complete surgical resection [1-1]. course c/b pericarditis and radiation pneumonitis and esophageal stricture, requiring G-tube placement. Chronic sinusitis DM2 due to chronic pancreatitis History of recurrent gallstone pancreatitis with resultant chronic pancreatitis, status post cholecystectomy. GERD Hypercholesterolemia H/o aspiration pneumonia Sinus tachycardia - resting HR is 100 Social History: Lives in [Hospital1 1474] with wife and several children, former Tobacco use (30 pack years), denies ETOH, illicit drugs. Family History: Mother with DM, Father with emphysema Physical Exam: GENERAL: Alert & Oriented x 3. HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple; No JVD, no thyromegaly, No LAD. CARDIAC: tachycardic, nl S1,S2, no m/r/g noted. LUNGS: Crackles at lung bases b/l, L>R, otherwise clear ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No cyanosis, clubbing, or edema. 1+ pulses. NEURO: CN2-12 intact. Pertinent Results: Admission Labs [2136-2-21] 12:35PM BLOOD WBC-11.3* RBC-2.99* Hgb-10.5* Hct-31.3* MCV-105* MCH-35.2* MCHC-33.5 RDW-15.4 Plt Ct-139* [2136-2-21] 12:35PM BLOOD Neuts-82.4* Lymphs-11.3* Monos-5.3 Eos-0.7 Baso-0.3 [2136-2-21] 12:35PM BLOOD Glucose-174* UreaN-55* Creat-1.1 Na-138 K-4.0 Cl-94* HCO3-34* AnGap-14 [2136-2-21] 12:35PM BLOOD ALT-29 AST-55* AlkPhos-110 TotBili-0.4 [2136-2-21] 12:35PM BLOOD Albumin-4.6 Calcium-10.0 Phos-1.8* Mg-2.4 [2136-2-21] CXR - Limited study due to low lung volumes. Relative increased ill-defined density at the left lung base which may represent early developing pneumonia or possibly aspiration, although atelectasis remains a consideration. The abnormal densities in the right apex are atypical for infectious foci. Further evaluation with chest CT after acute presentation subsides is advised due to the possibility of underlying mass lesion in patient with history of prior malignancy and risk factors for primary lung cancer (emphysema) [2136-2-22] RUQ US: Normal right upper quadrant ultrasound with no etiology for fever of unknown origin identified. Prior cholecystectomy with unchanged mild extrahepatic biliary dilation likely related to postcholecystectomy state. Brief Hospital Course: 72 year old male with esophageal cancer, COPD, multiple aspiration pneumonia who presented on [2136-2-21] with productive cough, tachycardia, relative hypotension and altered mental status. 1. Pneumonia: Presented with fever, tachcardia, productive cough and LLL infiltrate on CXR concerning for pneumonia. Empirically started on Vancomycin/meropenem due to history of ESBL and MRSA in the cough in the past. He was also started on prednisone 60 mg daily steroid burst for presumed COPD exacerbation. He had systolic blood pressure in 90s on admission which responded to three liters of normal saline bolus. On the floor, his antibiotic regimen was narrowed to levaquin. He went discharged with instructions to complete a 7 day course of levaquin. 2. Altered mental status: Likely in the setting of infection. No report of fall or other reason to suspect intracranial pathology. Mental status improved with fluid resuscitation and antibiotic treatment. 3. RUQ tenderness: Patient did not complain of abdominal pain but did have tenderness on initial exam without rebound or guarding. Liver enzymes were normal normal except for minimally elevated AST @ 55. Has history of gallstone pancreatitis s/p cholecystectomy. RUQ US showed normal pathology. 4. Diastolic heart failure: Was noted to have significant crackles on exam on day 2 likely from fluid resuscitation. Restarted on home lasix 60 mg po qam and 30 mg po qpm with good response in urine output and improvement in exam. 5. R apex lung lesion: Concerning for malignancy in the setting of cancer history and risk factors for primary lung CA (significant smoking history). Per heme-onc note in [Name (NI) 205], pt has many waxing and [Doctor Last Name 688] lesions in his lungs (c/w aspiration). They have discussed with the family that even if this were recurrent cancer, there is no treatment that would be reasonable to pursue, given that he would be unlikely to tolerate chemo, radiation, or even biopsy (risk of PTX). 6. DM - held metformin; started ISS. 7. CAD - continued home statin, ASA and metoprolol Medications on Admission: - metformin 1000mg QHS - humulin NPH 30U QHS - lasix 60mg QAM, 30mg QPM - metoprolol 12.5mg [Hospital1 ] - simvastatin 20mg daily - aspirin 81mg daily - prevacid 30mg solu tabs [Hospital1 ] - senna 2 tabs daily - ferrous sulfate 325mg daily - vitamin B12 1000mcg daily - MVI - flovent 2 puffs [Hospital1 ] - ipratropium QID - fluticasone 2 sprays daily PRN Discharge Medications: 1. metformin 1,000 mg Tablet [Hospital1 ]: One (1) Tablet PO at bedtime. 2. Humulin N 100 unit/mL Suspension [Hospital1 ]: Thirty (30) units Subcutaneous at bedtime. 3. furosemide 20 mg Tablet [Hospital1 ]: Three (3) Tablet PO DAILY (Daily). 4. furosemide 20 mg Tablet [Hospital1 ]: 1.5 Tablets PO QPM (once a day (in the evening)). 5. metoprolol tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 6. aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 7. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] twice a day. 8. senna 8.6 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO once a day as needed for constipation. 9. cyanocobalamin (vitamin B-12) 250 mcg Tablet [Last Name (STitle) ]: Four (4) Tablet PO DAILY (Daily). 10. fluticasone 110 mcg/Actuation Aerosol [Last Name (STitle) ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 11. fluticasone 50 mcg/Actuation Spray, Suspension [Hospital1 ]: Two (2) sprays Nasal at bedtime. 12. ferrous sulfate 325 mg (65 mg Iron) Tablet [Hospital1 ]: One (1) Tablet PO once a day. 13. ipratropium bromide 0.02 % Solution [Hospital1 ]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. levofloxacin 250 mg Tablet [Hospital1 ]: Three (3) Tablet PO DAILY (Daily) for 4 days. Disp:12 Tablet(s) Refills:0 15. simvastatin 20 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] & Hospice Discharge Diagnosis: Primary Diagnosis: - Community Acquired Pneumonia Secondary Diagnosis: - Esophageal Cancer - Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Vital Signs: HR range 100-120, SBPs 90-110, 99% 3L NC Discharge Instructions: Dear Mr. [Known lastname 24529], It was a pleasure taking care of you at [Hospital1 827]. You were admitted to the hospital with low blood pressure and fevers. You were found to have an infection in your lung. You were started on a course of antibiotics, and your condition improved during your hospital course. You will continue these antibiotics upon returning home with your family. . Please START the following medication: Levaquin 750 mg daily for a period of four days Please continue all other medications as they have been prescribed. Should you experience worsening shortness of breath, fevers, chills, chest pain, dizziness, or any other symptoms that concern you upon return home, please call your doctor or return to the emergency room as son as possible. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please call Dr.[Name (NI) 8716] office ([Telephone/Fax (1) 3183]) on Monday in order to schedule a follow-up appointment in the next week. Please follow-up at the following time/places: Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2136-4-6] at 9:00 AM With: [Name6 (MD) 251] [Last Name (NamePattern4) 15108], 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: CARDIAC SERVICES When: WEDNESDAY [2136-6-6] at 9:00 AM 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: MEDICAL SPECIALTIES When: MONDAY [2136-7-16] at 8:30 AM With: DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 612] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "840.4", "416.8", "428.32", "530.81", "486", "491.21", "V10.03", "272.0", "V44.1", "428.0", "250.00", "530.3" ]	icd9cm	[ [ [] ] ]	[ "96.6" ]	icd9pcs	[ [ [] ] ]	8549, 8630	4431, 5199	337, 343	8805, 8805	3170, 4408	9937, 11058	2731, 2770		6945, 8526		8651, 8651		6552, 6922			9044, 9914									2785, 3151																			1479, 1924		254, 299							371, 1460					8722, 8784				8670, 8701			8820, 9020					1946, 2570	2586, 2715
62,187	174,760	40479	Discharge summary	report	Admission Date: [2164-6-17] Discharge Date: [2164-8-8] Date of Birth: [2109-1-17] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Shellfish / Motrin Attending:[First Name3 (LF) 8810] Chief Complaint: AML Major Surgical or Invasive Procedure: PICC placement Bone marrow biopsy Bronchoscopy Intubation History of Present Illness: 55yo male with no known significant past medical history presents with new diagnosis of acute leukemia. . He has went to [Hospital ] Hospital outpatient clinic for evaluation for fatigue and redness of the left lower extremity. He had a CBC drawn and was asked to return to the ER the same day for concerning blood work (CBC from [Hospital ] Hospital: wbc 15 with 53% blasts; h&h 6.8 & 20; plt 29K). He was transferred to [Hospital1 18] ER and then admitted to medicine service. His CBC at [Hospital1 18] showed wbc 13 with 48% blasts. . Patient was also started on vancomycin IV for cellulitis of the left lower extremity. . He reports that he noticed fatigue for several months now but got much worse over the past week. He couldn't exercise as he usually does. Felt short of breath climbing stairs and carrying grocery bags. . No chest pain, fevers, chills, night sweats. No weight loss or headaches. No loss of appetite. No diarrhea or abdominal pain. No nausea or vomiting. No neurologic symptoms. Past Medical History: BPH HTN HL anxiety Social History: Work as a clerk at the [Company ]. Lives with his companian/girlfriend for the past ten years. No children. He has one sister (here with him today) who lives in [Hospital1 ]. No history of smoking. Does not drink alcohol. Does not do illicit drugs. Family History: Father had prostate cancer in his 70's but died from congestive heart failure. Mother deceased. Sister healthy Physical Exam: ADMISSION EXAM: GEN: AOx3, in NAD HEENT: PERRLA. MM dry. Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, Extremities: left lower leg cellulitis over the shin area. appears improved from initial marking. Skin: dry, no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. gait WNL. . Exam on Transfer to [Hospital Unit Name 153] Vitals: T: 100.8 BP: 89/61 P: 168 R: 28 O2: 98% on 4L General: Alert, oriented, appears comfortable despite increased respiratory rate HEENT: Sclera anicteric, pale, dry mucous membranes Lungs: rhochi throughout, RUL more pronounced CV: tachycardic Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, no clubbing, cyanosis or edema Skin: resolving erythema over left lower leg, no tenderness or warmth, left sided PICC- clean dressing, right upper neck with area of scale and erythema at site of former CVL, marker circling spot . Exam on transfer back to BMT: vs: T 96.2, BP 136/68, HR 84, RR 24, O2 sat 96% on 2L NC. GEN: sleepy, easily arousable; slow to answer but is appropriate HEENT: NCAT, anisocoria (L>R) secondary to past cataract surgery but pupils react appropriately to light; MMM, OP clear. Cards: RRR, nl S1/S2, no m/r/g Pulm: poor air movement throughout, decreased breath sounds in RUL, no crackles or wheezes Abd: +BS, nondistended, nontender to palpation GU: +foley draining clear urine Extremities: DP 2+ bilaterally, no c/c/e Skin: scab over R IJ site, scab over R antecubital area; L PICC line site c/d and without surrounding erythema or tenderness. Neuro: CN II-VII intact, follows commands slowly. Exam on discharge: VS: T 96.2 BP 148/72 HR 76 RR 18 O2 97% RA GEN: anxious, sitting up in a chair, NAD HEENT: NCAT, anisocoria (L>R) secondary to past cataract surgery but pupils react appropriately to light; MMM, OP with mild thrush. CV: RRR, nl S1/S2, no m/r/g Pulm: good air movement throughout, no crackles or wheezes Abd: +BS, soft, nondistended, nontender to palpation GU: no foley Extremities: trace peripheral edema, warm to palpation Skin: L PICC line site c/d and without surrounding erythema or tenderness. Neuro: language intact, gait ok with cane. CN II-XII intact. Pertinent Results: ADMISSION LAB: [2164-6-16] 11:25PM COMMENTS-GREEN TOP [2164-6-16] 11:25PM LACTATE-0.9 [2164-6-16] 11:17PM GLUCOSE-124* UREA N-15 CREAT-1.0 SODIUM-137 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13 [2164-6-16] 11:17PM ALT(SGPT)-25 AST(SGOT)-24 LD(LDH)-506* ALK PHOS-92 TOT BILI-0.3 [2164-6-16] 11:17PM LIPASE-21 [2164-6-16] 11:17PM ALBUMIN-4.1 CALCIUM-8.4 PHOSPHATE-2.9 MAGNESIUM-1.9 [2164-6-16] 11:17PM WBC-13.5* RBC-1.72* HGB-7.1* HCT-19.8* MCV-115* MCH-41.4* MCHC-36.1* RDW-14.8 [2164-6-16] 11:17PM NEUTS-26* BANDS-0 LYMPHS-21 MONOS-3 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-48* [2164-6-16] 11:17PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [2164-6-16] 11:17PM PLT SMR-VERY LOW PLT COUNT-30* [2164-6-16] 11:17PM FIBRINOGE-470* [2164-6-16] 11:17PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.004 [2164-6-16] 11:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG DISCHARGE LAB: XXXXXXXXXXXXXXXXXXXXXX IMAGING: ======== CT Head [6-16]: IMPRESSION: No acute intracranial hemorrhage or mass effect. . ECHO [2164-6-18] The left atrium and right atrium are normal in cavity size. 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 aortic arch is mildly dilated.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild mitral regurgitation with normal valve morphology. . Left lower extremity ultrasound [2164-6-18] IMPRESSION: No evidence of DVT. . CT CHEST [2164-7-12]: Right PICC line tip is in the proximal right atrium. Aorta is normal in diameter. Main pulmonary artery is not enlarged, but right main pulmonary rtery is 3 cm in diameter, might be reflecting pulmonary hypertension. Coronary calcifications are extensive. There is minimal amount of pericardial effusion, grossly unchanged since the prior study. Small but new bilateral pleural effusion is noted. Within the axilla, there are multiple minimally enlarged lymph nodes. There are no bone lesions worrisome for infection or neoplasm. Airways are patent till the level of subsegmental bronchi bilaterally. Right upper lobe consolidation seen on the prior CT and radiographs has significantly progressed since the prior study, currently involving the apical posterior aspect of the right upper lobe as well as superior aspect of right lower lobe. There is lucency within the lateral aspect of the consolidation in the right upper lobe, most likely representing still aerated lung and unlikely to represent cavitation although should be closely monitored. The left lung is clear except for basal opacities that in part might represent atelectasis and unlikely to represent infectious process. The progression of the consolidation has been also demonstrated on the chest radiograph when compared to [2164-7-8], thus further followup of the abnormality can be obtained with chest radiographs. The differential diagnosis would include rapidly progressing bacterial pneumonia. The other options would be invasive aspergillosis (less likely) as well as massive aspiration (unlikely). . TTE [2164-7-13]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic arch 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. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2164-6-18], the heart rate and estimated pulmonary artery pressures are higher. Other findings are similar . CT Torso [2164-7-19] Impression: 1. Continued interval worsening of multifocal pulmonary consolidations now involving most of the right upper lobe and majority of the lower lobe basal segments bilaterally. This process began only involving the posterior segment of the right upper lobe and has been slowly worsening over prior last 10 days. Small bilateral pleural effusions have also increased. 2. No significant pathology noted within the abdomen and pelvis other than slight interval increase of soft tissue anasarca and mild amount of intra-abdominal ascites. There are no findings of ileus or obstruction. . Liver and Gallbladder US [2164-7-22] IMPRESSION: Limited right upper quadrant ultrasound demonstrates a normal gallbladder without evidence of acute cholecystitis. . CT Chest [2164-7-30] As compared to the prior CT torso from [2164-7-19], there is significant interval improvement in the right upper lobe consolidation and left lower lobe consolidation with improved aeration of both lobes. The consolidation which are currently present are still substantial and involve the posterior segment of right upper lobe as well as apical and part of the basal segments of right lower lobe. There is interval improvement of pleural effusion, small. In the left lung, there is interval resolution of left lower lobe consolidation with only minimal residual present. There are multiple mediastinal lymph nodes, but none of them pathologically enlarged. Extensive coronary calcifications are present, unchanged. There is small amount of pericardial effusion, minimally increased since the prior study. There is evidence of anemia. The aorta is normal in diameter. Airways are patent to the level of subsegmental bronchi bilaterally. The left PICC line tip is at the cavoatrial junction level. Right lung pulmonary nodules are noted in the previously consolidated area of the lungs, most likely representing residua of prior infection, with similar appearance in the left lower lobe and might be reevaluated in three months for documentation of resolution. No evidence of interstitial abnormality is present. ======================= MICRO: BCx: all sterile UCx: all sterile Cryptococcal antigen: negative BAL ([2164-7-10]): neg Gram stain, commensal respiratory Cx, neg for legionella/KOH prep/PCP/fungus/nocardia/AFB/mycobacteria/CMV BAL ([2164-7-14]): Gram stain +leukocyte, no microorganism; neg respiratory Cx, neg for legionella/KOH prep/PCP/fungus/nocardia/AFB/mycobacteria/CMV MRSA screen negative Respiratory viral Cx ([2164-7-20]): negative C diff toxin ([2164-7-25]): negative Brief Hospital Course: Mr. [Known lastname 88668] is a 55yo male with no significant past medical history who presented with cellulitis and elevated WBC with high percentage of blasts and was diagnosed with AML-M2 carrying a (8:21) translocation. . # AML: Patient presented for evaluation of cellulitis and was found to have WBC 22 with 85% blasts. He underwent bone marrow biopsy [6-27] which showed new acute leukemia, AML-M2 with cytogenetics carrying translocations at ETO at 8q21 which is considered a to be a good prognostic indicator. Baseline ECHO showed mild MR and was otherwise unremarkable. He was treated with 7+3 induction chemotherapy and tolerated chemotherapy well. Day 14 bone marrow biopsy was hypocellular consistent with ablated marrow. ANC nadir was 0, and recovery began on day 18. His recovery bone marrow biopsy done on day 37 also showed complete remission. He will follow up with Dr. [Last Name (STitle) 3759] for consolidation chemotherapy. . # Pneumonia: Patient developed productive cough [7-8] in the setting of neutropenic fever, a CT chest showed a right upper lobe round infiltrate with surrounding ground glass opacities (halo sign). Concern for invasive aspergilosis was raised, ID was consulted and he was started on voriconazole (in addition to vancomycin and cefepime). He underwent broncheoalveolar lavage which revealed purulent material in the right upper lobe, cultures were taken which was unrevealing. He developed hypoxia and tachypenia and repeat CT showed progression of the previously seen right upper lobe infiltrate. His ANC had begun to recover at this time and clinical deterioration was partly due to immunereconstitution. Given tenuous respiratory status, he was transferred to the ICU for close monitoring in the context of tachycardia and hypotension. He had persistently high work of breathing during his second night, and failed treatment with BiPAP necessitating intubation. Repeat imaging showed worsening of his right upper lobe pneumonia, with opacities extending throughout the right hemithorax. As he failed to improve with broad spectrum antibiotics and fungal coverage, and as BAL failed to reveal a microbial pathogen on culture, a lung biopsy was initially pursued, though eventually postponed due to elevated PEEP and for fear of inciting pneumothorax in a tenuous patient. Flagyl and ciprofloxacin were added for c diff prophylaxis and additive GNR coverage, respectively. BAL was repeated on [2164-7-14] and [2164-7-20], which again failed to show any pathogenic culprit. He received a single dose of steroids on [7-22] in treatment of questionable BOOP, though this was discontinued in discussion with the BMT team who felt that infection was still most likely. He was eventually extubated on [7-23] to room air. He was transferred back to BMT on [7-26] and his antibiotics were stopped slowly. He is being covered with posaconazole at the time of discharge, and will continue this medication until end of his consolidation chemotherapy. The repeat Chest CT on [2164-7-30] showed significant improvement of pneumonia, but still significant consolidation of R lung and pulmonary nodules, likely infectious. . # Leukocytosis/Fever. Thought to be infectious with most likely source being in the lungs based on clinical presentation, imaging, and bronchoscopy. See above for management of pneumonia. However, BAL has not been revealing in terms of the causative microbe, but there is concern for fungal vs. bacterial pneumonia. He was started on broad spectrum antimicrobials. C. diff was also suspected given his ileus and rapid rise in WBC; therefore, he was started on IV flagyl and vancomycin enema, although he has been unable to tolerate vancomycin enemea. C. diff PCR was ordered for more definitive diagnosis, but he has not had BM. BMT service believes taht his leukocytosis and fever could be partly from robust return of his bone marrow s/p 7+3. After transfer back to the BMT service and with improvement of his pneumonia, he remained afebrile on the floor until discharge. . # Atrial fibrillation/flutter: Patient had new onset of atrial fibrillation with rapid ventricular response in the setting of sepsis from the above noted pulmonary infection. He was treated with metoprolol IV and PO and went in and out of sinus rhythm. He was transferred to the ICU as above in atrial fibrillation, though spontaneously converted soon after transfer in response to IV lopressor. He was placed on TID PO lopressor though again reverted to a fast atrial flutter at 150bpm during his second ICU night with hypotension to 80s systolic. He received bolus diltiazem and then diltiazem gtt with levophed support, and he eventually reverted to sinus rhythm. He began amiodarone loading to prevent further arrhythmia. He received IV amiodarone until [2164-7-20] because of concern for ileus, resumed po as bowel sounds returned, but ultimately stopped on [7-21] as he was persistently in sinus rhythm and with increasing alkaline phosphatase, thought [3-7] medications. His heart remained in normal rate at the time of discharge. . # Hypotension: He had hypotension to 80s systolic while in the MICU, which was initially fluid responsive. These pressures had occurred with his tachycardia and nodal blockade, and he was eventually placed on pressors as we struggled to control his HR. He remained hypotensive on high doses of fentanyl/midazolam to control agitation. While likely septic, his pressure improved with sedation weaning, suggesting a substantial iatrogenic source. He was weaned off pressors. He was eventually extubated, and his SBP remained in 110-130s on the floor. . # Cellulitis: Patient was presented with a left lower leg swelling and erythemia. Ultrasound was negative for DVT. He was diagnosed with cellulitis and treated with Vancomycin and Cefepime for an extended course given neutropenia. He completed a 24 day course of antibiotics and his cellulitis resolved. . # Rash: patient developed an erythematous, maculopapular non puritic rash over the extensor surface of his forearms bilatearlly. At the time, he had been treated with cefepime for 14 days and drug rash was considered possible. The rash was not severe and cefepime was continued given ongoing neutropenia. The rash resolved over time. . # Social Issues: The patient was very hesistant towards treatment throughout his stay and required encouragement to start chemotherapy. He benefited greatly from social work and chaplain support. . # Ileus. Tubefeeds restarted and now at 40 cc/ml. Still no bowel movement. - off vancomycin enema as above - on mostly IV formulation for meds at this time - continue bisacodyl pr prn - continue TF, check residual Medications on Admission: Trazodone Aspirin 81mg Terazosin Alprazolam Discharge Medications: 1. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:30 Tablet(s) Refills:0 2. posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: 5 (five) mL PO Q6H (every 6 hours). Disp:600 mL Refills:2 3. Xanax 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: AML (acute myeloid leukemia) Pneumonia (infection of lung) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (cane). Discharge Instructions: Mr. [Known lastname 88668], . It was a pleasure taking care of you in the hospital. You were admitted with new AML. You were treated with induction chemotherapy. We also treated cellulitis with antibiotics and this improved greatly. You developed neutropenia (low white cell counts) with chemotherapy and had fevers, for which you received antibiotics and had CT scan of your chest. CT scan of your chest showed pneumonia (infection of lungs) in your right lung, which was treated with antifungal medications. You also developed irregular, rapid heartbeat which were treated with medications, and your heartbeats are now normal. Because you had difficulty breathing with your pneumonia, you had to be intubated and have help with breathing for a while. You came out of the ICU, and did well on the floor with PT. You are still being treated with posaconazole for your pneumonia. You will continue taking this medication through the second round of chemotherapy. . We made many changes to your medications. Please see attached list to know what medications you should be taking. . -STARTED Posaconazole suspension 200 mg by mouth every 6 hours for your pneumonia. Please take this with fatty foods to increase the absorption of the medication. -STOPPED terazosin for your benign prostatic hypertrophy, you can restart this medication after discussing it with your primary care physician. [Name10 (NameIs) 88669] aspirin, please do not start taking this medication before discussing it with Dr. [Last Name (STitle) 3759]. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2164-8-10] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3884], MD [Telephone/Fax (1) 3237] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: HEMATOLOGY/BMT; Infectious Diseases Doctor When: THURSDAY [2164-8-23] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4861], MD [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "E930.5", "E933.1", "285.9", "112.0", "427.32", "038.9", "276.0", "205.00", "427.31", "458.29", "518.81", "707.03", "276.4", "117.9", "288.60", "600.00", "682.6", "707.22", "528.01", "E879.8", "999.31", "309.24", "576.8", "E930.1", "995.92", "288.03", "560.1", "693.1", "401.9", "300.4", "272.4", "484.7" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "38.97", "96.72", "99.25", "33.24", "96.6", "41.31", "38.91" ]	icd9pcs	[ [ [] ] ]	18757, 18840	11556, 18311	350, 410	18943, 18943	4262, 11533	20672, 21351	1792, 1905		18406, 18734		18861, 18922		18337, 18383			19116, 20649									1920, 3663																					307, 312							438, 1459		3682, 4243										18958, 19092					1481, 1501	1517, 1776
8,494	192,555	25974	Discharge summary	report	Admission Date: [2114-1-1] Discharge Date: [2114-1-16] Date of Birth: [2049-1-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Brochoscopy Intubation Selective embolization of bronchial circulation x2 Central venous catheter placement History of Present Illness: 64 y.o. man with hairy cell leukemia x 10 years, protate CA, non-small cell lung Ca in RUL presenting from [Hospital3 ] for hemoptysis. Pt was admitted there on [12-28] for febrile neutropenia. On day of admission, pt noted himself to be febrile to 101 and he had been having increased productive cough with some blood tinged sputum. He also had some DOE, 8 pound wt loss over 2 weeks. Pt was maintained on levaquin which he was already on for salmonella prophylaxis. CXR showed increased opacity of RUL c/w PNA. Pt was treated with levaquin. . On [12-30], he developed hemoptysis. He was taken to the OR, intubated on [12-31]. A bronchosopy was performed which showed a large clot at the carina and some minor oozing but no active bleeding. The patient maintained good oxygenation and ventilation on the ventilator. A pre-bronch Hct was 26.1 (from 28 on admit) and went to 24.3 post-bronch and 21.2 this morning. He received 1 U PRBC and 2 U FFP for INR of 1.4. . Patient was admitted on [12-28] Past Medical History: 1) Hairy cell leukemia: 2) Prostate CA: treated with XRT in '[12]. 3) non-small cell adenoCA of lung (RUL): Diagnosed after hemoptysis in [9-13] and subsequent biopsy by bronch; failed resection in '[12], now treated with XRT and chemo (taxol and carboplatin). 4) h/o salmonella sepsis: pt now on chronic levaquin. 5) HTN 6) GERD 7) Pneumothorax: in '[11] 8) + PPD: neg AFB smear and culture, on INH. .. Social History: SHx: Former smoker of 40 pk-years quit 10 yrs ago. Occassional social EtOH. Lives with wife. Retired meat-cutter. . FHx: Father: MI in 40s Family History: Noncontributory Physical Exam: 101.4---105/47---92---22---98% on AC 600 x 14 (22) FiO2=1.0 PEEP=5 Gen: sedated and intubated. HEENT: NCAT, PERRL, anicteric. OP with ETT and OGT--no obvious lesions Neck: no JVD Lungs: decreased BS on right CV: RRR, nml S1S2, no mrg Abd: soft, mildly distended, NT, naBS Ext: chronic venous stasis hyperpig of b/l LE without edema, cords. Back: mild diffuse blancing erythema; no focal lesions. Neuro: sedated but moves all 4s. Pertinent Results: Labs on Admission: [2114-1-1] 07:23PM BLOOD WBC-0.8* RBC-2.84* Hgb-9.5* Hct-26.1* MCV-92 MCH-33.3* MCHC-36.2* RDW-18.6* Plt Ct-132* [2114-1-1] 07:23PM BLOOD Neuts-78* Bands-14* Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [2114-1-1] 07:23PM BLOOD PT-14.4* PTT-32.7 INR(PT)-1.4 [2114-1-1] 07:23PM BLOOD Gran Ct-750* [2114-1-1] 07:23PM BLOOD Glucose-136* UreaN-19 Creat-0.4* Na-136 K-3.6 Cl-98 HCO3-30 AnGap-12 [2114-1-1] 07:23PM BLOOD ALT-18 AST-12 AlkPhos-107 Amylase-35 TotBili-1.1 [2114-1-1] 07:23PM BLOOD Lipase-13 [2114-1-1] 07:23PM BLOOD Calcium-7.9* Phos-2.2* Mg-1.9 [2114-1-1] 08:30PM BLOOD Type-ART Temp-37.8 pO2-156* pCO2-48* pH-7.46* calHCO3-35* Base XS-9 . Micro: [1-5] BAL neg;[1-4] UCx-neg, Bld Cx (p); [1-3] Bld Cx (p), neg fungal/AFB, UCx-neg; [1-1] sputum-yeast w/ pseudohyphae, bld cx NGF, UCx-neg . Studies: . RADS: . -- [1-5] CT Chest-extensive tumor/hemorrhage/inflamm in RUL . -- [1-5] CXR-RIJ CVL w/ tip overlying SVC, mild decr in pulm edema, otherwise no sig change; . -- [1-2] CXR-clear L hemithorax, R side minimal aerated lung Brief Hospital Course: Hospital Course: 64 y.o. man with hairy cell leukemia x 10 years, protate CA, non-small cell lung Ca in RUL presenting from [Hospital3 ] for hemoptysis. He was admitted to OSH on [12-28] with fever and borderline neutropenia; he was started on levofloxacin for ? RUL PNA. He developed massive hemoptysis and was transferred here intubated. He remained febrile and neutropenic. He has undergone two major IR procedures to stop the bleeding from his RUL which is full of tumor. There are no further interventions that IR can do if he bleeds more. Thoracics has seen him in case he bleeds more an needs emegency surgery. . On day of admission to the OSH, pt noted himself to be febrile to 101 and he had been having increased productive cough with some blood tinged sputum. He also had some DOE, 8 pound wt loss over 2 weeks PTA. Pt was maintained on levaquin which he was already on for salmonella prophylaxis. CXR showed increased opacity of RUL c/w PNA. . On [12-30], he developed hemoptysis. He was taken to the OR, intubated on [12-31]. A bronchosopy was performed which showed a large clot at the carina and some minor oozing but no active bleeding. The patient maintained good oxygenation and ventilation on the ventilator. A pre-bronch Hct was 26.1 (from 28 on admit) and went to 24.3 post-bronch and 21.2 thereafter. He received 1 U PRBC and 2 U FFP for INR of 1.4. . In terms of his NSCLC treatment, he has undergone three cycles of Taxol/Carboplatin, completed ~4 weeks PTA. Treatment was halted [1-11] pancytopenia. Has also been receiving radiation treatment with last treatment [2113-12-28]. Has received about 24 treatments (5 treatments/wk x 5 weeks). Has been taking Procrit for chronic anemia, and received 1U PRBC on [2113-12-22]. Also on daily SC neupogen, started in-house. . The patient was admitted to [Hospital1 18] for the specific interventional radiology and pulmonology procedures unique to the institution. Multiple attempts to control the bleeding via selective embolization were undertaken, and tenuous hemostasis was acheived. The patient, who had been intubated for airway protection, was extubated without incident and suffered no respiratory failure. He had arrived with fever and neutropenia from the OSH, and vanco/caspo/cefepime broad coverage was initiated. Multiple cultures were drawn given the persistent fever, and all were negative in the final read. Although the patient was stabilized via multiple bronchoscopies and interventional radiologic procedures, rebleeding remains a significant risk, and little could be done if another catastrophic bleed were to develop. . His persisent neutropenia was unexpected so far out from his last dose of chemotherapy. However, with persistent Neupogen dosing the patient's ANC and total leukocyte counts gradually increased into a non-neutropenic state. He was continued on vanc/cefepime/caspo until ANC > 1000, then all were discontinued since the patient had remained afebrile for > 48 hours and had persistently negative culture data. . At the time of discharge, the patient was with stable hematocrit, adequate pain control, stable O2 requirement, improving functional mobility, and good mental status. The family would like to transition care to Hospice, likely at a long-term institution as this patient would be very difficult to care for at home. . Plan: . #. Hemoptysis: Recently extubated, with stable Hct and no visible hemoptysis. IR options have been exhausted. CT surgery has evaluated patient and would only take back to the OR if massive bleeding recurs. IP and IR have exhausted all options. Patient will likely suffer recurrent bleeding and hemoptysis despite our best efforts. -- QD Hct. Would likely be very obvious if rebleeds. Transfused 1u PRBC [1-15]. -- End of life issues currently being addressed with family, SW involved, palliative care involved. -- Patient recently extubated. Follow pulmonary exam and VS for signs of decompensation. Continue inhalers. Nebs available PRN. -- Respiratory status stable, slightly improved over last several days. -- Hct slow decrease over past week, may be [1-11] decreased production. 1u PRBC transfused on [1-15]. No signs of active bleeding. Hemolysis labs negative. . #. Fever/Neutropenia: Cause of neutropenia remains obscure, definitely a component of chemo-induced neutropenia, but also a possible component of HCL relapse. Filgrastim being held now for lack of response. Heme/Onc followed throughout hospitalization. Off all abx currently, patient has not spiked a fever, although temps were increased last night. Will continue to culture if spikes greater than 100.4. -- Afebrile >72 hours, no F/C. -- Off all abx since [1-12] -- Culture if > 100.4 -- Have held filgrastim. -- ANC each AM, CBC with diff -- ANC decreased slightly over past 2 days, 810 the AM of discharge. Per primary oncologist Dr. [First Name (STitle) 4223] at [Hospital3 ], this is close to his baseline. . #. NSCLC and HCL: Large tumor burden. Chemo has been d/c'd due to pancytopenia. Has gotten 24 doses of XRT. Unclear if any further chemo/rads would be beneficial; will follow heme/onc recommendations. Patient of Dr. [First Name (STitle) 4223] as outpatient. -- Appreciate Heme/onc recommendations, unsure if palliative chemo/rads would be indicated. Certainly chemo could not be undertaken right now due to low blood counts. Completed 24 doses of XRT prior to admission. -- Follow up with Dr. [First Name (STitle) 4223] after discharge -- No filgrastim for now as above -- Morphine PRN for pain . #. History of positive PPD: Continuing INH as per previous. Been on therapy since [Month (only) 462] or [2113-9-9], started after low grade fevers and cough with positive PPD. -- Continue INH for now. . #. History of salmonella sepsis: Patient on chronic levaquin as outpatient for this. Have resumed after d/c of F&N coverage. -- Continue levaquin prophylaxis. . #. LE edema: EF normal on echo, although ? of ASD. No intervention would be warranted at this time as pressures appear normal and no evidence of shunting with saline contrast. Due to strong cancer history, concern for LE DVTs. LENIs checked prior to discharge. -- R popliteal DVT seen on [1-16], very distal with no proximal extension -- * This should be followed up in 1 week to assess for proximal extension * -- Patient would be an extremely poor candidate for anticoagulation . #. Hyperglycemia(?): Patient on RISS, has had several high FS recorded. Will continue RISS for now, as tight glycemic control is likely to be beneficial from an ID standpoint. -- Continue RISS . #. Hypertension: Transitioned from labetolol to metoprolol. Will follow BP and titrate up B-blocker as tolerated/required. -- Follow BP and titrate metoprolol as needed, good control recently. . #. MS changes: Seems improved greatly since transfer out of ICU. Patient with likely ICU delirium, fluctuant mental status. Pain control medications likely not helping this. At time of discharge patient was A&Ox3. -- Consider low dose IV haldol if recurrs . #. Prostate CA: History of prostate CA s/p radiation treatment in [2112]. Patient reports significant urinary frequency/hesitancy at home. -- Patient unable to void yesterday, straight cath'ed with 600cc drainage and patient relief. Foley left in place. -- Started Flomax at outpatient dose. -- Should have voiding trial with d/c foley after transfer to rehab. . #. Dysuria: Developed dysuria [1-14]. Have d/c'd foley and checked UA, cx. UA with 50 RBC, 0-2 WBC, moderate bacteria. -- Levaquin ongoing. -- Urine culture negative . #. Diarrhea: New onset of diarrhea over weekend, moderate in severity. Have sent for c. diff, would be at risk for this given recent ICU stay and broad spectrum antibiotics. -- C. diff negative. . #. FEN: General diet, soft with thin liquids per S&S. Will provide IVF as needed to keep I/O even. Replete lytes PRN. . #. PPX: No heparin [1-11] bleeding risk. On PPI, will continue. Elevate HOB > 30 degrees. Fall precautions. . #. Code: DNR/DNI following discussion with wife, who is HCP. Confirmed again with patient prior to discharge on [1-16]. Patient is not to be intubated or rescucitated under any circumstances. Medications on Admission: MEDS on transfer: Vanco 1.25 gram q12h Isoniazid 300mg daily Levaquin 500mg daily HCTZ 25 mg daily Cartia XT 180mg daily Neupogen 480 mcg SC daily Protonix 40mg daily Flomax 0.4 mg daily Propofol gtt Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-11] Drops Ophthalmic PRN (as needed). 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 4. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: 15. ml PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO BID (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 16. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis: Non-small cell lung carcinoma Massive hemoptysis . Secondary Diagnosis: Hairy cell leukemia Prostate cancer Discharge Condition: stable, tolerating adequate PO, pain well managed. Discharge Instructions: If you experience fevers, chills, nausea, vomiting, chest pain, shortness of breath, increasing pain, or any other concerning symptoms, contact your physician or return to the emergency room. Please contact your oncologist, Dr. [First Name (STitle) 4223], for a follow up appointment after your discharge. Followup Instructions: Please contact your oncologist, Dr. [First Name (STitle) 4223], for an appointment after your discharge. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] Completed by:[2114-1-16]	[ "202.40", "511.8", "486", "162.8", "518.81", "008.45", "284.8", "401.9", "293.0", "786.3", "795.5", "780.6", "V02.3", "453.8", "788.20" ]	icd9cm	[ [ [] ] ]	[ "88.44", "39.79", "96.72", "88.42", "99.04", "88.43", "33.24", "32.01", "99.07", "38.93", "33.22", "96.05" ]	icd9pcs	[ [ [] ] ]	13759, 13831	3742, 3742	324, 434	14002, 14055	2580, 2585	14414, 14675	2098, 2115		12312, 13736		13852, 13852		12087, 12087	3759, 12061		14079, 14391									2130, 2561																					274, 286							462, 1481					13943, 13981				13871, 13922	2599, 3719							1503, 1925	1941, 2082		12105, 12289
16,684	143,930	7811	Discharge summary	report	Admission Date: [2189-2-24] Discharge Date: [2189-3-4] Date of Birth: [2156-12-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3705] Chief Complaint: Left lower extremity calf pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 32 year old male with HIV/AIDS not on anti-retroviral therapy(last CD4 5 on [2189-1-28]), history of coagulase negative staph endocarditis status post aortic valve replacement and mitral valve replacement in [1-25], strep viridans prosthetic valve endocarditis in [8-25] complicated by aortic root abscess (medically managed), and end stage kidney disease on hemodialysis who presented with chief complain of left lower extremity pain. He reported a sharp pain in the back of his calf that began three days prior to presentation associated with this he reported worsening of his bilateral lower extremity edema over several weeks prior to presentation. Regarding other issues he reported that his baseline dyspnea on exertion that he had for months had worsened over the previous few weeks. He reports that he has dyspnea when walking only a few steps. Overall, he reported being very sedentary and spending the majority of his day in bed due to his multiple medical problems. [Name (NI) ] uses oxygen at home as much as possible. He denied cough, chest pain, increased sputum, or pleuritic chest pain. He reported chronic orthopnea and denied paroxysmal nocturnal dyspnea. In addition, he reported nausea/vomiting over the past few days prior to admission. He reported non-bloody, non-bilious emesis after each meal. He also had diarrhea with 6-7 loose stools per day over the three days prior to admission without blood. On presentation he was denying abdominal pain but said he had had it over the past days. In the ED, vitals were T96.5, BP 100/71, HR 116, RR 20O2 Sat 100% on 3L. Patient was given vancomycin, levoflaxcin, and pipercillin-tazobactam due to question of right lower lobe infiltrate and new effusion. He was given 1LNS. Initial labs revealed LFT's elevated from baseline so a RUQ U/S was performed that showed no acute biliary pathology but findings consistent with cirrhosis. Review of Systems: ==================== Positives are per HPI. He denied fevers, chills, or night sweats. Denied headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. HIV/AIDS, CD4 count of 5 in [1-26]. Not on HARRT. 2. History of native valve bacterial endocarditis with coagulase negative staph in [1-/2188] requiring mitral and aortic valve replacements and four weeks of vancomycin 3. Prosthetic valve endocarditis in fall of [2187] with strep viridans, medically managed with prolonged vancomycin and gentamicin therapy complicated by partial dehiscence of prosthetic aortic valve (also had pacemaker placed temporarily for symptomatic 1st degree AV delay but this was removed due to pocket infection) 3. Chronic hepatitis C though no circulating virus 4. Hepatitis B infection + but HBc equivocal [10/2186] 5. End stage renal disease (hemodialysis dependent) secondary to HIV nephropathy and focal sclerosing glomerulonephritis 6. Secondary hyperparathyroidism secondary to ESRD 7. Chronic low back pain reportedly to osteoarthritis & nerve impingement 8. Asthma Social History: He reports a short period of IVDU during his teens but denies any use since then. Per his report he acquired HIV through sexual contact. [Name (NI) 15110] to his multiple medical problems and poor physical condition he lives with his mother. Smoked 1 ppd for 20 years and currently smoking 6 cigarettes/day. Family History: Notable for DM and HTN in his father. Physical Exam: At Presentation: Vitals: BP 104/70, HR 95, RR 19, 100% on 3LNC General: cachectic, somnolent HEENT: Sclera icteric, dry mucous membranes with evidence of thrush and oral ulcers, Neck: supple, elevated JVP Lungs: diminished breath sounds at right base, otherwise clear CV: Regular rate and rhythm, loud systolic murmur at apex and at base with trill at base Abdomen: mild tenderness diffusely, guarding, no rebound, unable to assess for hepatosplenomegaly Ext: b/l LE swelling with pitting edema to knees, cool hands and feets. Dopplerable LLE pulse. LLE calf with erythema and tendernss. Darkness of skin in hands and toes. Pertinent Results: LABORATORY RESULTS: ====================== On Presentation: WBC-4.7 RBC-4.53* Hgb-14.4 Hct-44.7 MCV-99* RDW-21.9* Plt Ct-35* ----Neuts-58 Bands-5 Lymphs-12* Monos-25* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-47* RBC Morph: Hypochr-3+ Anisocy-3+ Poiklo-2+ Macrocy-3+ Microcy-NORMAL Polychr-1+ Spheroc-OCCASIONAL Target-1+ Schisto-1+ Tear Dr[Last Name (STitle) 833] [Name (STitle) 23262] Pappenh-1+ Ellipto-1+ PT-29.3* PTT-33.5 INR(PT)-3.0* Fibrino-144* FDP-10-40* Hapto-<20* Glucose-166* UreaN-69* Creat-5.8* Na-137 K-4.8 Cl-92* HCO3-25 AnGap-25* ALT-95* AST-247* LD(LDH)-583* CK(CPK)-149 AlkPhos-542* TotBili-3.9* DirBili-2.7* IndBili-1.2 CK-MB-10 MB Indx-6.7* cTropnT-0.49* Albumin-3.2* Calcium-9.4 Phos-6.1# Mg-2.6 BLOOD Tox: ASA-NEG Ethanol-NEG Acetmnp-NEG BZD-NEG Barbitr-NEG Tricycl-NEG On Transfer to Floor: BLOOD WBC-6.5 RBC-4.58 Hgb-13.9* Hct-44.5 MCV-97 RDW-21.3* Plt Ct-20* PT-27.9* PTT-37.2* INR(PT)-2.8* Glucose-117* UreaN-49* Creat-4.5# Na-139 K-4.5 Cl-95 HCO3-29 ALT-88* AST-150* LD(LDH)-424* AlkPhos-387* TotBili-5.8* MICROBIOLOGY: ============= Blood Culture [2189-2-24]: PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 4 S CEFEPIME-------------- 2 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R HBV Viral Load: HBV DNA not detected. HCV Viral Load: HCV-RNA NOT DETECTED. OTHER STUDIES =============== ECG [2189-2-24]: Sinus rhythm. Right axis deviation. Left atrial enlargement. Left ventricular hypertrophy with ST-T wave change. Compared to the previous tracing of [2188-10-27] no diagnostic interim change. Chest Radiograph [2189-2-24]: IMPRESSION: Right lower lobe pneumonia with pleural effusion. Cardiomegaly with vascular engorgement. RUQ ultrasound - No acute cholecystitis. Right Upper Quadrant Ultrasound [2189-2-24]: IMPRESSION: 1. Presence of gallbladder wall thickening and right upper quadrant ascites is likely related to liver disease. No definite signs of acute cholecystitis. 2. Right pleural effusion. Bilateral Lower Extremity Ultrasounds [2189-2-24]: IMPRESSION: No evidence of DVT in either lower extremity. Transthoracic Echocardiogram [2189-2-24]: Conclusions: The estimated right atrial pressure is 10-20mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. [Intrinsic left and right ventricular systolic function is likely more depressed given the severity of mitral and tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. A bioprosthetic aortic valve prosthesis is present. The prosthetic aortic valve leaflets are thickened. Motion of the aortic annulus is abnormal and suggestive of partial dehiscence. There is a probable vegetation on the aortic valve. Mild to moderate ([12-19]+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral valve leaflets are thickened. The gradients are higher than expected for this type of prosthesis. There is small vegetation on the mitral valve. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2188-10-24], aortic valve ring motion is now more prominent consistent with worsening dehiscence, aortic regurgitation is now present and there is a new mobile echodensity on the aortic valve consistent with vegetation. Tricuspid regurgitation is now more prominent. The right ventricle is now dilated with more depressed systolic function. Left ventricular systolic function appears slightly more vigorous. CT Abdomen and Pelvis [2189-2-25]: IMPRESSION: 1. Colon is decompressed and is unremarkable. 2. New moderate ascites. 3. Stable moderate right pleural effusion. 4. New trace left pleural effusion. 5. New anasarca. CT Left Lower Extremity [2189-2-25]: IMPRESSION: 1. Nonspecific but marked edema involving the subcutaneous fat of the calf and extending to the dorsum of the foot. 2. Edema noted in the soleus muscle, but no evidence of muscle abscess. 3. Degenerative change at the tibiotalar joint. Non-Invasive Resting Lower Extremity Arterial Studies [2189-2-25]: IMPRESSION: Mild-to-moderate bilateral outflow arterial disease in the lower extremities. Brief Hospital Course: Mr. [Known lastname ] was a 32 yo male with HIV/AIDs, CD4 of 5 who presented with left lower extremity pain as well as worsening dyspnea on exertion and found to have another episode of pseudomonas prosthetic valve endocarditis. 1) Prosthetic valve endocarditis: Soon after presentation a TTE was performed that showed new vegetations on the patient's mitral and aortic valves as well as persistent partial dehiscence of the aortic valve. ID consult was obtained and recommended vancomycin/pipercillin-tazobactam/and gentamicin so these were started. Eventually, the patient's regimen was simplified to ceftazidime with ID guidance as blood cultures grew out pseudomonas sensitive to ceftazidime. The patient was on ceftazidime through the day of his death. 2) Left lower extremity swelling/pain: The patient presented with three days of left lower extremity pain of unclear etiology. At presentation this did appear larger than the other side and therefore lower extremity ultrasound was obtained and showed no DVT. A CT was also obtained in order to evaluate and found generalized subcutaneous edema consistent with a cellulitis. Primary concern was for a possible septic embolic lesion from what had been found to be new vegetations. The patient was kept on broad spectrum antibiotics and vascular consult was obtained to rule out major vascular compromise. Non-invasive vascular studies did not show this. Eventually, the patient's generalized reddened area became a discreet purple area, then a bulla, and then it spontaneously drained. Wound care was consulted to suggest management strategies for this wound. Given the patient's general goals of care were leading toward a maintenance of current management without new invasive procedures no biopsy was performed for definitive diagnosis. 2. Dyspnea on exertion. The patient has chronic dyspnea on exertion but denies any chest pain, cough, or sputum production. This responds well to supplementary O2 and morphine therapy and the patient was denying any dyspnea at baseline at the time of discharge. 3. End Stage Renal Disease: The patient was maintained on HD per nephrology throughout his hospitalization. 4. Nausea/vomiting: The patient reported persistent nausea and heartburn symptoms thorughout his hospitalization Patient has history of nausea/vomiting, abdominal pain and diarrhea. Given CD4 count of 5, concern for multiple infectious etiologies. As the patient had visible thrush at presentation he was empirically treated with fluconazole and clotrimazole. Still, despite this treatment he continued to have considerable symptoms. There was some concern that he could continue to have etiologies like CMV esophagitis or another viral etiology. As reported above, however, goals of care were not favoring invasive etiologies at that time and risk/benefit ratio did not favor empiric treatment with ganciclovir. Therefore, treatments were symptomatically offered with empirically increased pantoprazole, sucralfate, and maalox-lidocaine-diphenhydramine. With these treatments symptoms initially improved prior to patient's final decompensation (description below). 5. Coagulopathy: On presentation the patient had elevated INR's as well as PT and PTT. Fibrinogen and FDP were also decreased. As PTT was only slight decreased DIC was considered a less likely process and progressive liver failure was considered a more likely etiology. As goals of care were changing however after being given FDP no further treatments were offered. 6. Thrombocytopenia: The patient had considerable thrombocytopenia at presentation around the 20's. The most likely etiology of this thrombocytopenia was considered to be most likely his cirrhosis and splenomegaly consuming platelets. 7. HIV/AIDS: The patient has recently not been treated with HAART and has a most recent CD4 count of 5. For this CD4 count TMP/Sulfa prophylaxis was continued. 8. Lactic acidosis. The patient had persistent lactic acidosis on presentation and was later noticed to have hypothermia. Most likely etiology was considered a chronic sepsis or infection. 9. Hypertension: The patient was initially hypertensive on multiple medications for this. He slowly became hypotensive to normotensive over the course of his hospitalization presumedly due to SIRS and active infectious process. 10. Volume overload: The patient was initially volume overloaded and then mild fluid removal was accomplished by HD. Unfortunately, as blood pressures fell throughout hospitalization no more volume removal was possible. 11. Goals of Care: The patient initially chose to go back to being full code during this hospitalization. The intensivist had a discussion with the patient, however, about his very poor prognosis and the ultimate incurability of his endocarditis. Therefore, he became DNR/DNI once again. As the hospitalization continued further discussion with the patient and his health care proxies as well as the health care team continued to address the patient's extremely poor prognosis and minimal salvage options should he decompensate. Therefore, goals of therapy gradually shifted toward comfort based care and no further new invasive therapies, though no therapies were discontinued. The plan was made to transfer the patient to a [Hospital1 1501] with plan to continue antibiotics and HD as long as these were desired by the patient and his proxies with probable eventual transition to comfort care. Unfortunately, shortly after a [Hospital1 1501] was found to accept the patient between the evening of [3-2] and the morning of [3-3] the patient developed severe worsening of his abdominal pain with guarding. His pain was so severe as to require large doses of opioids and he slipped into unconsciousness. Given his precipitous worsening abdominal exam and our knowledge of large valvular vegetations the treating teams assumption was that the patient had an embolic event to his gastrointestinal vasculature. This was discussed with the family as well as the dire prognosis associated with it. Given the patient would not be a candidate for surgery even were this verified and his overall very poor prognosis no further diagnostic modalities were pursued. The patient was given analgesics, anti-emetics, and other symptomatic therapies and made CMO. He died on the morning of [2189-3-4] with his family in attendance. Medications on Admission: 1. Nystatin PO QID PRN 2. Hydroxyzine HCl 25 mg QID 3. Oxycodone 5 mg PO Q6H 4. Lidocaine 5 % patch 5. Nitroglycerin 0.2 mg/hr Patch 24 6. Lorazepam 0.5 -1 mg prn anxiety 7. Roxanol Concentrate prn pain 8. Methadone 40 mg q8 hours 9. Camphor-Menthol 0.5-0.5 % Lotion prn 10. Erythromycin 5 mg/g Ointment 1 inch Ophthalmic QID 11. Omeprazole 20 mg daily 12. Trimethoprim-Sulfamethoxazole 160-800 mg q HD 13. Captopril 50 mg TID 14. Acetaminophen 650 mg prn pain 15. [Date Range 7222] HCl 800 mg PO TID with meals 16. Hydralazine 25 mg PO TID 17. Amlodipine 10 mg daily Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: AIDS ESRD Prosthetic valve endocarditis Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable	[ "276.2", "585.6", "112.0", "070.54", "287.5", "042", "557.0", "572.8", "998.31", "428.0", "996.61", "E878.2", "421.0", "070.30", "486", "416.8", "588.81", "305.1", "038.43", "428.33", "397.0", "493.90", "789.59", "995.92", "449", "286.9" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	17029, 17038	9947, 16367	345, 352	17141, 17150	4673, 9924	17213, 17230	3973, 4013		16990, 17006		17059, 17120		16393, 16967			17174, 17190									4028, 4654																			2352, 2668		275, 307							380, 2333																	2690, 3624	3640, 3957
24,280	168,031	27316	Discharge summary	report	Admission Date: [2119-5-2] Discharge Date: [2119-5-11] Date of Birth: [2080-2-16] Sex: M Service: SURGERY Allergies: Penicillins / Ampicillin / Peanut Oil / Aspirin Attending:[First Name3 (LF) 5880] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: Halo placement [2119-5-4] Percutaneous tracheostomy [2119-5-4] Percutaneous gastrostomy [2119-5-4] History of Present Illness: 39 yo male wheelchair bound, who fell out of his wheelchair from a [Doctor Last Name ] onto the ground hitting his head and knees. No LOC. Transported to [Hospital1 18] for continued trauma care. Injuries included: scalp laceration (stapled in ED), C1 [Location (un) 5621] fracture, dissection of the R vertebral artery. Past Medical History: Mental retardation Seizure disorder [Doctor Last Name 13621] Syndrome Social History: Lives in facility, parents involved. No tob/EtOH. Family History: Noncontributory Physical Exam: 99.8 97/48 110 26 97RA Awake, activity at baseline EOMI, PERRL MAE, looks toward R RRR CTAB soft, ND normal rectal tone, guaiac neg brown stool GU normal abrasion L knee Pertinent Results: [2119-5-2] 05:00PM PT-14.3* PTT-26.8 INR(PT)-1.3* [2119-5-2] 04:44PM GLUCOSE-97 LACTATE-5.6* NA+-144 K+-4.8 CL--104 TCO2-23 [2119-5-2] 04:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2119-5-2] 04:20PM GLUCOSE-103 UREA N-17 CREAT-0.7 SODIUM-139 POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-20* ANION GAP-21* [2119-5-2] 04:20PM PHENYTOIN-7.5* [2119-5-2] 04:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2119-5-2] 04:20PM WBC-13.9* RBC-4.43* HGB-14.5 HCT-41.4 MCV-94 MCH-32.8* MCHC-35.1* RDW-12.4 [2119-5-2] 04:20PM PLT COUNT-217 C-SPINE, TRAUMA [2119-5-10] 1:37 PM C-SPINE, TRAUMA Reason: need ap lat and odontoid views [Hospital 93] MEDICAL CONDITION: 39 year old man with [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] s/p halo REASON FOR THIS EXAMINATION: need ap lat and odontoid views HISTORY: Follow up [Location (un) 5621] fracture. THREE PROJECTIONS OF THE CERVICAL SPINE (FIVE RADIOGRAPHS). Exam is limited by overlying halo fixation device. The spine is visualized to the top of C7 in lateral projection. On AP film of the dens, there is lateral displacement of both C1 lateral masses relative to [Name (NI) 12952] [Name2 (NI) ] of the dens is inadequately assessed. This widening of the C1 ring has increased on each side relative to supine bedside similar image [2119-5-4]. Although suboptimally assessed, the anterior arch of C1 maintains a normal position relative to the dens on lateral projection. No prevertebral soft tissue swelling. Tracheostomy tube. Impression: Interval distraction/displacement of C1 [Location (un) 5621] fracture. Findings discussed with Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] at 4-3150. CT C-SPINE W/O CONTRAST [2119-5-2] 4:48 PM CT C-SPINE W/O CONTRAST Reason: fracture or dislocation. [Hospital 93] MEDICAL CONDITION: 37 year old man with MR, fall on head, L knee effusion after falling on knee. Unable to assess mental status. REASON FOR THIS EXAMINATION: fracture or dislocation. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 37-year-old man with mental retardation, fall on head. Assess for fracture or dislocation. COMPARISON: None. TECHNIQUE: Non-contrast CT of the C-spine with coronal and sagittal reformations. FINDINGS: There is significant upper cervical prevertebral soft tissue swelling, measuring up to 10mm, anterior to the C2 vertebral body. There is [Initials (NamePattern4) ] [Last Name (NamePattern4) 5621]-type burst fracture of the C1 vertebral body. Fractures are seen through both the right and left portions of the anterior arch of C1 as well as the right portion of its posterior neural arch. Though there is a small bony fragment in the right ventral aspect of the spinal canal, no fragments impinges upon the thecal sac at this level. The right posterior arch fracture is near the expected course of the right vertebral artery. The fractures do not extend into the foramen transversarium on either side. Though there is presumed avulsion of the right attachment of the transverse dental ligament, the atlanto-axial alignment appears maintained, with significant clockwise rotation of the atlas on the axis. There is also a minimally displaced oblique-sagittal fracture through the medial aspect of the base of the right occipital condyle, at the presumed attachment of the alar ligament. Despite this fracture, and the comminution of the right lateral mass of C1, the overall atlanto-axial relationship is maintained, without rotatory subluxation. No other acute skull base or cervical spine fracture is identified. There is apparent cervical dextroscoliosis, but the alignment is otherwise anatomic. C2 through C7 vertebral body heights are preserved. There is no gross stenosis of the spinal canal. The mastoid air cells are well pneumatized bilaterally. The lung apices appear clear. Mucosal thickening is seen of the right maxillary sinus. Noted is fixation hardware in the T3 vertebral body and posterior elements, presumably related to previous fusion. IMPRESSION: Unstable [Location (un) 5621]-type fracture of the C1 vertebral body with associated prevertebral soft tissue swelling. There is a related fracture of the base of the right occipital condyle. There are fragments in the spinal canal, without evident cord impingement. Fracture lines appear close to the expected course of the right vertebral artery. COMMENT: Findings were immediately conveyed to the emergency department dashboard at approximately 1800H, [2119-5-2]. Concern regarding associated vertebral artery injury will be addressed by dedicated CT angiogram (already performed), while associated craniocervical ligamentous injury would be best assessed by MRI, when feasible. . TWO VIEWS EACH OF THE LEFT AND RIGHT KNEES No fractures are seen in the right knee. There is no large effusion in the right side. Subtle lucency is seen at the medial aspect of the left tibial plateau. Large effusion is seen in the left knee. There is a evidence of a fat-fluid level on the cross-table lateral view of the left knee. TWO VIEWS OF THE LEFT FOOT: No acute displaced fractures are identified. The mortise is not well evaluated on these views. No abnormal soft tissue calcifications are seen. IMPRESSION: Subtle lucency at the medial aspect of the left tibial plateau with large effusion seen in the left knee suggesting probable tibial plateau fracture. No fractures seen in the right knee. . CT knee: negative for fx . Brief Hospital Course: The patient was admitted to the Trauma Service. Orthopedic Spine surgery immediately consulted because of his injuries; Halo application performed on [5-4]. He also had a percutaneous trach and gastrostomy tube placed at that time. Neurology was consulted for a vertebral artery dissection; non operative intervention he was maintained on Heparin gtt, later transitioned to Lovenox and started on Coumadin. His Lovenox will need to continue until his INR is within therapeutic range 2.0-3.0. Infectious disease was consulted because of fever spike and leukocytosis, patient prior to this was started on Levofloxacin; his fevers persisted which prompted ID consult. He was pan cultured, no organisms identified. He was taken off of his Levofloxacin; his temperatures were followed closely and began to trend downward. His fevers did eventually resolve; temperature this morning 99.8. Speech and swallow consulted for Passy-Muir valve (PMV) evaluation; patient was able to tolerate the PMV without a decrease in O2 Sats and without respiratory distress. He should have Speech and Swallow evaluation once at rehab. Physical and Occupational therapy consulted and have recommended rehab stay post hospitalization. Medications on Admission: Dilantin 100" Valproate 40 cc [Hospital1 ] MVI Tolectin DS 400' Levoxyl 0.025' Peridex oral rinse [Hospital1 ] Diazepam 5 prn [Last Name (un) ] prn MOM prn Fleets prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed: per g-tube. 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day): per g-tube. 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily): per g-tube. 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): per g-tube. 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain: per g-tube. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): per g-tube. 7. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous [Hospital1 ] (2 times a day): Please discontinue when INR at goal ([2-17]). 8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day as needed for per sliding scale: See attached sliding scale. 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO tonight: Dose Coumadin daily based on INR. 12. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO twice a day. 13. Dilantin 100 mg/4 mL Suspension Sig: One (1) PO three times a day: via feeding tube. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: s/p Fall Cervical spine [Location (un) 5621] fracture C1 Discharge Condition: Stable Discharge Instructions: 1. Follow up with Orthopedic Spine Surgery: [Telephone/Fax (1) 3573] Dr. [Last Name (STitle) 66961] in 2 weeks. 2. Take medications as prescribed. 3. Call your doctor or go to the ER for new or worrisome symptoms, including but not limited to: pain, weakness, fever >101.4, trouble breathing. 4. Follow up with Neurology as below. 5. The rehab will monitor your levels of dilantin and your INR and adjust your medications as needed. Followup Instructions: Call [Telephone/Fax (1) 3573] for a followup appointment with Dr. [Last Name (STitle) 66961], Orthopedic Spine in 2 weeks. Plan to have C-spine trauma with odontoid view xray prior to appointment; this can be arranged when you call to scehdule the follow up appointment. Follow up in [Hospital 878] clinic in 4 weeks with Dr. [Last Name (STitle) 1693], call to schedule appointment: [Telephone/Fax (1) 44]. They will arrange for an MRA to be performed to assess the vertebral artery. Follow up in trauma Clinic with Dr. [Last Name (STitle) ] in 4 weeks at [Telephone/Fax (1) 6439]. Call to schedule appointment. Completed by:[2119-5-11]	[ "E884.3", "805.01", "823.00", "780.39", "318.1", "443.24", "873.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "31.1", "93.41", "86.59", "96.6", "43.11", "02.94" ]	icd9pcs	[ [ [] ] ]	9588, 9667	6814, 8033	315, 428	9773, 9782	1196, 1938	10271, 10946	970, 987		8262, 9565	3160, 3270	9688, 9752		8059, 8239			9806, 10248									1002, 1177																					267, 277	3299, 6791						456, 790																	812, 887	903, 954
29,137	173,929	30238	Discharge summary	report	Admission Date: [2106-10-14] Discharge Date: [2106-10-25] Date of Birth: [2039-3-9] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: acute CHF exacerbation Major Surgical or Invasive Procedure: capsule endoscopy [2106-10-20] History of Present Illness: 67M well known to our service, has PMH of EtOH cirrhosis with HCC and is s/p OLT on [8-17] with ongoing issues of CHF exacerbation and acute on chronic renal failure. He was recently admitted to our service and was discharged on [2106-9-28] for CHF exacerbation. His discharge summary and hospital course can be found in OMR. Previously worked up on several admissions for GI bleeding. EGD on [3-22] showing gastritis and varices. For the past week, patient p/w acute onset dyspnea, weight gain, weakness and edema. His symptoms were similar to that of his recent hospitalization. He was admitted at [Hospital3 ] hospital and was treated for CHF exacerbation. However, patient developed oliguria and required transfer to their ICU. He was started on Lasix 200 IV BID and began to diurese abt 30-40ml/hr. His respiratory status improved as he was weaned to nasal cannula from BIPAP. Moreover, from their laboratory results, his Hct was found to be 18, requiring 4 units pRBC. Per family's request, patient is transferred to [Hospital1 18] for further management and care. Otherwise, denies any fever, abdominal pain, N/V, hematochezia or hematemesis. Appropriate appetite. He did develop diarrhea and required rectal tube placement. Past Medical History: liver transplant ([2104-8-22]) EtOH cirrhosis HCC anemia essential thrombocytosis prior complications of ascites malnutrition portal [Month/Day/Year ] with grade 2 esophageal varices h/o duodenitis [7-18] grade 1 rectal varices grade 2 esoph varices and gastritis by EGD [3-/2106] CAD: ([2104-7-1] coronary angiography -inferolateral akinesis & substantial lateral hypokinesis. 50% LAD lesion. Circ occluded distally. RCA 40% stenosis) CHF: ECHO [9-19], EF 25% failure to thrive s/p PEG Social History: The patient owns business in [Hospital3 ]: a clothing store and a limousine business. Recently he started working from home due to his poor health. He lives with his wife, who is very supportive. He smokes. No drugs. Stopped EtOH in 6/[2103]. Family History: Non contributory Physical Exam: weight baseline 44.1, now 49.5 Vitals: 97.8 74 134/71 20 97% 2L NC Gen: NADS, cachetic, good spirited Lungs: decreased bs to bases bilaterally, coarse Cardio: RRR, 1+ SEM Abd: soft, firm, incisions c/d/I, G tube in place, act BS, NT, ND, G+ Ext: 2+ pedal edema, palpable pulses bilaterally Neuo: no foal deficits elicited Pertinent Results: [2106-10-14] 10:13PM GLUCOSE-129* UREA N-89* CREAT-4.7* SODIUM-143 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-19 [2106-10-14] 10:13PM ALT(SGPT)-8 AST(SGOT)-16 CK(CPK)-49 ALK PHOS-51 TOT BILI-0.7 [2106-10-14] 10:13PM CK-MB-NotDone cTropnT-0.25* [2106-10-14] 10:13PM CALCIUM-8.1* PHOSPHATE-7.0# MAGNESIUM-2.1 [2106-10-14] 10:13PM WBC-7.3 RBC-3.70# HGB-10.1# HCT-30.8# MCV-83 MCH-27.2 MCHC-32.7 RDW-16.3* [2106-10-14] 10:13PM PLT COUNT-417# [2106-10-14] 10:13PM PT-13.1 PTT-34.0 INR(PT)-1.1 [2106-10-14]: CXR showed bilateral pleural effusions. Brief Hospital Course: The patient was admitted to the SICU on [10-14] with sudden onset oliguria, acute CHF exacerbation, diarrhea and G+ stool. Nephrology transplant, hepatology, gastroenterology, and cardiology were consulted. Cardiac enzymes were followed and trended downward. He was fluid restricted and diuresed. Daily serum creatinine levels were 4.5-4.8. Initial hematocrit was stable at 30.8 and trended upward with appropriate reticulocyte count. Daily rapamycin levels were followed. On [10-16] he was stable to be transferred to the floor. On [10-20] he underwent capsule endoscopy to evaluate for midgut GI bleed and results were pending. He also received IV iron on [10-21], but towards the end of this infusion (500mg/500cc), he became acutely short of breath after ambulating to the bathroom off O2. O2 dropped to low 80s. He was hypertensive and tachypneic. A non-rebreather was applied with improved O2 to 90-91%. IV lasix and iv lopressor were given with slight improvement. CXR showed severe symmetric bilateral opacification worse in the lower lungs had progressed, particularly on the left, accompanied by stable moderate left and small right pleural effusion. EKG was stable. Levaquin was started for pneumonia. He was transferred to the SICU for management. He was briefly placed on bipap and was subsequently weaned to a non-rebreather after more iv lasix and IV hydralzine were given. A lasix drip was started. O2 sats improved and the non-rebreather was switched to nasal cannula. The lasix drip was changed to po lasix. He was transferred out of the SICU. Nephrology discussed potential need for hemodialysis in the future. Vein mapping was recommended. This was done on [10-25]. He was discharged to home with home O2 as he desaturated to 87% while ambulating. Vital signs were stable. Of note, rapamune dose was adjusted for trough level of 10 on [10-24]. Dose was decreased to 2.5mg qd. A script for liquid rapamune was provided. Levaquin course was completed as of [10-25]. Medications on Admission: Meds from [Hospital3 ]: epo, coreg 12.5'', iron, pancrease, rapamune 3 tabs daily, lasix 200 IV'', nitropaste, testosterone patch, pepcid 20, prednisone 5, remeron 15, sodium bicarb 1300''', tums 1000''', zocor 10 Discharge Medications: 1. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 2. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) mL Injection once a week. 4. Rapamune 1 mg Tablet Sig: 2.5 Tablets PO once a day. Disp:90 Tablet(s) Refills:2 5. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:180 Tablet(s) Refills:2 6. Nitro-[Hospital1 ] 2 % Ointment Sig: Take as directed. Transdermal as directed. 7. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). Disp:180 Tablet, Chewable(s) Refills:2 12. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. 14. Colace 50 mg/5 mL Liquid Sig: Five (5) mL PO twice a day. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day. 16. Home Oxygen Please provide home Oxygen 2 liters nasal canula continuous Patient desats to 87% on room air 17. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Rapamune 1 mg/mL Solution Sig: 2.5 ml PO once a day. Disp:60 bottle Refills:2 Discharge Disposition: Home Discharge Diagnosis: Oliguria Acute CHF exacerbation Anemia with occult GI bleed acute on chronic renal failure pneumonia Discharge Condition: Hemodynamically stable, tolerating regular diet, and pain under adequate control. Discharge Instructions: You were transferred to the [Hospital1 18] transplant surgery service for continued management of low urine output, acute CHF exacerbation, anemia with detected blood in stool. You received blood transfusions at [Hospital3 ] Hospital, but since transfer to [Hospital1 18], your hematocrit was stable at 30 and continued to improve to 34-36. You were kept on a fluid-restricted diet and administered diuretic medications to control your CHF. Weigh yourself every morning, [Name8 (MD) 138] MD if weight change > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 1.5 L daily. Please call your doctor or go to the emergency room if you develop fever, chills, nausea, vomiting, bloody vomit or stools, chest pain, difficulty breathing, or any other concerning symptom. Followup Instructions: Provider: [Name10 (NameIs) ] STUDY Phone:[Telephone/Fax (1) 327] Date/Time:[2106-10-22] 8:30 Please call ([Telephone/Fax (1) 3618] to schedule a follow-up appointment with Dr. [Last Name (STitle) ] in [2-12] weeks. Please follow up with your nephrologist in [2-12] weeks. Please call ([Telephone/Fax (1) 2306] in 1 week to obtain the results of your capsule endoscopy from Dr. [Last Name (STitle) ] and follow up accordingly. Completed by:[2106-10-25]	[ "V42.7", "578.1", "428.0", "238.71", "411.89", "V10.07", "414.01", "456.21", "V58.65", "428.23", "261", "V11.3", "280.0", "577.8", "584.9", "585.4", "V85.0", "799.4", "456.8", "486", "305.1", "799.02", "572.3" ]	icd9cm	[ [ [] ] ]	[ "88.01" ]	icd9pcs	[ [ [] ] ]	7387, 7393	3476, 5502	337, 373	7538, 7622	2852, 3453	8460, 8957	2477, 2495		5770, 7364		7414, 7517		5528, 5747			7646, 8437									2510, 2833																					275, 299							401, 1657																	1679, 2192	2208, 2461
70,651	173,155	14231	Discharge summary	report	Admission Date: [2175-8-12] Discharge Date: [2175-8-22] Date of Birth: [2148-9-25] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1406] Chief Complaint: weight loss, malaise Major Surgical or Invasive Procedure: [2175-8-18] Mitral valve replacement with a 31mm St. [Male First Name (un) 923] Epic tissue valve History of Present Illness: 26M, IVDU, cocaine induced cardiomyopathy and Hep C who p/t new PCP for evaluation with reported 60lb weight loss over 1 year, 30lb loss over 2 months. He developed subsequent abdominal pain and CT revealed possible septic embolus to spleen. Blood cultures were drawn and grew Gram Positive Cocci. Echo today reveals Mitral Valve vegetations. Cardiac Surgery is consulted for Mitral Valve Replacement. Past Medical History: Bacterial Endocarditis Mitral Regurgitation High grade bacteremia Polysubstance abuse oppositional behavior with low-health literacy acute on chronic systolic heart failure Social History: Lives with: splits time between mom's house and fiance Contact: Phone # Occupation: not working currently, previously employed by power washing company Cigarettes: Smoked no [] yes [x] last cigarette _____ Hx: Other Tobacco use: [1-30] ppd x 10 yrs. -currently smoking ETOH: denies < 1 drink/week [] [3-7] drinks/week [] >8 drinks/week [] Illicit drug use Family History: non-contributory Physical Exam: Pulse: 82 Resp: 16 O2 sat: 99%RA B/P Right: Left: 108/68 Height: 5'4" Weight: 138lb General: NAD, flat affect Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade _2/6 systolic__ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _1+__ Varicosities: None [x] Neuro: Grossly intact [] Pulses: patient will not allow palpation of LE pulses Femoral Right: Left: DP Right: Left: PT [Name (NI) 167]: Left: Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: Pertinent Results: Intra-op TEE [2175-8-18]: Conclusions Prebypass The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. he 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 a large 1.5 x 1.4 cm homogenous, echodense lesion on the atrial aspect of the anterior and posterior m itralleaflet tips consistent with vegetation. There is no valve abscesses seen. There is a central, severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room. POST-BYPASS: Normal biventricular systolic function. LVEF 55%. There is a m itral bioprosthesis,stable and functioning well. There no peri valvular leaks. Transmitral regurgitant gradient is peak 9 and mean 3 mm of Hg. Intact thoracic aorta. No new valvular findings. . [2175-8-22] 04:15AM BLOOD WBC-12.2* RBC-3.46* Hgb-8.8* Hct-27.2* MCV-79* MCH-25.4* MCHC-32.2 RDW-17.0* Plt Ct-208 [2175-8-21] 06:00AM BLOOD WBC-13.7* RBC-3.73* Hgb-9.2* Hct-29.3* MCV-79* MCH-24.7* MCHC-31.5 RDW-17.0* Plt Ct-208 [2175-8-20] 04:47AM BLOOD WBC-10.9 RBC-3.62* Hgb-8.9* Hct-27.9* MCV-77* MCH-24.7* MCHC-32.1 RDW-16.2* Plt Ct-177 [2175-8-20] 04:47AM BLOOD PT-12.1 PTT-28.9 INR(PT)-1.1 [2175-8-22] 04:15AM BLOOD UreaN-20 Creat-0.5 Na-136 K-4.4 Cl-95* [2175-8-21] 06:00AM BLOOD Glucose-101* UreaN-15 Creat-0.5 Na-135 K-4.3 Cl-96 HCO3-35* AnGap-8 [2175-8-20] 04:47AM BLOOD Glucose-115* UreaN-14 Creat-0.6 Na-136 K-4.4 Cl-102 HCO3-30 AnGap-8 [2175-8-22] 04:15AM BLOOD Mg-1.9 [2175-8-21] 06:00AM BLOOD Mg-1.9 Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION ================================== #) ENDOCARDITIS and SEPSIS: Likely directly inoculated from IVDA. Likely to have been subacute, explaining the patient's recent unexplained weight loss, fatigue, and general malaise. The patient was admitted for abdominal pain and fever and was found to have leukocytosis to 16K and blood cultures positive for gram positive organisms. Empiric therapy was begun with vancomycin and his white count fell and he defervesced. Speciation came back as Viridans family Streptococcus sensitive to ceftriaxone, so ID recommended narrowing antibiotic coverage to ceftriaxone. Also was tachycardic with a new III/VI systolic murmur and peripheral edema worrisome for valvular heart failure. TTE performed showed large > 1cm vegitations on the mitral valve with mitral regurgitation. TEE was deferred since patient initially refused and necessary images could be performed perioperatively. Patient constantly complained of chest pain but would continually refuse EKGs. Tele showed sinus tachycardia with no evidence of ischemia or AV block. Troponins <0.01. Had symptoms suggestive of septic emboli in abdomen, neck, left hand, and right foot. Neuro exam stable throughout the admission with no focal deficits. CT abdomen revealed wedge shaped hypodensity in spleen felt to represent infarct instead of abscess, so no drainage was required. Neck MRI showed no evidence of embolization. Right foot MRI showed expanding tubular structure in right posterior tibial artery, likely from septic embolization. Vascular surgery consulted and because of good distal pulses in right foot, felt the limb was not threatened. Given size of mitral valve vegitations, evidence of continued septic embolization, and clinical evidence of valvular heart failure, CT surgery decided on mitral valve replacement for curative therapy. #) MITRAL VALVE REPLACEMENT: The patient was brought to the Operating Room on [2175-8-18] where the patient underwent Mitral Valve Replacement (31mm St.[Male First Name (un) 923] tissue) with Dr. [Last Name (STitle) ]. 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. PICC line was placed for long term antibiotic therapy. Dilaudid PCA was initiated for pain. 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 5 the patient was ambulating freely, the wound was healing and pain was controlled with Dilaudid PCA along with oral analgesics for breakthrough pain. The patient was discharged to [Hospital 5503] Rehab in good condition with appropriate follow up instructions. Medications on Admission: suboxone 20mg daily (stopped taking Monday prior to admission) Discharge Medications: 1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 2. Aspirin 81 mg NG DAILY if intubated. DC when NGT removed. 3. CeftriaXONE 2 gm IV Q24H give over 30 min 4. Docusate Sodium 100 mg PO BID 5. 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. 6. HYDROmorphone (Dilaudid) 0.24 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 0.24 mg(s) RX hydromorphone 60 mg/30 mL (2 mg/mL) 0.24mg IVPCA Lockout Interval: 6 minutes Disp #30 Not Specified Refills:0 7. Metoprolol Tartrate 37.5 mg PO TID 8. Milk of Magnesia 30 mL PO DAILY:PRN constipation 9. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN break thru pain RX oxycodone 5 mg 1 tablet(s) by mouth q3h Disp #40 Tablet Refills:0 10. Ranitidine 150 mg PO BID 11. Furosemide 40 mg PO BID 12. Potassium Chloride 20 mEq PO BID Hold for K >4.5 Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital - [Location (un) 5503] Discharge Diagnosis: Bacterial Endocarditis Mitral Regurgitation High grade bacteremia Polysubstance abuse oppositional behavior with low-health literacy acute on chronic systolic heart failure Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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: Cardiologist Dr. [First Name (STitle) 437] [Telephone/Fax (1) 62], [2175-9-20], 9:40am [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 2010] Date/Time:[2175-9-11] 3:50 ID: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 23870], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2175-10-4] 10:30 The Cardiac Surgery Office will call you with this appt: Surgeon Dr. [Last Name (STitle) ] [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 Completed by:[2175-8-22]	[ "444.21", "425.4", "421.0", "070.54", "428.0", "038.0", "305.1", "799.4", "423.1", "995.91", "449", "444.22", "444.89", "428.23", "304.00", "292.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "38.97", "35.23", "37.12" ]	icd9pcs	[ [ [] ] ]	8929, 9027	4644, 7855	331, 439	9244, 9410	2243, 4621	10198, 10946	1490, 1509		7968, 8906		9048, 9223		7881, 7945			9434, 10175									1524, 2224																					271, 293							467, 873																	895, 1070	1086, 1474
64,153	167,245	3273	Discharge summary	report	Admission Date: [2159-11-20] Discharge Date: [2159-11-26] Date of Birth: [2116-12-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: Acute mental status change in the setting of hyperglycemia Major Surgical or Invasive Procedure: Lumbar Puncture Hemodialysis History of Present Illness: A 42 year old lady with a history of ESRD on HD from Type 1 DM presented to the ED with hyperglycemia in the 500s and confusion since earlier that morning. . In the ED, initial vs were: 98.4 72 132/119 18 97. The patient was found to have a K in the 7-8 range, ? peaked T waves and a RLL consolidation on CXR. Patient was given Ceftriaxone 1g, Insulin drip (10 bolus, 7/hour), 1L NS, Calcium gluconate for hyperglycemia and hyperkalemia. While enroute to CT scan, her confusion degenerated to agitation and she was diverted to the MICU for further evaluation. . On arrival to the MICU, the patient is wildly agitated, not responding to commands and requiring restraints. Her sister is present and confirms that the patient is altered. . The patient's sister reports that the patient was experiencing lethargy and weakness with worsening severe headaches and photophobia in the past few days, on a background of [12-29] months of headache. Per her nephrologist, the patient learned 2 nights prior that she is temporarily de-listed for transplant. Per notes, the patient may have recently restarted Oxycodone/Acetaminophen and Metoclopramide Past Medical History: - Type 1 diabetes mellitus complicated by neuropathy, retinopathy, and nephropathy - End stage renal disease on dialysis, goes M,W,F - s/p LUE AV fistula [9-2] which failed to mature, thrombosed and failed thrombectomy. Now has R IJ permacath, h/o inxn in past catheter [2158-1-3] - Hypertension - Hyperlipidemia - Anemia of chronic disease - Right Charcot Foot - s/p Left Toe Amputation - Hypothyroidism Social History: She lives with her mother and sister in [Name (NI) 2251]. Another sister is her HCP. She has a boyfriend, who is currently being evaluated as a potential living kidney donor as he is a match. She has only a brief remote smoking history as a teen for about 6 months time. She has a history of alcohol abuse, but has been sober for two years. She denies any ilicit drug use. Family History: Significant for coronary artery disease in her mother, as well as stroke; a maternal grandmother had heart failure, and her father had coronary artery disease. Physical Exam: PE on Admission: Vitals: T: 98.6 BP: 193/76 P: 89 R: 21 O2: 98% RA General: Altered, thrashing about in bed. HEENT: Dry mucous membranes, pupils slow but reactive once sedated Neck: Patient does react to neck movement, some resistance/rigidity Lungs: Clear anteriorly CV: S1 & S2 regular without murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses with edema, R charcot foot Pertinent Results: Admission labs ([2159-11-20]): WBC-6.5 RBC-4.18* Hgb-11.9* Hct-38.5 MCV-92 MCH-28.5 MCHC-31.0 RDW-16.1* Plt Ct-250 Glucose-679* UreaN-60* Creat-8.9# Na-121 K-8.5* Cl-82* HCO3-20* AnGap-28* . [11-20]: proBNP-[Numeric Identifier 15280] CXR [11-20]: Upright portable chest radiograph is obtained. Cardiomegaly is noted with pulmonary [Month/Year (2) 1106] congestion. No large effusions or pneumothorax is seen. Mediastinal silhouette appears grossly unremarkable. Osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Findings compatible with fluid overload. . [11-20] CT head: There is no acute hemorrhage, large areas of edema, large masses or mass effect. There is preservation of normal [Doctor Last Name 352]-white matter differentiation. The ventricles and sulci are normal in size and configuration. Visualized paranasal sinuses and mastoid air cells are clear. Calcification is noted of the carotid siphons and vertebral arteries bilaterally. IMPRESSION: No acute intracranial process. NOTE ADDED IN ATTENDING REVIEW: The extensive atherosclerotic calcification involving the distal vertebral and cavernous and supraclinoid internal carotid arteries is quite unusual in a patient of this age and gender, and should be correlated with clinical information. . CXR: [11-21]: There is significant interval improvement up to almost complete resolution in widespread pulmonary edema. . [11-22] MRI head IMPRESSION: Markedly limited study. No mass effect or hydrocephalus seen. Hyperintensities in the white matter could be due to small vessel disease. MRV shows medial portion of the right transverse sinus to be narrowed without corresponding signal abnormality on FLAIR and T2-weighted images. This could be normal variation in absence of abnormal signal. If there is continued clinical concern, CT venography of the head could help for further assessment. MRI with repeat study with diffusion could also help if continued concern for acute infarct. [11-24] MRI/MRA The examination was ordered as gadolinium-enhanced images but after consultation with the MRI technologist, it was decided that gadolinium would not be administered given patient's low EGFR. However, gadolinium injection was performed inadvertently. These findings were reported as an "incident report" to the hospital system by MRI duty supervisor. Additionally, findings were discussed with the family by Dr. [First Name (STitle) ] [Name (STitle) ] of Medicine as well as Dr. [First Name8 (NamePattern2) ] [Name (STitle) 805] of Radiology. The patient was arranged to have dialysis within 24 hours. FINDINGS: BRAIN MRI: There is no evidence of acute infarct seen. There is no mass effect, midline shift or hydrocephalus. Periventricular hyperintensities are noted indicative of small vessel disease. These finding are inappropriate for patient's age but are likely related to patient's renal failure. There is no evidence of abnormal parenchymal, [Name (STitle) 1106] or meningeal enhancement seen following the administration of gadolinium. Normal enhancement of both transverse sinuses is noted. IMPRESSION: No evidence of acute infarct or abnormal enhancement. Small vessel disease. Other findings as detailed above. MRV HEAD: Head MRV shows slightly narrowed medial portion of the right transverse sinus which is unchanged. There is normal flow enhancement identified in this region on post-gadolinium images and there is no evidence of thrombosis seen. This may be secondary to congenital variation or due to a remote thrombosis and recanalization. No acute thrombosis is identified. IMPRESSION: No evidence of venous sinus thrombosis seen. [11-26] carotid u/s There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. Impression: Right ICA with stenosis <40%. Left ICA with stenosis <40%. Brief Hospital Course: 42 year old female with ESRD from Type 1 diabetes presents with confusion/altered mental status with a recent headache and worsening lethargy in the setting of hyperglycemia. Admitted to the MICU. . # Altered Mental Status: The patient was seen by psych and neuro and altered mental was untimately attributed to a toxic metabolic state given her hyperglycemia and uremia. There was also a concern that the ativan that she received may have exacerbated her AMS. All tox screens were negative. Patient did not show objective signs of infection (no fever or white count). LP was not concerning for infection however she was treated with acyclovir until viral cultures were resulted. She had blood, urine and sputum cultures drawn that were negative when leaving the MICU. Urine Legionella antigen negative as well. She was treated empirically for bacterial meningitis d/t history and marked improvement on antibiotics, however these were discontinued as the pt never showed signs of infection clinically. Head CT was normal, MRI/MRV showed no acute changes, only chronic microvascular ischmic changes. Pt had carotid U/S which showed <40% stenosis bilaterally. Pt was back to baseline neurologically by discharge and was neurologically intact and asymptomatic. . #. Hyperglycemia: The patient was hyperglycemia with alterations in mental status but no evidence of ketones. Her anion gap was difficult to interpret given her underlying renal disease. She had an insulin drip that was titrated to a insulin sliding scale. Her FS were between 100-200 when transferred to medicine floor and remained WNL for the duration of her stay. . #. Hypertension: The patient was hypertensive with SBP in 200s, with baseline in 150s. We administered IV lopressor and hydralazine until her mental status improved and she was able to take her home regimen. Her valsartan was ultimately uptitrated given poor BP control while on the floor. . #. ESRD: The patient was admitted to dialyze off an elevated potassium, but potassium normalized. She also had an elevated BNP and showed fluid overload on exam therefore underwent routine HD. She also required extra hemodialysis sesions for inadvertent exposure to gad during MRI. . #. CXR findings: Her CXR was concerning for PNA vs. fluid overload. It was repeated after dialysis and showed resolution of symptoms . #. Hypothyroidism: Normal dose 200-250mcg of levothyroxine continued in the MICU with IV 100mcg. Thyroid studies demonstrated elevated TSH, therefore she was restarted on her home dose. Medications on Admission: Atenolol 25mg PO Daily B Complex-Vitamin C-Folic Acid 1mg PO daily Doxazosin 2mg PO QAM; 4 mg PO QHS Epoetin Alfa [Procrit] Insulin Glargine [Lantus] 18 Units QHS Insulin Lispro [Humalog] Sliding Scale Irbesartan Levothyroxine 250 mcg PO daily LIPITOR 10mg PO QHS Lisinopril 20mg PO daily Metoclopramide 10mg PO QID PRN Nausea Nortriptyline 50mg PO QHS Oxycodone-Acetaminophen 5-325mg PO Q4-6 PRN Pain Pantoprazole 40mg PO daily Prochlorperazine Maleate 10mg PO Q8 PRN Nausea Sevelamer HCl PO TID Aspirin 325mg PO daily Docusate Sodium 100mg PO BID Discharge Medications: 1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO qAM. 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 9. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) dose Injection ASDIR (AS DIRECTED): during dialysis. 10. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Cap(s) 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime: Take 10U Glargine in the morning and take 10U of Glargine in the evening . Disp:qs units Refills:2 15. Insulin Lispro 100 unit/mL Cartridge Sig: sliding scale units Subcutaneous three times a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Altered Mental Status Secondary: Hypertension Diabetes Discharge Condition: Stable, mental status at baseline, BP 140s-160s, BS<200. Discharge Instructions: You were admitted for altered mental status, weakness and slurred speech. You had an extensive workup which did not reveal a cause for your symptoms but luckily you gradually improved. During your evaluation, you had an MRI which was performed with a contrast dye which can be toxic to patient with kidney disease. Because of this, you had several additional sessions of dialysis. The following changes were made to your medications: 1) Increase Lantus to 20mg every evening 2) Change Atenolol to Metoprolol 50mg twice daily 3) Change Irbesartan to Valsartan 160mg daily 4) Changed Glargine 18U qhs to Glargine 10U qam and 10U qpm. Several medications were held to see if they were contributing to your altered mental status: Reglan, Nortriptyline, Percocet, Compazine Please call your doctor or return to the hospital if you develop confusion, hallucinations, weakness, difficulty speaking or any other concerning symptoms. It was a pleasure taking care of you, we wish you the best! Followup Instructions: Please call and make an appointment with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 4390] within the next week. Provider: [Name10 (NameIs) ] STUDY Phone:[Telephone/Fax (1) 327] Date/Time:[2159-11-26] 8:30 Provider: [Name10 (NameIs) 5536] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 5537] Date/Time:[2159-11-27] 10:00 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2160-2-12] 10:20 Please go to HD at [Location (un) ] in [Location (un) ] this Wednesday [2159-11-28] as we discussed. Completed by:[2159-12-2]	[ "285.21", "303.93", "585.6", "V49.83", "V45.11", "244.9", "362.01", "272.4", "250.43", "V58.67", "403.91", "V49.72", "780.1", "357.2", "293.0", "250.63", "276.7", "250.53" ]	icd9cm	[ [ [] ] ]	[ "03.31", "39.95" ]	icd9pcs	[ [ [] ] ]	11619, 11625	7075, 7285	376, 406	11734, 11793	3129, 3763	12831, 13496	2431, 2592		10216, 11596		11646, 11713		9643, 10193			11817, 12531									2607, 2610																					278, 338							434, 1583			3772, 7052							2625, 3110		12546, 12808					1605, 2020	2036, 2415
40,160	192,451	35636	Discharge summary	report	Admission Date: [2199-3-21] Discharge Date: [2199-3-25] Date of Birth: [2148-10-29] Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7733] Chief Complaint: Large defect of the hard and soft palate secondary to resection of malignant tumor. Major Surgical or Invasive Procedure: [3-21]: 1. Debridement and local flaps to hard and soft palate (Dr. [Last Name (STitle) 79441]. 2. Partial coronoidectomy, right side of the mandible (Dr. [Last Name (STitle) 79441]. 3. Free microvascular fasciocutaneous flap transfer from left forearm to palate. (Dr. [Last Name (STitle) 5385]. 4. Full-thickness skin graft to left forearm (left upper medial arm donor site). (Dr. [Last Name (STitle) 5385]. 5. Plastic closure of forearm wound. (Dr. [Last Name (STitle) 5385]. History of Present Illness: This is a 50 yo F who was referred with a very large oronasal fistula to her palate. She previously had had a large tumor resected of the palate which required removal of the greater portion of the hard and soft palate. The posterior portion of the soft palate with uvula remained. The alveolar ridge with all of the maxillary teeth remained. The hole was much too larger for local vomer flaps, and too large for any type of intraoral pedicle FAMM flaps. She is brought to the operating room for definitive closure using a radial forearm fasciocutaneous flap. Social History: lives with husband Family History: non-contributory Physical Exam: AF/VSS comfortable, NAD Pertinent Results: none Brief Hospital Course: Pt was admitted post-operatively from her Free microvascular fasciocutaneous flap transfer from left forearm to palate. She tolerated the procedure well, and was brought to the ICU for Q1H flap checks. After 24 hours, the patient was doing well and was transferred to the floor and started on clear liquids. On POD 2 she was noted to have increasing swelling on her R face near the operative site. The wound was opened slightly by the bedside and was found to be free from hematoma. Over the next 48 hours her swelling improved. On POD 3, the patient was tolerating applesauce and on POD4 her diet was advanced to include anything blenderized. During her entire stay she had dopplerable pulses to her temple and graft and her graft site remained pink and well-perfused. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q4H:PRN as needed for severe pain: Please do no drive on this medication. Disp:250 ML(s) Refills:0 4. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 10 days. Disp:40 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Large defect of the hard and soft palate secondary to resection of malignant tumor Discharge Condition: Stable Discharge Instructions: Please resume all regular home medications and take any new meds as ordered. Please keep the cast on your left arm dry. Please only eat a blenderized diet and avoid putting anything in your mouth except for as instructed. Please keep the head of your bed elevated if possible, or use several pillows at home to keep your head elevated as this will help significantly with reducing swelling. Do not drive or operate heavy machinery while taking any narcotic pain medication. 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. Immediate report any signs of breathing difficulty or increased swelling in your face. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 5385] in 1 week, please call ([2199] to make that appointment. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 7738]	[ "526.89", "V10.02" ]	icd9cm	[ [ [] ] ]	[ "27.31", "27.49", "27.56", "27.57", "76.31", "27.55" ]	icd9pcs	[ [ [] ] ]	2946, 2952	1668, 2441	400, 920	3079, 3088	1639, 1645	4322, 4557	1561, 1579		2464, 2923		2973, 3058					3112, 4299									1594, 1620																					276, 362							948, 1509																		1525, 1545
30,882	132,521	51738+59375	Discharge summary	report+addendum	Admission Date: [2105-9-13] Discharge Date: [2105-9-18] Date of Birth: [2048-7-30] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 618] Chief Complaint: difficulty speaking, right sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: [Known firstname ] is a 57yo LHD woman who presents to the [Hospital3 ] emergency room as a transfer from an outside hospital. She presented there with a history of being last heard well (over the telephone) @ 00:30 on [2105-9-13]. At 08:00 this AM, her husband found her in the parlor seated on the couch and staring off into space. She had no speech and would not follow commands. He attempted to move her and realized that the right side of her body was immobile. He then called 911. Due to unknown duration of symptoms, TPA was not administered. Of note, she recently had arthroscopic surgery on her left knee. Family states that she complained of pain in her knee since the operation and has had significant bleeding from the site. ROS: unable to obtain from patient because she is aphasic. Per family: No fevers/chills/sweats, CP, SOB, palpitations, N/V, URI, abd pain, dysuria, rash; she has lost 15lb in the last 2 weeks (unintentional) - prior to this presentation she had no deficits noted in: memory, personality, vision, hearing, language/speech, swallowing, coordination, writing, walking, bowel/bladder function. No history of stroke, or seizures. No sensory loss, no neck pain. She did have weakness on the left side and was unable to move it post-operatively. Past Medical History: - h/o migraines - hypothyroidism - hypotension - hypercholesterol - recent arthroscopic surgery of left knee w/ scraping - s/p hysterectomy - s/p x4 cesarean sections - s/p tonsillectomy @ 45yo Social History: Lives at home with husband in [Location (un) ]. no h/o TOB, ETOH use. Family History: - mother with lupus and diabetes - father with diabetes - family with history of CAD and hypertension, but no strokes Physical Exam: VS: T afebrile HR 88 BP 139/80 Sat 96% on RA PE: HEENT AT/NC, MMM no lesions Neck Supple, no bruits Chest CTA B CVS RRR, no m/r/g ABD obese EXT left leg with brace and bandage; area appears to be clear but bandage not removed. NEUROLOGICAL MS: General: asleep; easliy arousable by calling her name, but if not persistently stimulated, will go back to sleep. Repeatedly yawning during exam. Orientation: unable to assess because patient is aphasic Attention: inattentive to the examiners; easily falls back asleep and does not make eye contact with people in the room; husband concerned that she doesn't appear to recognize him. Speech/[Doctor Last Name ]: global aphasia; will only follow commands of open your eyes and close your eyes. Cannot perform beyond that. CN: II,III: pupils 4-->2 mm bilaterally to light; does not blink to visual threat on the right side. III,IV,V: EOMI, no ptosis. VII: mild flattening of the nasolabial fold on the right. Motor: No tremor, rigidity, or bradykinesia. She is unable to hold up right arm, but can easily sustain elevation of the left (but not following the command to do so; she will elevate on her own). Delt [Hospital1 ] Tri Grip IP Quad Hamst [First Name9 (NamePattern2) 95237] [Last Name (un) 938] C5 C6 C7 C8/T1 L2 L3 L4-S1 L4 L5 L 5 5 5 5 2 0 0 0 0 R 0 0 0 0 1 0 0 0 0 Reflex: [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 defer 2 Flexor R 3 3 3 3 2 triple flexion Sensation: right arm with extensor posturing to pressure on the nailbed. left side withdraws to noxious stimuli. Coordination: unable to assess because patient is aphasic Gait: right dense hemiplegia Discharge Exam: MS- Alert, arouses easily, repeats 3 word phrases. Follows simple commands "close your eyes," some difficulty with complex appendicular commands. Motor- Left Upper and lower extremity [5-23], flicker of finger flexion on R, otherwise dense right hemiplegia of arm and leg. Sensation- intact ot light touch bilaterally. Pertinent Results: CK: 62 MB Urinalysis: negative 141 106 15 - - - - - - - 130 3.8 25 0.8 Ca: 9.2 Mg: 2.3 P: 3.5 WBC: 11.5 Hgb:12.6 Hct:36.1 Plt:345 PT: 12.2 PTT: 21.5 INR: 1.0 [2105-9-17] 05:05AM BLOOD WBC-10.7 RBC-3.66* Hgb-11.7* Hct-33.3* MCV-91 MCH-31.9 MCHC-35.0 RDW-14.0 Plt Ct-310 [2105-9-13] 01:00PM BLOOD WBC-11.5* RBC-3.91* Hgb-12.6 Hct-36.1 MCV-92 MCH-32.3* MCHC-35.0 RDW-13.7 Plt Ct-345 [2105-9-13] 01:00PM BLOOD Neuts-82.7* Lymphs-14.2* Monos-2.3 Eos-0.3 Baso-0.5 [2105-9-13] 01:00PM BLOOD PT-12.2 PTT-21.5* INR(PT)-1.0 [2105-9-16] 11:20AM BLOOD Glucose-122* UreaN-16 Creat-0.6 Na-144 K-3.8 Cl-111* HCO3-24 AnGap-13 [2105-9-13] 01:00PM BLOOD Glucose-130* UreaN-15 Creat-0.8 Na-141 K-3.8 Cl-106 HCO3-25 AnGap-14 [2105-9-14] 01:37AM BLOOD ALT-16 AST-24 CK(CPK)-92 AlkPhos-100 [2105-9-16] 11:20AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.5 [2105-9-14] 01:37AM BLOOD %HbA1c-6.1* [2105-9-14] 01:37AM BLOOD Triglyc-151* HDL-42 CHOL/HD-4.5 LDLcalc-115 [2105-9-14] 02:58PM BLOOD Type-ART pO2-202* pCO2-45 pH-7.39 calTCO2-28 Base XS-2 IMAGING: CT brain (from outside hospital): Hypodensity in the inferior division of left MCA and left striatocapsular area consistent with acute infarct. No acute blood, mass, or midline shift. No atrophy. Transthoracic echocardiogram: Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and o aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The timated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal study. No cardiac source of embolism identified. If a paradoxical embolus is suspected, a TEE with agitated saline contrast is suggested. Transesophageal Echocardiogram- Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A small secundum atrial septal defect is identifiedy by color Doppler with left-to-right flow. Right-to-left flow is seen with saline contrast injection at rest (clip [Clip Number (Radiology) ], frame 360). Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Small atrial septal defect with left-to-right flow on color Doppler and evidence of right-to-left shunting on saline injection at rest. MR HEAD W/O CONTRAST [2105-9-13] 7:47 PM FINDINGS: This study was compared with [2105-9-13] CT scan. Diffusion abnormality in the left middle cerebral artery territory, including the left temporal lobe, frontal lobe, insula, basal ganglia, and anterior left parietal lobe, correspond with areas of abnormality on the ADC map, and also with the findings on the CT scan, representing an acute infarction. The magnetic susceptibility sequence demonstrates low signal within the left basal ganglia, suggesting the possibility of early hemorrhagic change, close follow up with non contrast head CT is recommended if clinically is warranted. Additionally, MR angiography images demonstrate severe narrowing of the distal M1 segment of the left middle cerebral artery, partial filling of the M2 segments, and relative little filling of the [Name (NI) ] and M4 segments. The right- sided circulation, the anterior circulation, and posterior circulation appear patent. No other areas of infarction are seen. Edema in the basal ganglia causes mass effect on the left lateral ventricle, however, there is negligible midline shift. Perimesencephalic cisterns remain patent. Incidentally noted are a polyp/retention cyst in the right maxillary sinus, and partial opacification of the right sphenoid sinus. IMPRESSION: 1. Infarction in the left MCA territory, with edema causing mass effect but no herniation. Areas of infarction correspond with area of attenuated flow in the left middle cerebral artery. No other areas of infarction are seen. 2. The magnetic susceptibility sequence demonstrates low signal within the left basal ganglia, suggesting the possibility of early hemorrhagic change, close follow up with non contrast head CT is recommended if clinically is warranted. This study was reviewed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. CT HEAD W/O CONTRAST [2105-9-17] 9:02 AM NON-CONTRAST HEAD CT: Comparison with [2105-9-15]. The large area of left middle cerebral artery territory infarction is again seen, with hypodensity and edema, and minimal rightward midline shift, approximately 5 mm. Some blood products are seen within the lentiform nucleus, however, not increased since the last examination. No new areas of infarction are seen. The osseous structures are unchanged. The known right maxillary sinus polyp/retention cyst is only partially imaged. IMPRESSION: No significant interval change in large left middle cerebral artery infarction with partial hemorrhagic transformation. Brief Hospital Course: Ms. [Known lastname 107179] was admitted with a large subacute infarct of her left middle cerebral artery and resulting right hemiplegia and global aphasia. She was transferred from an outside hospital outside of the window for IV tpa or IA tpa administration. She was not on prior antiplatelet or anticoagulation as she was immediately post operative from a left arthroscopic knee surgery. Bilateral lower extremity ultrasound was without evidence for DVT. TEE revealed a small ASD, which could be a potential route for paradoxical emboli. Carotid ultrasound evaluation was pending at time of discharge and will be added as an addendum to this summary. Given the large size of the infarct she was monitored in the neuro ICU. Interval CT revealed early hemorrhagic transformation of her infarction with small 1-2mm midline shift. Her neurologic exam was stable and she was transferred to the stroke unit where interval CT scan showed stable hemorrhage and midline structures. She was started on aspirin therapy for secondary prevention of stroke. Repeat swallowing evalution recommends: 1. Continue with PO diet of nectar-thick liquids and ground-consistency solids. If she appears to tolerate this diet at rehab without signs or symptoms of aspiration, it may be appropriate to introduce trials of thin liquid and/or regular solids. 2. Pills may be given whole in puree. With regard to her left knee arthroscopy. Her sutures may be removed on [9-22]. She should follow up with her orthopedic surgeon for further care. She will follow up with Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ] and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 877] in vascular neurology clinic. She has been enrolled in Dr. [Name (NI) 107180] Dysphagia study following stroke. Medications on Admission: - motrin - aspirin - protonix - vicodin - simvastatin - verapamil (for migraine research study) - percocet - augmentin (post-op prophylaxis) - synthroid - flexeril - [Doctor First Name 130] - colace - triamcinolone Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: 4 days of treatment remaining for catheter associated UTI. . 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Left Middle Cerebral artery infarction Discharge Condition: Right sided hemiplegia. Speaking in [2-21] word sentences. Follows simple commands. Discharge Instructions: You were admitted for stroke resulting in weakness to the right side of your body and difficulty speaking. Please take all medications as prescribed. Call your doctor or 911 if you experience any worsening weakness, numbness, tingling, double vision, difficulty producing speech, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: You have a follow up appointment [2105-11-2] at 4pm with Drs. [First Name8 (NamePattern2) 2530] [Name (STitle) ] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 877]. Please call [Telephone/Fax (1) 2574] prior to your appointment to update, you will need a referral from your primary care doctor prior to the appointment. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Name: [Known lastname 17498],[Known firstname 6758] Unit No: [Numeric Identifier 17499] Admission Date: [2105-9-13] Discharge Date: [2105-9-18] Date of Birth: [2048-7-30] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 608] Addendum: Bilateral carotid ultrasound evaluation was without significant stenosis. Discharge Disposition: Extended Care Facility: [Hospital6 3465] - [Location (un) 824] [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 610] Completed by:[2105-9-18]	[ "V45.89", "342.90", "434.11", "784.3", "745.5", "272.0", "244.9" ]	icd9cm	[ [ [] ] ]	[ "88.72" ]	icd9pcs	[ [ [] ] ]	14328, 14522	9889, 11701	323, 330	12932, 13022	4245, 9258	13418, 14305	1986, 2106		11971, 12754		12870, 12911		11727, 11948			13046, 13395									2121, 3885						3901, 4226															242, 285							358, 1660						9267, 9866											1682, 1878	1894, 1970
28,675	157,426	13038+56423	Discharge summary	report+addendum	Admission Date: [2150-11-3] Discharge Date: [2150-11-9] Date of Birth: [2083-3-25] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: chest pain, fatigue Major Surgical or Invasive Procedure: [11-3] CABGx3 (LIMA->LAD, SVG->Diag, SVG-> PDA) History of Present Illness: 67 yo M with known CAD, s/p multivessel stenting with increasing symptoms, referred for cath which showed 3VD and ISRS. Referred for CABG. Past Medical History: ^lipids, NSTEMI [8-27], CAD s/p sent to distal and proximal RCA, mid LCx [8-27], cypher stent to prox and mid LAD [8-27], cypher stent to prox LAD [1-28], pancreatitis [2142], deviated septum/occasional epitstaxis, s/p R hip replacement Social History: lives with wife no tobacco no etoh Family History: mother with MI in 60s Physical Exam: NAD HR 41 RR 16 BP 175/74 Lungs CTAB Heart RRR, no Murmur Abdomen soft, NT, ND extrem warm, no edema, 2+pp no carotid bruits no varicosities Pertinent Results: [2150-11-9] 06:12AM BLOOD WBC-8.4 RBC-2.94* Hgb-8.8* Hct-25.2* MCV-86 MCH-29.9 MCHC-34.8 RDW-14.5 Plt Ct-417 [2150-11-8] 07:45AM BLOOD WBC-7.9 RBC-2.67* Hgb-7.7* Hct-22.2* MCV-83 MCH-28.8 MCHC-34.5 RDW-14.8 Plt Ct-296 [2150-11-9] 06:12AM BLOOD Plt Ct-417 [2150-11-3] 04:39PM BLOOD PT-14.9* PTT-29.4 INR(PT)-1.3* [2150-11-9] 06:12AM BLOOD Glucose-117* UreaN-21* Creat-0.8 Na-140 K-4.4 Cl-105 HCO3-27 AnGap-12 CHEST (PA & LAT) [2150-11-7] 5:13 PM CHEST (PA & LAT) Reason: interval change [Hospital 93] MEDICAL CONDITION: 67 year old man with s/p CABG REASON FOR THIS EXAMINATION: interval change TWO-VIEW CHEST [2150-11-7] COMPARISON: [2150-11-5]. INDICATION: Status post CABG. Post-operative widening of the cardiomediastinal contours is stable in appearance allowing for differences in technique. Lung volumes are slightly improved, and areas of atelectasis in the left mid and both lower lungs appear minimally improved. Small pleural effusions are seen bilaterally. On the lateral view, a few small foci of gas are present in the retrosternal region, likely related to recent median sternotomy and coronary bypass surgery procedure. No apical pneumothorax is identified. IMPRESSION: Slight improvement in bibasilar atelectasis. Small pleural effusions. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 32947], [Known firstname ] [Hospital1 18] [Numeric Identifier 39911] (Complete) Done [2150-11-3] at 11:45:08 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 1112] W. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2083-3-25] Age (years): 67 M Hgt (in): 69 BP (mm Hg): 134/75 Wgt (lb): 195 HR (bpm): 72 BSA (m2): 2.05 m2 Indication: Intra-op TEE for CABG ICD-9 Codes: 440.0, 424.1 Test Information Date/Time: [2150-11-3] at 11:45 Interpret MD: [Name6 (MD) 928] [Name8 (MD) 929], MD, MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 929], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.3 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.0 cm Left Ventricle - Fractional Shortening: 0.26 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: 3.1 cm <= 3.0 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.1 cm Findings LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mild mitral annular calcification. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Physiologic TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: 1. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. 6. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. POST-BYPASS: Pt is being A paced, and is on an infusion of phenylephrine 1. Bi ventricular function is preserved 2. Aortic contours are intact post decannulation 3. Other findings are unchanged Brief Hospital Course: He was taken to the operating room on [11-3] where he underwent a CABG x 3. He was transferred to the ICU in critical but stable condition on neo and propofol. He was transfused for HCT 25. He was extubated later that same day. He was transferred to the floor on POD #2. He had some intermittent atrial fibrillation and his lopressor was increased and he was started on amiodarone. He was transfused 1 unit again for hct 22 with increase to 25. He converted to NSR but continued to have intermittent bouts of afib and was started on coumadin. He was ready for discharge home on POD #6 in NSR. Spoke with [Doctor Last Name 39912] at Dr.[Name (NI) 39913] office who agreed to follow coumadin. Medications on Admission: ASA 325', atenolol 25', plavix 75', lisinopril 10', omeprazole 20', lipitor 40' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Sig: 400 mg daily x 1 week, then 200 mg daily until dc'd by cardiologist. Disp:40 Tablet(s) Refills:0 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). Disp:90 Tablet(s) Refills:0 9. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Check INR [11-11] with results to Dr. [Last Name (STitle) 1637]. Disp:60 Tablet(s) Refills:0 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 11. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: CAD now s/p CABG ^lipids, NSTEMI [8-27], CAD s/p sent to distal and proximal RCA, mid LCx [8-27], cypher stent to prox and mid LAD [8-27], cypher stent to prox LAD [1-28], pancreatitis [2142], deviated septum/occasional epitstaxis, s/p R hip replacement Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. SHower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Coumadin followed by Dr. [Last Name (STitle) 1637]. Followup Instructions: Dr. [Last Name (STitle) 1637] 2 weeks Dr. [Last Name (STitle) ] 4 weeks Completed by:[2150-11-9] Name: [Known lastname 1522],[Known firstname 77] Unit No: [Numeric Identifier 7201] Admission Date: [2150-11-3] Discharge Date: [2150-11-9] Date of Birth: [2083-3-25] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4551] Addendum: Mr. [Known lastname ] was called at home after his discharge and instructed NOT to take the coumadin listed on his discharge instructions. Discharge Disposition: Home With Service Facility: [Hospital 136] Homecare [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 358] MD [MD Number(1) 359] Completed by:[2150-11-9]	[ "411.1", "V15.82", "272.4", "414.8", "412", "401.9", "427.31", "414.01", "V43.64", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "99.07", "36.12", "39.61", "99.04", "36.15" ]	icd9pcs	[ [ [] ] ]	9837, 10050	6147, 6851	341, 395	8800, 8808	1111, 1626	9163, 9814	911, 934		6981, 8401	1663, 1693	8503, 8779		6877, 6958			8832, 9140									949, 1092																					282, 303	1722, 6124						423, 563																	585, 843	859, 895
70,148	195,958	37080	Discharge summary	report	Admission Date: [2173-11-13] Discharge Date: [2173-12-2] Date of Birth: [2137-11-26] Sex: M Service: CARDIOTHORACIC Allergies: Zosyn Attending:[First Name3 (LF) 5790] Chief Complaint: tracheal stenosis with tracheostomy Major Surgical or Invasive Procedure: Cervical tracheal resection reconstruction by Dr. [Last Name (STitle) ] on [2173-11-19] Flexible bronchoscopy by Dr. [First Name (STitle) ] [Name (STitle) ] on [2173-11-29] History of Present Illness: Patient is a 35-year-old gentleman, with morbid obesity and obstructive sleep apnea. He has had a tracheostomy in place since [2173-8-24] following a prolonged intubation for aspiration pneumonia and MRSA sepsis, s/p right foot surgery in [2173-6-23]. He underwent bronchoscopy with Dr. [Last Name (STitle) ] on [2173-10-20] and a segement of mild to moderate tracheobronchomalacia was observed at the distal trachea and proximal bronchi. He was admitted to the Interventional Pulmonology service from rehab for possible decannulation on [2173-11-9]. He was not decannulated and was scheduled for surgery with Dr. [Last Name (STitle) ] on [2173-11-19]. Patient was discharged to home on [2173-11-12] with VNA after refusing rehab, following discussions with the patient, his father and other family memebers regarding self-suctioning and insulin teaching. Patient was discharged with scripts for his medications including insulin and insulin syringes. Patient was told by the pharmacy he usually uses that he would be unable to get insulin there until Monday so he went home without obtaining it. VNA came to his home and [2173-11-13] and saw that he was without the medications he was discharged on and instructed him to go to the ED. His being admitted because he is claiming he is unable to care for himself at home. Past Medical History: Morbid Obesity Obstructive sleep apnea Clubfoot deformity s/p multiples surgical repairs and grafting Diabetes Social History: Single lives with his father who is retired. Tobacco exsmoker. ETOH none Family History: Mother died lung cancer Physical Exam: VS: T: 98.6, BP 126/60, RR 20, 99% on 4LNC Gen: pleasant in NAD, obese Neck: incision with slight erythema, but not healing with purulence or drainage. Lungs: clear bilaterally t/o to ausc. CV: RRR, S1, S2, no MRG Abd: soft, NT Ext: obese, right foot with healing closed skin graft site. Neuro: Alert and oriented x 4, with left upper extremtity [12-28] motor strength and 2+ edema. [4-27] motor otherwise. Pertinent Results: [2173-11-30] 02:52AM BLOOD WBC-7.9 RBC-3.40* Hgb-9.7* Hct-30.6* MCV-90 MCH-28.4 MCHC-31.5 RDW-16.0* Plt Ct-549* [2173-11-30] 02:52AM BLOOD Glucose-114* UreaN-8 Creat-0.5 Na-145 K-3.7 Cl-102 HCO3-37* AnGap-10 CXR [2173-11-27] Impression: The patient was extubated in the meantime interval. The cardiomediastinal silhouette is stable, but there is interval progression of the vascular engorgement that might be related to development of pulmonary edema in the presence of increased venous return. The right PICC line tip appears to be low and potentially may be in the proximal right atrium and might be pulled back for approximately 4 cm. There is no evidence of pneumothorax. Brief Hospital Course: Mr. [Known lastname 83579] was readmitted to [Hospital1 18] on [2173-11-13] after unsuccessful discharge home. He underwent tracheal resection and reconstruction by Dr. [Last Name (STitle) ] for his tracheal stenosis, on [2173-11-19]. He was transferred to the ICU where he required mechanical ventilation. He was successful extubated on [2173-11-26] and watched in the ICU, until transfering to the floor on [2173-11-30]. The following is a systems review of his prolonged hospital course: Neuro: Alert and oriented x 4. On presentation the patient had [12-28] motor in the left arm due to an old injury involving dialysis catheter at an outside hospital, of which is unclear. On [2173-12-1] the patient developed worse swelling, with numbness, US showed no DVT. Neck: Neck incision for tracheal resection and reconstruction is healing with slight stable erythema and no purulence or drg. Retention sutures were dc'd on [2173-11-29]. Lungs: The patient had BAL x 2 and ETT aspirate growing pan-sensitive pseudomonas, ID was consulted and recommended cipro x 15 days. The patient was switched to levofloxacin on [2173-11-30] to be completed [2173-12-9]. The patient is maintaining his airway without shortness of breath, saturating 92% on 3LNC. This should be eventually weaned off as possible. Bronchoscopy done on [2173-11-29] showing healthy anastamosis. CV: stable GI/Nutrition: eating a regular diet without problems. [Name (NI) ] BM three days ago. GU: foley DC'd [2173-11-30] voiding well. ID: per lungs above Pain: transitioned to oral regimine on [2173-11-30], with pain control on percocet. Has lidocaine patch which will be dc'd on transition to rehab. Psych: hx of depression after mother died with weight gain. started on citalopram 10 mg po daily per psych eval on [2173-11-30]. Should increase to 20 mg daily and have outpt psych eval in one week. Lines: Right PICC line dc'd intact [2173-12-2]. PT/OT: PT to eval [2173-12-1], but deconditioned from prolonged ICU stay. On lovenox 40 mg SQ q 12 hrs for DVT prophylaxis given immobility. LUE edema. US was negative for DVT on [2173-12-1]. Endo: on levothyroxine 50 mcg po daily, will need outpt TFT f/u. DM- [Last Name (un) ] diabetes clinic following. NPH held [2173-12-2] and there was initiation of metformin with sliding scale. This needs to be followed closely and changed by rehab physician with [Name9 (PRE) 3782] endocrine follow up. We would like the blood glucoses to be 150 or less for healing of anastamosis. Discharge Medications: 1. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML Miscellaneous Q6H (every 6 hours) as needed for wheeze. 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 4. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 5. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours): while immobile. 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: do not exceed >4 grams/day, and do not drink alchohol with this, or drive while on this. 10. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as needed for depression: in one week increase to 20mg/day, and should have outpt psych f/u dosing/efficacy. 12. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours): last dose on [2173-12-9] . Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: 1. Post tracheostomy tracheal stenosis, s/p cervical tracheal resection reconstruction by Dr. [Last Name (STitle) ] on [2173-11-19] 2. Clubfoot deformity s/p multiple surgeries 3. Diabetes Discharge Condition: stable Discharge Instructions: -Call Dr.[Name (NI) 2347] office if [Telephone/Fax (1) 2348] for any questions, fevers >101.5, chills, shortness of breath, chest pains, or if neck incision opens with puss, drainage, or gets increasingly red. -monitor blood sugars before meals, and at bedtime at rehab, and adjust diabetic meds [Hospital ] rehab physicians will be in charge of this. - walk three times a day, and work with PT - do incentive spirometer 10x every couple hours. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] on [2172-12-28] at 10 am on [Hospital Ward Name 517] [Hospital1 18] [Hospital1 ] 116. After this you will see Dr. [Last Name (STitle) ] 10:30, then have bronchoscopy 11 am. Please go to Clinical Center on [Hospital Ward Name 517] [Location (un) 470] radiology department for Chest xray at 9:15. Call [Telephone/Fax (1) 2348] with questions. Please do not eat the night before your procedure. Completed by:[2173-12-2]	[ "250.00", "278.01", "519.02", "327.23", "V85.4", "518.81" ]	icd9cm	[ [ [] ] ]	[ "31.5", "96.04", "38.93", "96.72", "33.22", "31.79", "33.24" ]	icd9pcs	[ [ [] ] ]	7328, 7383	3332, 3834	310, 505	7624, 7633	2618, 3309	8139, 8640	2142, 2167		5946, 7305		7404, 7603			3852, 5923		7657, 8116									2182, 2599																					235, 272							533, 1899																	1921, 2034	2050, 2126
9,110	169,868	6571+6572+55765	Discharge summary	report+report+addendum	Admission Date: [2129-10-14] Discharge Date: [2129-10-20] Date of Birth: [2055-5-22] Sex: M Service: CCU CHIEF COMPLAINT: Shortness of breath HISTORY OF PRESENT ILLNESS: This is a 74 year old male with a history of diabetes, peripheral vascular disease, chronic renal insufficiency, history of atrial fibrillation who was recently admitted on [2129-9-21] for atrial fibrillation and mildly elevated troponins, and discharged on [2129-9-26] and went to [Hospital3 12564] Hospital. He recently presented back to an outside hospital with room air, oxygen saturations of 80% and had chest x-ray consistent with pulmonary edema, intubated and received Lasix 40 times one and another 80 times two upon transfer to [Hospital6 1760] for further management. When he presented to the outside hospital he was sating in the low 80s with a nonrebreather and was very tachypneic. PAST MEDICAL HISTORY: Diabetes mellitus Type 2. Peripheral vascular disease, status post left below the knee amputation. Chronic renal insufficiency, creatinine baseline about 2.5. Dementia, type unknown. Left intertrochanteric fracture, status post open reduction and internal fixation on [2129-9-17]. History of coronary artery disease, P-MIBI in [2127] showed large inferior reversible defect. Echocardiogram in [2129-9-12] showed left atrial mildly dilated left wall thickness, normal ejection fraction of 40 to 50%, secondary to severe hypokinesis, inferior free wall and moderate hypokinesis of posterior wall, mild to 1+ mitral regurgitation. History of atrial fibrillation. History of hepatitis C. Cirrhosis, mentioned in outside hospital, secondary to history of hepatitis C, followed by hepatologist in [Location (un) 86]. History of questionable hemorrhagic cerebrovascular accident. ALLERGIES: Allergic to Captopril, unknown reaction. SOCIAL HISTORY: Married to second wife, retired, denies tobacco or ethanol use. HOME MEDICATIONS: Aspirin 162 q.d.; Prilosec 30 q.d.; Lopressor 100 b.i.d.; Iron 300 q.d.; Isosorbide 20 b.i.d.; subcutaneous heparin; Folate two q.d.; Vitamin B12 1000 mcg q.d.; Vitamin B6 12.5 mg q.d.; Zyprexa 2.5 q.h.s.; Norvasc 5 q.d.; NPH 26 in AM, 8 in PM; Tylenol prn PHYSICAL EXAMINATION: Vital signs on admission revealed temperature 102.0, heartrate 92, blood pressure 135/55, respiratory rate 11. He was intubated, sedated and his ventilated. His ventilator settings were SIMV with pressure support, title volume of 800, rate 10, positive end-expiratory pressure of 5 and FIO2 60%. General: Sedated and intubated. Head, eyes, ears, nose and throat: Intubated, moist membrane mucosal, pupils equal, round and reactive to light and accommodation. Cardiovascular: Regular rate and rhythm with normal S1 and S2, no murmurs, rubs, gallops or rubs. Respiratory: Bilateral bibasilar crackles, otherwise no changes. Abdomen: Soft, bowel sounds present, nontender, nondistended, no hepatosplenomegaly. Extremities: Left below the knee amputation, no edema, cyanosis or clubbing. Neurological: Sedated. LABORATORY DATA: Laboratory data on admission revealed white blood count 12.8, hemoglobin and hematocrit 11 and 33.3, platelets 462, MCV 90, sodium 142, potassium 4.9, chloride 106, bicarbonate 24, BUN 61, creatinine 2.8, glucose 105. Creatinine kinase 181. Chest x-ray at presentation was pending. AST 51, ALT 30, alkaline phosphatase 271, total bilirubin .6, INR 1.0, PTT 26.6. Arterial blood gases 7.50, 30, 158 pO2, 24 bicarbonate. Electrocardiogram showed a normal sinus rhythm and no major changes noted. HOSPITAL COURSE: This was a 74 year old male with a history of atrial fibrillation and diabetes, status post open reduction and internal fixation for left trochanteric fracture, coronary artery disease, chronic renal insufficiency who presented with worsening shortness of breath times one day and was also noted to be febrile to 102 on admission. Etiology of his shortness of breath was concerning given his congestive heart failure history and cardiac versus pulmonary secondary to pneumonia as such. Cardiac - Coronaries, cycled enzymes were negative and he was ruled out. He was continued on Aspirin, beta blocker and Amlodipine. Pump, he was given Lasix for diuresis which was able to get extubated without any difficulty and he was weaned off oxygen, now down to 2 liters, started two days before discharge and starting to have increased wheezing. He was started on nebulizers which seemed to help but also decreased urinary output most likely to fluid overload, so on the day before his discharge his Hydralazine was increased to 75 q.i.d. and he was started on a nesiritide to better perfuse the kidneys since his creatinines were bumping and also to decrease his afterloads. His goals the day before discharge was 1 liter negative and he has been followed with daily weights. Blood pressure - He is normal sinus rhythm, he has history of intermittent atrial fibrillation. Since admission he is on Amiodarone and beta blocker for now and continuing to be checked on Telemetry. Pulmonary - The day before discharge he was initially extubated without any difficulty and weaned off of the oxygen without any difficulty. On the day before discharge he was on 2 liters of oxygen but continued to have extreme wheezing, bilaterally diffuse and he was started on scheduled nebulizers which helped the patient and will continue with the nebulizers when discharged to the rehabilitation center. He was also started on nesiritide for afterload reduce and perfuse kidney further which decrease in volume overload will help his pulmonary status. Infectious disease - He has been afebrile since admission. He had a temperature of 102 but has not had one since. He was started on Levaquin for presumed pneumonia and to continue a 14 day course. He has been on day #4 now and is to continue ten more days upon discharge to rehabilitation. Neurology - He has baseline dementia of unknown etiology, questionable. He is alert and oriented intermittently. Questionable if dementia secondary to a current metabolic disorder or his baseline or new baseline. Neurology will follow closely and Neurology recommended it is most likely secondary to metabolic disorder, partially secondary to his baseline now. Renal - In terms of his renal status he now has an acute renal failure secondary to his chronic renal insufficiency. His baseline creatinine is about mid 2s to .5, now he is bumped up to 4s and this is most likely secondary to Lasix, possibly decreased volume to his kidneys. He is started on a nesiritide data before discharge to better perfuse the kidneys, also Renal Consult Service was consulted to put in their input. Their input was appreciated. Will continue to follow his creatinine closely. He may need hemodialysis at some point. Endocrine - For his diabetes he was continued on his fixed dose of insulin and also regular insulin sliding scale with a q.i.d. fingerstick glucose. Diet - For his diet he was being repleted for his electrolytes prn. He was kept on a cardiac, renal and diabetic diet. Prophylaxis - Prophylactically he was given proton pump inhibitor, bowel regimen and heparin subcutaneously. He did well and was in stable condition upon discharge to rehabilitation. DISCHARGE INSTRUCTIONS: He was discharged to rehabilitation center. The patient was instructed to follow weights daily and to call his medical doctor if his weight had increased more than 3 pounds and to adhere to a 2 gm sodium diet very strictly and also a fluid-restricted diet and to seek medical attention as needed if new symptoms or old symptoms return. He was also to follow up with his primary care physician early next week, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 25154]. FINAL DIAGNOSIS: Congestive heart failure, no major surgical invasive procedures done except intubation. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Aspirin 81 times two, 162 mg q.d. 2. Heparin subcutaneously q. 12 3. Folic acid 1 gm two tablets q.d. 4. Olanzapine 2.5 mg q.d. 5. Amlodipine 5 mg q.d. 6. Tylenol prn 7. Miconazole powder b.i.d., apply to region as needed 8. Lansoprazole 30 mg q.d. 9. Amiodarone 200 mg, two tablets b.i.d., 400 b.i.d., to change after one week to q.d. by primary care physician at the rehabilitation center 10. Levofloxacin 250 mg q.d. for the next ten days 11. Isosorbide mononitrate 30 mg q.d. 12. Metoprolol 75 mg t.i.d. 13. Albuterol nebulizer q. 4 hours 14. Hydralazine 75 mg q.i.d. 15. Regular insulin sliding scale, fixed dose 18 and 8 with q.i.d. fingersticks FOLLOW UP: As directed above. DIET: Diabetic consisting of carbohydrates, low cholesterol, low saturated fat and no-added salt. Renal - Renif, breakfast, lunch and dinner with fluid-restricted diet. ACTIVITIES: The patient is to receive physical therapy and respiratory therapy while at rehabilitation. Activities, out of bed to chair with supervision at all times. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15176], M.D. [MD Number(1) 15177] Dictated By:[Name8 (MD) 12818] MEDQUIST36 D: [2129-10-19] 14:01 T: [2129-10-19] 14:11 JOB#: [Job Number 25155] Admission Date: [2129-10-14] Discharge Date: [2129-11-16] Date of Birth: [2055-5-22] Sex: M Service: The patient presumed to be discharged to rehabilitation facility. Given the patient's worsening shortness of breath and rising creatinine, the patient remained in house for appropriate workup. Creatinine continued to rise from 2.8 to 4.4 with worsening shortness of breath. X-ray shows signs of significant congestive heart failure. The patient was aggressively diuresed although limited due to the patient's renal failure. Renal consultation was obtained which initially showed acute tubular necrosis with numerous muddy brown casts in the urine. The decision to use Lasix to reduce congestive symptomatology as well as a contributor to the patient's worsening renal failure. The patient was ruled out by cardiac enzymes, initiated on Nesiritide which showed improved urine output. Decision to hold on hemodialysis at the time was made. The patient continued to improve from a respiratory standpoint. On day ten, the patient was shown to have acute mental status change, nonresponsive to painful stimulation. The patient was transferred back to the CCU and intubated. Upon intubation, the patient seemed to become reoriented. Arterial blood gases were normal. Blood cultures on the [2129-10-28], [2129-10-29], and [2129-10-30], positive for four out of four culture sets positive for Methicillin resistant Staphylococcus aureus. Three days of significant bacteremia, was started on Vancomycin and renally dosed Gentamicin. Mental status improved. The patient was extubated the following day. Electroencephalogram was obtained which showed changes suggestive of chronic metabolic encephalopathy without evidence of seizure disorder. CT of the head revealed absence of bleed or lesion. The patient continued to improve and remain culture negative. Decision to transfer back to the floor and transfer to care of Medicine was made at this time. Finish seven day course of Gentamicin and awaited decrease in leukocytosis prior to inserting long term indwelling line for hemodialysis. The patient was transferred to general medicine [Hospital1 ] for further workup of acute on chronic renal failure, Methicillin resistant Staphylococcus aureus bacteremia, metabolic encephalopathy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15176], M.D. [MD Number(1) 15177] Dictated By:[Last Name (NamePattern1) 972] MEDQUIST36 D: [2129-11-16] 20:14 T: [2129-11-16] 20:38 JOB#: [Job Number 25156] Name: [Known lastname 4276], [First Name3 (LF) ] Unit No: [Numeric Identifier 4277] Admission Date: [2129-11-5] Discharge Date: [2129-11-17] Date of Birth: [2055-5-22] Sex: M Service: ADDENDUM HISTORY OF PRESENT ILLNESS: Medicine service accepted this 74 year old male who presents with worsening renal insufficiency from the CCU team. History of diabetes, peripheral vascular disease, status post open reduction and internal fixation of the left hip at an outside hospital on [9-17]. History of hepatitis C. Status post below the knee amputation on the left, secondary to peripheral vascular disease with atrial fibrillation, controlled now in normal sinus rhythm. He presents with Methicillin resistant Staphylococcus aureus growing in his blood cultures and urine. Last blood culture positive for Methicillin resistant Staphylococcus aureus was [10-28]; all others have remained negative. [10-15] films show no osteomyelitis. Films of the 19th show negative osteomyelitis of the hips. Lumbar puncture was done and was negative for the source of Methicillin resistant Staphylococcus aureus. A Transesophageal echocardiogram was performed on [10-31] which showed no endocarditis. The patient presents on Vancomycin dosed by level less than 15. The patient also has diarrhea. Clostridium difficile cultures were sent and were negative. The patient is a full code. The patient was seen and examined on presentation. Temperature was 98.1; blood pressure 90 to 108 over 38 to 50; heart rate 61 to 73; respiratory rate 18; saturating 97% on three liters of oxygen. In general, he was withdrawn. He had a flat affect. His mucous membranes were moist. There was no scleral icterus. His neck was supple. There was no jugular venous distention noted. Cardiovascular: Distant heart sounds with S1 and S2, regular rate and rhythm. Lungs were clear to auscultation bilaterally. He had prominent bowel sounds and soft abdominal examination, nontender, nondistended. Extremities: Notable for a left below the knee amputation. Range of motion on the left is limited secondary to pain since his open reduction and internal fixation in [Month (only) 4278]. LABORATORY DATA: On transfer to medicine, white count was 21.0. All blood cultures had remained negative since [10-28] which was positive for Methicillin resistant Staphylococcus aureus. The patient was maintained on heparin drip for a left atrial appendage thrombus. HOSPITAL COURSE: 1.) Cardiovascular: Atrial fibrillation was controlled throughout this admission for this period of time on Amiodarone 200 mg q. day. The patient had a known left atrial appendage thrombus and was maintained on heparin until all interventions were performed. The patient was transitioned to Coumadin starting [11-16] after his permanent hemodialysis access had been established. Cardiovascular disease: The patient was on aspirin, heparin, beta blocker, Isosorbide, Hydralazine per the CCU regimen. Infectious disease: The patient had no identifiable source of his Methicillin resistant Staphylococcus aureus infection. Several studies were performed to further evaluate cause of the Methicillin resistant Staphylococcus aureus infection and his leukocytosis, initially presenting with a white blood cell count of 21. This slowly trended down over the course of the hospital stay, until it returned to a baseline of ten, prior to his discharge. The patient was maintained on Vancomycin levels, dosed when blood levels were less than 15. He had some synergistic dosing which was discontinued after four days time. A bone scan was performed which demonstrated increased uptake in the left proximal femur and acetabulum, consistent with osseous repair following fracture and surgical repair and infected component could not be excluded from the proximal left femur based on the bone scan findings. Orthopedic surgery was consulted. They said they could not rule out a Methicillin resistant Staphylococcus aureus seeding of the hardware based on this bone scan. They suggest a six week course of Vancomycin with a follow-up bone scan at that time to further evaluate the surgical repair versus hardware seeding of this patient's Methicillin resistant Staphylococcus aureus bacteremia. A magnetic resonance scan was performed which demonstrated a left psoas muscle abscess, measuring two by three by 2 cm. CT also demonstrated diffusely atrophic pancreas with multiple small cystic structures, measuring several mm in the head of the pancreas. No obvious masses were seen. Findings probably represent ITMT or changes in chronic pancreatitis. Follow-up evaluation is recommended. The left psoas muscle abscess was further evaluated on CT and determined to be a possible psoas hematoma. The interventional radiologist did not feel that the psoas muscle abscess versus hematoma was drainable. They suggested antibiotic regimen and follow-up with a rescan to assess the progression of the hematoma versus the abscess in four to six weeks. If this is a hematoma, one cannot exclude the possibility that it has been infected or seeded by the Methicillin resistant Staphylococcus aureus bacteremia. End stage renal disease. The patient was maintained on hemodialysis. Initially, a temporary line was placed until the patient was cleared of infection and white count had returned to [Location 1867]. The patient had no difficulties tolerating the dialysis procedure. On [11-16], a permanent dialysis catheter was put in place. The patient was started on Wolfram. The patient will be dosed with Vancomycin at hemodialysis as an outpatient. Mental status: The patient's mental status returned to baseline, though he remained profoundly depressed. The patient was evaluated by psychiatry for this change in mental status who suggested an adjustment disorder with depressed mood and suggested dosing Remeron to increase appetite and sleeping q h.s. They also suggested further cognitive testing as an outpatient at the skilled nursing facility. Diabetes: The patient was maintained on 15 units of NPH at breakfast, 4 units of NPH at bedtime as well as six units of regular insulin at dinner, on top of a regular insulin sliding scale as well as a diabetic diet. The patient had a noticeable pressure ulcer over his coccyx, for which he was treated with appropriate wound care. He also had a fungal rash, for which he was treated with appropriate Miconazole powder and Nystatin ointment. Gastrointestinal: The patient had electrolytes repletion prn as well as Loperamide occasionally prn for diarrhea. Anemia: The patient was followed and maintained on a hematocrit above 30. The patient had a baseline hematocrit resting at 29 to 30. Access: The patient had a PICC line placed for access for his heparin infusion. This PICC line may be discontinued as the patient is transitioned off heparin to Wolfram as his Vancomycin will be dosed by levels and may be administered at hemodialysis. DISCHARGE CONDITION: Tolerating p.o. His affect is brighter. He is getting hemodialysis per catheter and is being transitioned to Wolfram from his heparin drip. DISCHARGE DIAGNOSES: Congestive heart failure. Status post open reduction and internal fixation, left atrial appendage thrombus. Psoas abscess versus hematoma. Coronary artery disease. Atrial fibrillation, now in sinus on Amiodarone. Methicillin resistant Staphylococcus aureus in his urine. Methicillin resistant Staphylococcus aureus in his blood. ESRD on hemodialysis. Diabetes mellitus. Hepatitis C. Adjustment disorder with depressive symptoms and dementia not otherwise specified. RECOMMENDED FOLLOW-UP: The patient will be admitted to a skilled nursing facility, where he will be followed by their in house physician. [Name10 (NameIs) ] will monitor his INR for a goal of two to three while transitioning to Wolfram. [Month (only) 412] need to reduce Wolfram dosing. Will be followed by INR. The patient will need to have Vancomycin levels dosed when they are less than 15. The patient will receive one gram of Vancomycin when levels are less than 15. He needs a six week total course of Vancomycin post discharge. The patient should call his primary care doctor, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], and touch base and arrange an appointment. The patient has a follow-up CAT scan scheduled on [12-19] as well as a bone scan scheduled on [12-19]. The patient will follow-up with infectious disease on [12-26] to follow-up his infectious process. The patient will be followed at dialysis per routine. DISCHARGE MEDICATIONS: Aspirin 81 mg once a day. Folic acid 1 mg two tablets once a day. Acetaminophen 325 mg q. four to six hours as needed. Lansoprazole 30 mg one q. day. Isosorbide mononitrate 30 mg q. day. Fluticasone 110 mg one puff twice a day. Hydralazine 25 mg three tablets q. eight hours, hold if systolic blood pressure is less than 100. Miconazole powder apply three times a day. Ipratropium bromide 18 mcg two puffs four times a day. Calcium carbonate 500 mg q. one tablet three times a day. Docusate sodium 100 mg twice a day. Senna twice a day. Metoprolol 50 mg 1.5 tablets twice a day. Amiodarone 200 mg one tablet q. day. Nystatin ointment prn. Retazepine 15 mg take half tablet q h.s. Wolfram 5 mg q h.s., may be adjusted when therapeutic INR between 2 and 3. Heparin weight based dosing starting at 1,500 units per hour, as directed until Wolfram is therapeutic. NPH insulin 15 units q. a.m., 4 units q h.s. Insulin regular 6 units subcutaneous with dinner. Regular insulin sliding scale. DR.[Last Name (STitle) ],[First Name3 (LF) 77] 12-986 Dictated By:[Last Name (NamePattern1) 4245] MEDQUIST36 D: [2129-11-16] 05:55 T: [2129-11-16] 19:21 JOB#: [Job Number 4279]	[ "427.31", "428.0", "349.82", "584.5", "038.11", "585", "070.51", "707.0", "599.0" ]	icd9cm	[ [ [] ] ]	[ "93.90", "96.04", "00.13", "38.95", "38.93", "03.31", "39.95" ]	icd9pcs	[ [ [] ] ]				19035, 19176				19197, 20644	20667, 21879					14499, 17656	7874, 7963	7340, 7856												1988, 2246					8697, 12222				2269, 3603									156, 177							12251, 14481												17672, 19013					943, 1887	1904, 1969	7988, 7997
59,980	108,685	36891	Discharge summary	report	Admission Date: [2187-7-26] Discharge Date: [2187-8-10] Date of Birth: [2163-3-3] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: Multi-trauma Major Surgical or Invasive Procedure: [7-26] PROCEDURES: 1. Exploratory laparotomy. 2. Right chest tube placement. [2187-7-27] PROCEDURES: 1. Unpacking of liver injury. 2. Hemostasis of residual hepatic hemorrhage. 3. Abdominal closure. [2187-7-30] PROCEDURES: 1. T3 through T5 laminectomy. 2. Right T4 transpedicular decompression. 3. Repair of a spinal fluid leak primarily. 4. Local autograft. 5. Right iliac crest bone graft (nonstructural) graft through a separate incision. 6. Pedicle screw instrumentation ([Last Name (un) 83297] Expedium) from T2 to T8. 7. Posterolateral arthrodesis, T2 through T8. History of Present Illness: 24 year old male who was involved in a high speed motor vehicle crash. He was ejected from the car and suffered a grade 4 liver laceration, multiple cervical and thoracic spine fractures, as well as a possible vertebral artery dissection. He was transported to [Hospital1 18] for further care. Past Medical History: s/p Right arm surgery Family History: Noncontributory Physical Exam: T: 37.4 BP: 114/75 HR: 136 R 19 O2Sats 98% intubated Gen: intubated, paralyzed, open abdomen HEENT: Pupils: pinpoint, non reactive EOMs UTA Extrem: Warm and well-perfused. Mental status: intubated, paralyzed, sedated. Cranial Nerves: UTA Motor: UTA Sensation: UTA. Reflexes: B T Br Pa Ac Right UTA Left UTA Coordination: UTA Pertinent Results: [2187-7-26] 07:44PM TYPE-ART PO2-135* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1 [2187-7-26] 07:44PM LACTATE-4.7* [2187-7-26] 07:30PM GLUCOSE-118* UREA N-11 CREAT-0.9 SODIUM-143 POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-22 ANION GAP-14 [2187-7-26] 07:30PM CALCIUM-7.8* PHOSPHATE-3.6 MAGNESIUM-1.3* [2187-7-26] 07:30PM WBC-11.4* RBC-3.61* HGB-10.7* HCT-29.9* MCV-83 MCH-29.5 MCHC-35.7* RDW-14.8 [2187-7-26] 07:30PM PLT COUNT-100* [2187-7-26] 07:30PM PT-13.7* INR(PT)-1.2* CT Head [2187-7-26] IMPRESSION: 1. Increased diffuse cerebral edema with partial effacement of the cisterns and ventricular system and loss of [Doctor Last Name 352]-white differentiation consistent with diffuse edema, possibly related to [Doctor First Name ]. Close clinical followup is recommended. Pl. see above details regarding inadequate evaluation for tonsillar herniation. 2. Decreased conspicuity to small right-sided tentorial subdural hematoma noted on outside imaging. No regions of subarachnoid hemorrhage identified on current exam. CTA neck [2187-7-26] IMPRESSION: 1. Lateral mass/articular facet fracture of C2 with comminuted right transverse process fractures at C2, C3, and C4 with right vertebral artery caliber change at the C3 and C4 level suspicious for intimal injury or dissection. Further delineation can be attempted with MRA neck if clinically indicated . 2. Complex unstable appearing comminuted and distracted posterior element fractures involving T3 and T4 partially visualized. Comminuted left scapular body fracture. 3. Increased contusion and/or effusion at the left apex. No visualized pneumothorax within the included portions of the upper lungs. CT Chest/Abdomen [2187-7-26] IMPRESSION: 1. No evidence of active extravasation. This patient is status post exploratory laparotomy left open with surgical packing surrounding the liver 2. Left greater than right pleural effusion and bilateral atelectasis. 3. Right basilar chest tube, nasogastric tube in standard positions. 4. Stable appearance of known right renal laceration. 5. Markedly edematous loops of small and large bowel with free abdominal fluid and pericholecystic fluid that is suggestive of third spacing. 6. Replaced left hepatic artery arising from the left gastric and replaced right hepatic artery arising from the common hepatic artery which originates from the SMA. MRI Cervical/Thoracic Spine [2187-7-28] IMPRESSION: 1. Ligamentum flavum disruption at T2-3 and T3-4 level with widening of the interspinous distance indicative of flexion injury with fractures of right superior articular process of T3 and T4 and left superior articular process of T3 and fracture of the anterior superior portion of T4 vertebra. This combination of findings indicates an unstable flexion injury at this level. 2. Paraspinal hematoma seen with probable hematoma within the right side of the spinal canal at T3-4 level with narrowing of the spinal canal and displacement of the spinal cord to the left side. The narrowing also is contributed by malalignment and displacement of the bony structures to the right side of the spinal canal. Although there is an indentation on the spinal cord at T3-4 level, no definite increased spinal cord signal is seen. However, the evaluation is limited secondary to artifacts and a small area of spinal cord contusion cannot be excluded. Brief Hospital Course: He was taken to the operating room on arrival to [Hospital1 18] for exploratory laparotomy and was found to have a grade 4 liver laceration. His abdomen was packed in order to control the hemorrhage. He was then taken to the Trauma ICU. Postoperatively Neurosurgery was consulted and an intracranial bolt was placed to monitor his ICP. They were consistently in the range of [6-6]. During the first 24 hours he received >30 units of blood products including PRBC's, FFP, platelets, cryo, and Factor VII. His abdomen was left because of his severe edema and 3rd spacing. On POD 1 he returned to the OR to remove the packing and to close his abdomen. His bladder pressures were closely monitored and remained within the normal range. He was started on beta blockers for tachycardia and elevated blood pressures. Two days later he was taken back to the operating room by Neurosurgery for posterior fusion of his severe T2-8 fractures. There were no intraoperative complications. Postoperatively he was maintained in the hard cervical collar and was taken back to the Trauma ICU where he remained for another 6-7 days. He was weaned from sedation and the ventilator and was finally extubated. He was later transferred to the regular nursing unit. While on the nursing unit he continued to progress slowly; his mental status improved significantly over the remainder course of his stay. His blood pressures were intermittently elevated and he was continued on his Lopressor. He was tolerating regular diet and was not reporting any pain issues. He was evaluated by Physical and Occupational therapy and was cleared for home with 24 hour supervision. He was given prescriptions for outpatient PT and OT. Medications on Admission: Denies Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [4-23] hours as needed for pain. 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:1 3. Outpatient Occupational Therapy Dx: s/p Motor vehicle crash; Traumatic Brain Injury Sig: Evaluate & treat 1-2x/week 4. Outpatient Physical Therapy Dx: s/p Motor vehicle crash; Traumatic brain injury Sig: Evaluate and treat 1-2x/week Discharge Disposition: Home Discharge Diagnosis: s/p Motor vehicle crash Subarachnoid hemorrhage Subdural hematoma Liver laceration Grade III-IV Comminuted right transverse process fracture C2-4 Lateral mass/articular facet fracture C2-4 Left scapular fracture Posterior element fracture T3-4 Acute blood loss anemia Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adeqautely controlled. Discharge Instructions: You must continue to wear the cervical collar until follow up with Dr. [Last Name (STitle) 548] in 4 weeks. DO NOT participate in any contact sports of any kind or other activity that may cause injury to your abdomianl region because of your liver injury. Return to the Emergency room immediately if you develop: -Sudden onset of dizziness, become lightheaded as if going to pass out as these are signs thta you may be having internal bleeding from your liver injury. -Fevers, right sided abdominal pain or hiccups as these are symptoms concerning for a fluid collection or abscess in your abdomen as a result of your liver injury. Return to the Emergency room if you develop any fevers, chills, headaches, dizziness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Followup Instructions: Follow up with Dr. [Last Name (STitle) 548], Neurosurgery in 4 weeks, you will need repeat CT scan for this prior to appoint - call [Telephone/Fax (1) 2992] for appt date and time. Follow up with Dr. [Last Name (STitle) ] in 2 weeks, Trauma surgery for follow up of your exploratory laparotomy. Call [Telephone/Fax (1) 6429] for an appointment. Completed by:[2187-8-15]	[ "866.00", "806.20", "E815.0", "805.03", "811.09", "486", "789.59", "868.03", "285.1", "518.0", "852.09", "953.1", "415.19", "348.5", "276.2", "864.03", "852.21", "443.24", "805.02", "805.04", "860.0", "958.4", "E849.5" ]	icd9cm	[ [ [] ] ]	[ "38.93", "54.63", "34.04", "93.59", "88.01", "04.79", "93.90", "81.63", "99.05", "87.41", "99.06", "81.05", "01.10", "54.12", "54.19", "03.59", "96.72", "96.07", "96.6", "54.91", "03.53", "99.07", "03.09", "96.59", "33.24", "99.21", "39.98", "88.38", "99.09", "87.03", "77.79", "99.04" ]	icd9pcs	[ [ [] ] ]	7370, 7376	5132, 6843	326, 924	7688, 7768	1697, 5109	8671, 9063	1312, 1329		6900, 7347		7397, 7667		6869, 6877			7792, 8648									1344, 1519																					274, 288							952, 1251	1582, 1678											1534, 1566					1273, 1296
4,555	183,391	8852	Discharge summary	report	Admission Date: [2174-10-19] Discharge Date: [2174-10-29] Date of Birth: [2099-1-5] Sex: F Service: MEDICINE Allergies: Tegretol / Phenergan Plain / Bactrim / Keflex / Amoxicillin / Chlorhexidine / ceftriaxone Attending:[First Name3 (LF) 3984] Chief Complaint: Respiratory distress, hypoxemia, diarrhea Major Surgical or Invasive Procedure: Lumbar puncture Triple lumen central venous line placement. History of Present Illness: HPI: Ms. [Known lastname 4027] is a 75F with a h/o chronic diarrhea, ischemic colitis s/p partial colectomy and recurrent UTIs who presents to the ER with worsening diarrhea. She was admitted to [Hospital1 18] from [9-1] - [9-6] for hyperlkalemia, diarrhea, Non-Anion Gap Metabolic Acidosis, and was discharged to rehab. By her report, she was discharged from rehab 2 weeks ago, and since that time, she has had 8 loose, watery stools/day whereas she normally has approximately [4-12] more formed stools. The diarrhea is associated with abdominal cramping which is [5-17] in intensity and improves after each episode. She denies any fevers, chills, medication changes, sick contacts, dietary changes, blood or mucous in stool. The VNA came to visit her the day of admission, found her to be orthostatic with HR in the 90s, so she came to the ER for evaluation. Of note, she says that diarrhea and abdominal cramping has been constant over the 2 week period. In the ER, she received Tylenol for HA, NS 400cc, and Morphine 2mg IV which helped relieve her abdominal cramps. She has not had any bowel movements in the past 8 hours. Review of Systems: (+) Per HPI with mild nausea (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies vomiting, constipation, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: Past Medical History: #Chronic Diarrhea. She has had chronic diarrhea since [2163], presumed to result from her Biliroth 1 and colectomy. She was cleared for a suspected diagnosis of Crohn's disease by normal colonoscopy in [2167] and [2169]. #Recurrent UTIs. She had a pansensitive E. Coli UTI in [4-18] and [6-18]. She recently presented during [8-18] with pyelonephritis (evidence of peripheric stranding on CT). #GERD. Barrett's esophagus reported on previous EGD (date unknown). #Hypertension. Controlled with Amlodipine and Labetalol. #Seizure disorder. Admitted in [6-18] by neurology. They concluded that she had psychogenic nonepileptic seizures. #s/p partial right colectomy with ileosotmy and subsequent reversal, following an episode of ischemic colitis. #Status post appendectomy. #Status post open cholecystectomy with common bile duct exploration and choleduodenosotomy. She has a normal finding of pneumobilia, noted in KUB in [2167] and during recent admission. #ORIF Left wrist #Biliroth 1 #Spinal fusionx2. Date unknown. Sometimes a cause of LBP, particularly on right. Social History: Patient lives in [Location 745] with her husband. She has four children, but is estranged from two due to substance abuse issues. She reports that her husband helps her walk since her recent difficulty, but that she is fairly independent. [Location ] indicates a history of childhood sexual abuse. She denies alcohol, tobacco, or illicit drug use. Family History: Mother: died in 90s, unclear cause Father: died 73, alcoholism Siblings: died in 60s from throat cancer Children: 4 children, 56 to 50; no medical problems [Name (NI) ]: no FH of seizures or epilepsy Physical Exam: T: 98.1 bp 154/93 HR 73 RR 16 SaO2 100RA GENERAL - well-appearing woman in NAD, appropriate HEENT - NC/AT, EOMI, sclerae anicteric, very dry mucous membranes NECK - supple, no JVD LUNGS - CTA bilat, unlabored, no accessory muscle use HEART - RRR, 1/6 Systolic murmur crescendo-decrescendo. Loud S2. ABDOMEN - soft/ND, +mild tenderness in all quadrants with moderate palpation no masses or HSM, no rebound/guarding EXTREMITIES - WWP SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, no focal deficits, possible tardative dyskinesia, movements which she attributes to dry mouth PSYCH: appropriate, cooperative Pertinent Results: [2174-10-19] 05:50PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.005 [2174-10-19] 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2174-10-19] 05:50PM URINE RBC-0 WBC-12* BACTERIA-FEW YEAST-NONE EPI-<1 [2174-10-19] 05:50PM URINE MUCOUS-RARE [2174-10-19] 04:13PM GLUCOSE-95 UREA N-38* CREAT-2.2* SODIUM-135 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14 [2174-10-19] 04:13PM ALT(SGPT)-34 AST(SGOT)-53* LD(LDH)-198 ALK PHOS-94 TOT BILI-0.2 [2174-10-19] 04:13PM LIPASE-57 [2174-10-19] 04:13PM ALBUMIN-4.3 IRON-29* [2174-10-19] 04:13PM calTIBC-360 FERRITIN-16 TRF-277 [2174-10-19] 04:13PM WBC-3.7* RBC-4.30# HGB-11.1* HCT-33.5* MCV-78* MCH-25.8* MCHC-33.1 RDW-14.7 [2174-10-19] 04:13PM NEUTS-45* BANDS-0 LYMPHS-33 MONOS-11 EOS-10* BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2174-10-19] 04:13PM PLT SMR-NORMAL PLT COUNT-196 [2174-10-19] 04:13PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL IMAGING: NCHCT - IMPRESSION: Suboptimal scan due to patient motion in the scanner. With this limitation in mind, no acute intracranial process is seen. Brief Hospital Course: Medicine Floor Course: 1. Chronic diarrhea with acute worsening. Improved soon after admission with administration of lomotil. Stool studies were sent and pending at discharge. An appointment had already been made with her outpatient gastroenterologist for early [11-9]. Chronic kidney disease, stage III. The patient's baseline creatinine ranges quite widely and it is difficult to determine a true baseline. GFR with IVF and decrease in diarrhea. 3. Pyuria. Urine sample likely was contaminated with stool. 4. Hypertension with intravascular volume depletion. Continued Amlodipine and Labetolol. 5. Depression/Anxiety: Continued Klonopin, Seroquel, Cymbalta 6. Orthostatic hypotension. No symptoms with blood pressure drop. 7. GERD. Continued Omeprazole 8. Anemia, likely due to CKD and iron deficiency. ICU Course: The patient was transferred to the ICU on [2174-10-27] when she was noted to be hypoxic (83% on RA) and febrile (103F rectally). She also had altered mental status and minimally responsive and noted to have generalized body "twitching". Her oxygen saturation improved with NRB mask, however she was found to be acidotic and retained carbon dioxide. A head CT was done which suboptimal due to motion artifact, no acute intracranial process is seen. The patient also was started on EEG monitoring and her antibiotic coverage was broadened. An LP was attempted but was unsuccessful at the bedside and planned for an IR attempt. The patient continued to have difficulty breathing and retained increasing amounts of carbon dioxide. The patient did not wish to be intubated. The family decided to transition her care to comfort focused and she passed away later that evening. The cause for her acute decomenstaion was not identified at the time of her death. Medications on Admission: AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 2 Tablet(s) by mouth daily CHOLESTYRAMINE-SUCROSE - (Prescribed by Other Provider: [Name10 (NameIs) ] [First Name8 (NamePattern2) 2092] [Last Name (NamePattern1) 30863]) - 4 gram Powder - 1 tbs by mouth twice a day CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime DIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet - one Tablet(s) by mouth three times daily as needed for diarrhea DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth take one at bedtime DULOXETINE [CYMBALTA] - 30 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth at bedtime GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule - 1 Capsule(s) by mouth twice daily IBANDRONATE [BONIVA] - (Prescribed by Other Provider) - 150 mg Tablet - 1 Tablet(s) by mouth monthly LABETALOL - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth twice daily OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily QUETIAPINE [SEROQUEL] - 100 mg Tablet - 2 Tablet(s) by mouth at bedtime and 1 tablet extra prn SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider: [Name10 (NameIs) ] [First Name8 (NamePattern2) 2092] [Last Name (NamePattern1) 30863]) - 40 mg Tablet - 1 Tablet(s) by mouth daily Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D] - (Prescribed by Other Provider: [Name10 (NameIs) ] [First Name8 (NamePattern2) 2092] [Last Name (NamePattern1) 30863]) - 600 mg (1,500 mg)-200 unit Tablet - 3 Tablet(s) by mouth daily FERROUS SULFATE - (OTC) - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth daily MULTIVITAMIN - (Prescribed by Other Provider: [Name10 (NameIs) ] [First Name8 (NamePattern2) 2092] [Last Name (NamePattern1) 30863]) - Tablet, Chewable - 1 Tablet(s) by mouth daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Hypercapneic and hypoxic respiratory failure Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "288.50", "458.0", "787.91", "276.2", "338.29", "719.06", "530.81", "V58.69", "V45.4", "280.9", "V45.72", "557.1", "555.9", "530.85", "V15.51", "789.07", "724.2", "780.60", "518.81", "791.9", "300.4", "285.21", "276.51", "579.3", "403.90", "585.3", "780.39", "V49.86", "780.97" ]	icd9cm	[ [ [] ] ]	[ "38.93", "81.91" ]	icd9pcs	[ [ [] ] ]	9710, 9719	5930, 7720	393, 454	9807, 9816	4643, 5907	9872, 10008	3766, 3971		9678, 9687		9740, 9786		7746, 9655			9840, 9849									3986, 4624																			1661, 2230		312, 355							482, 1642																	2274, 3376	3392, 3750
59,889	183,382	48951	Discharge summary	report	Admission Date: [2117-5-12] Discharge Date: [2117-5-25] Date of Birth: [2033-11-17] Sex: F Service: MEDICINE Allergies: Verapamil / Beta-Adrenergic Agents / Captopril / Senna / Levofloxacin Attending:[First Name3 (LF) 594] Chief Complaint: Fever Major Surgical or Invasive Procedure: Tunneled HD line replacement [First Name3 (LF) ] Mechanical Intubation Tracheostomy G-tube advancement History of Present Illness: 83F with complicated medical history admitted with fevers and confusion in period surrounding her HD session. Reports to have had non-productive cough x 3 weeks. After HD today, noted to have T 103 and brought [Hospital1 18] ED for further evaluation. History of CVA with limited ability to communicate - mostly yes/no questions. Cared for at home by sister, [Name (NI) 5464] and home health aides. Limited ROS negative for chills, shortness of breath, chest pain, abdominal pain, diarrhea, constipation. In the ED, initial VS: 100.4 80 160/63 20 100%RA. CXR with atelectasis, CT head no acute process, CT A/P with small left lung base consolidation (?infection vs. atelectasis), cholelithiasis and renal atrophy. Given Vancomycin, Cefepime and Levaquin. Admitted to floor. REcieved 250 cc for relative hypotension. On arrival to the medical floor, vitals were stable, no complaints. glucose 40 admitted, recieved D50. Past Medical History: -h/o Klebsiella and enteroccus endocarditis - likely [2-18] old right femoral HD line, and vegetation on anterior and possibly posterior leaflet of mitral valve s/p 6 week course of amp/gent -Hx MRSA bacteremia [August 2114] w/HD cath s/p 6 wk vanco -Hx sacral osteo [December 2114] s/p 6 wk vanco/levoflox/flagyl - Multiple admissions for toxic metabolic encephalopathy- extensively worked up with MRI, EEG, and neurologic consultations. These episodes are typically secondary to infections, missed [Year (2 digits) 2286] sessions or other metabolic derrangements, and are quite profound clinically. - Type 2 Diabetes [Year (2 digits) ] with labile blood surgars - Coronary artery disease - Peripheral vascular disease - Hypertension - Pulmonary hypertension - h/o subdural hematoma and intracranial hemorrhage in [9-25] and neurosurgery in [2-25] (R parietal SDH and small right fontal IPH [9-25] complicated by GTC seizure, s/p left craniotomy for left SDH evacuation) - Toxic Multinodular Goiter - Chronic kidney disease on HD (Tues/ Thurs/ Sat) - Lumbar disc disease - Osteoarthritis - Anemia - low iron and EPO - s/p Breast biopsy - s/p Hysterectomy - s/p transmetatarsal amputation (right foot) - Sacral decubitus with possible osteomyelitis - Upper GI bleed (presented with several episodes of melana in the past, Hct stable and EGD never performed) - Right Humeral fracture (from recent fall off hoya lift [2115-5-8]) - MRSA colonized - Lung nodule (has not been worked up) - Dementia Social History: Has been in and out of various longterm care facilities and rehabs since admission in [5-26]. Prior to [5-26] patient was ambulatory with walker and could feed herself; but has not been ambulatory since that time. As of [12-26] living at home with [Name (NI) 269], sister is primary caretaker. At baseline, she is not confused (as per sister) but in normally barely verbal. - Tobacco: Denied in the past - Alcohol: Denied in the past - Illicits: Denied in the past Family History: - Diabetes [Name (NI) ] (sister) - Cancer in brothers and father (leukemia, prostate) Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 98.4 F, BP 145/67 , HR 71 , R 20, O2-sat 98% RA GENERAL - chronically ill elderly woman, no distress, easily awakened, responds to yes/no questions appropriately HEENT - right eye ptosis, MMM, op with dry secretions in teetch NECK - chronic contracture of muscle, no lad HEART - rrr, [2-22] early systolic murmur best hear at mitral position LUNGS - diminshed BS at bases, no crackles appreciated. no wheeze, no accessory muscle use. ABDOMEN - NABS, soft/NT/ND, no masses or HSM. g tube site appears normal with no sign of infection or irritation. EXTREMITIES - WWP, chronic contractures of bilateral legs and R>L arms. no edema. s/p tarsal amputations on right foot. SKIN - no rashes or lesions, back with no pressure ulcers. NEURO - awake, A&Ox1-2, CNs II-XII grossly intact, muscles contracted throughout body, difficult to examine. responds to touch in bilateral upper and lower extremities. reflex, cerebellar and gait not examined. . MICU ADMISSION EXAM VS - Temp 98.4 F, BP 145/67 , HR 71 , R 20, O2-sat 98% RA GENERAL - chronically ill elderly woman, no distress, easily awakened, responds to yes/no questions appropriately HEENT - right eye ptosis, MMM, op with dry secretions in teetch NECK - chronic contracture of muscle, no lad HEART - rrr, [2-22] early systolic murmur best hear at mitral position LUNGS - diminshed BS at bases, no crackles appreciated. no wheeze, no accessory muscle use. ABDOMEN - NABS, soft/NT/ND, no masses or HSM. g tube site appears normal with no sign of infection or irritation. EXTREMITIES - WWP, chronic contractures of bilateral legs and R>L arms. no edema. s/p tarsal amputations on right foot. SKIN - no rashes or lesions, back with no pressure ulcers. NEURO - awake, A&Ox1-2, CNs II-XII grossly intact, muscles contracted throughout body, difficult to examine. responds to touch in bilateral upper and lower extremities. reflex, cerebellar and gait not examined. . DISCHARGE EXAM Pertinent Results: ADMISSION LABS [2117-5-11] 03:54PM BLOOD WBC-7.3 RBC-4.19* Hgb-11.3* Hct-37.6 MCV-90 MCH-27.1 MCHC-30.1* RDW-18.3* Plt Ct-167 [2117-5-11] 03:54PM BLOOD Neuts-81.4* Lymphs-9.7* Monos-5.8 Eos-2.3 Baso-0.8 [2117-5-11] 03:54PM BLOOD PT-11.5 PTT-27.0 INR(PT)-1.1 [2117-5-11] 03:54PM BLOOD UreaN-24* Creat-3.0* [2117-5-11] 03:54PM BLOOD ALT-13 AST-18 CK(CPK)-35 AlkPhos-217* TotBili-0.2 [2117-5-11] 03:54PM BLOOD cTropnT-0.44* [2117-5-11] 03:54PM BLOOD Lipase-47 [2117-5-11] 03:54PM BLOOD Albumin-4.1 Calcium-8.6 Phos-1.6# Mg-2.0 [2117-5-11] 03:54PM BLOOD TSH-2.0 . DISCHARGE LABS . MICRO . [Date range (1) 46556] Blood culture: no growth [Date range (1) 31045] Blood culture: pending [2117-5-16] RESPIRATORY CULTURE (Preliminary): THIS IS A CORRECTED REPORT [2117-5-19] @1447. Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] #[Numeric Identifier 90038] @1449, [2117-5-19]. Commensal Respiratory Flora Absent. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. This isolate demonstrates carbapenemase production. Consider Infectious Disease Consultation.. RESISTANT TO CEFEPIME (MIC: => 16 MCG/ML) , Tigecycline = SENSITIVE AT <=1 MCG/ML. SENSITIVE TO DOXYCYCLINE. Intermediate TO MINOCYCLINE. DOXYCYCLINE AND MINOCYCLINE sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENT TO [Hospital1 4534] LABORATORIES FOR COLISTING SUSCEPTIBILITY TESTING. PREVIOUSLY REPORTED AS ([2117-5-18]). SENSITIVE TO CEFEPIME (MIC: = 8 MCG/ML). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- =>16 R TETRACYCLINE---------- 8 I TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R [5-17] STOOL DNA amplification assay (Final [2117-5-18]): CLOSTRIDIUM DIFFICILE, Positive for toxigenic C. difficile by the Illumigene DNA amplification. [2117-5-23] 7:27 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [2117-5-23]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): RESULTS PENDING. [5-23] Fecal Culture: pending . IMAGING . [5-11] CT HEAD IMPRESSION: 1. No acute intracranial process. 2. Interval slight decrease in thickness of a small right subdural collection, likely a resolving hematoma. 3. Chronic severe sinus disease. 4. Unchanged ventriculomegaly. [5-11] CXR UPRIGHT AP VIEW OF THE CHEST: Study is limited due to patient rotation. The heart size appears mild to moderately enlarged, but similar when compared to prior study. Stents are redemonstrated within the region of the left brachial and brachiocephalic veins. Low lung volumes are noted, without definite focal consolidation. There is crowding of the bronchovascular structures, but no overt pulmonary edema. Minimal atelectasis in the lung bases is noted, but no large pleural effusion or pneumothorax is seen. Remote proximal right humeral fracture is again demonstrated, and degenerative changes of the left glenohumeral and acromioclavicular joints are present. Atherosclerotic calcifications of the aorta are again demonstrated, and a central venous catheter entering via an inferior approach and terminating in the right atrium is again unchanged. IMPRESSION: Low lung volumes, mild bibasilar atelectasis. [5-12] CT ABD/PELVIS IMPRESSION: 1. Left lung base consolidation increased from prior, which may represent aspiration or infection in the appropriate clinical setting. There is an adjacent small left pleural effusion of intermediate density. 2. Numerous bilateral hypodense renal lesions, compatible with acquired cystic disease. 3. Extensive calcified atherosclerotic disease without associated aneurysmal changes. 4. Cholelithiasis without evidence of acute cholecystitis. [5-14] INITIAL EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of waxing and [Doctor Last Name 688] generalized periodic epileptic discharges representing electrographic seizures seen at the beginning of recording lasting about one hour. The patient occasionally showed tonic posturing of the left arm with a few superimposed myoclonic jerks. These [Doctor Last Name 4493] are consistent with status epilepticus. After administration of Ativan, the electrographic seizure resolved and the epileptic discharges occurred more sporadically. However, after 21:00 the discharges became more common and later after 1:00 am intermittent electrographic seizures were again present. Note was made of intermittent cardiac arrhythmia around 18:01 alternating between one sinus beat and one wide-complex ectopic beat lasting several seconds. . [5-13] REPEAT CT HEAD [Month/Year (2) ]: This study is limited due to patient motion. Within these limitations, there is no evidence of intra-axial or extra-axial hemorrhage, edema, mass effect, or shift of normally midline structures. The small right subdural collection seen on [2117-5-11] is not detected on today's exam. Encephalomalacic changes are again seen in the left occipital/parietal and right parietal lobed as well as the right cerebellar hemisphere which are likely secondary to prior infarcts and appear unchanged from the most recent prior study. A right thalamic lacunar infarct is also stable. The [Doctor Last Name 352]-white matter interface is otherwise preserved without evidence of acute major vascular territorial infarct. Diffuse periventricular and subcortical white matter hypodensities are consistent with the sequela of chronic microvascular ischemic disease. Marked prominence of the lateral ventricles out of proportion to the degree of sulcal prominence is unchanged. Air-fluid levels are noted in the bilateral maxillary sinuses with partial opacification at the ethmoid air cells bilaterally. Mucous retention cysts are seen in the bilateral sphenoid sinuses. There is opacification of the right mastoid air cells, also seen on [2117-5-11]. The middle ear cavities and left mastoid air cells remain clear. The patient is status post left craniotomy. IMPRESSION: 1. No acute intracranial process. The small right subdural collection seen on [2117-5-11] is not detected on today's exam. 3. Stable encephalomalacia without evidence of acute infarction. 4. Stable ventriculomegaly out of proportion to sulcal prominence. . [5-15] MR [First Name (Titles) ] [Last Name (Titles) ]: The study is compared with recent NECT of [2117-5-13], and most recent non-enhanced MR examination of [2115-3-19]. There is a thin subdural collection layering over the right frontovertex convexity, measuring no more than 5 mm in maximal thickness, difficult to identify on the recent examinations. There is no focus of slow diffusion to suggest an acute ischemic event and the principal intracranial vascular flow-voids are preserved. Again demonstrated is global atrophy with significantly disproportionate ventriculomegaly; although not significantly changed, this raises the possibility of underlying communicating hydrocephalus, as before. Also again demonstrated is evidence of moderately severe sequelae of chronic small vessel ischemic disease, as well as focal encephalomalacia in the left parieto-occipital and right parietal lobes, as well as the right cerebellar hemisphere, likely related to remote infarction. There is acute-on-chronic inflammatory disease in the maxillary sinuses and anterior ethmoidal and frontal air cells, as on the previous MR study; extensive fluid-opacification of the right mastoid air cells is significantly worse. IMPRESSION: Somewhat limited examination, with: 1. No finding to suggest acute infarction or hemorrhage. 2. Global atrophy with disproportionate ventriculomegaly; underlying communicating hydrocephalus remains a concern, and should be correlated clinically. 3. Equivocal thin subdural collection layering over the right frontovertex convexity, measuring no more than 5 mm in maximal thickness, with no significant mass effect. 4. Acute-on-chronic sinus inflammatory disease and fluid opacification of the right mastoid air cells, which also should be correlated clinically. COMMENT: A preliminary interpretation of "No diffusion abnormality to suggest new infarct. No new hemorrhage. No change in tiny right subdural collection." was posted to CCC by Dr. [Last Name (STitle) 1603], at time of the study. CXR [2117-5-21]: [Month/Day/Year ]: The patient is status post tracheostomy. There is moderate left lower lobe volume loss, unchanged compared to the study from the prior day. The femoral line and brachiocephalic stent are unchanged in position. Old right humeral displaced fracture is again visualized. TUNNEL [Month/Day/Year ] REPLACEMENT [2117-5-20]: 1. Uncomplicated and successful replacement of a tunneled left femoral hemodialysis line. 2. The line is ready to use. ABDOMINAL PLAIN FILM KUB [2117-5-20] [Month/Day/Year ]: Single supine abdominal radiograph demonstrates G-tube balloon in the region of the gastric antrum. Again seen is the left IVC/femoral/iliac stent. The bowel gas pattern is nonspecific. There is no evidence of pneumoperitoneum or pneumatosis. CXR POST-TRACH PLACEMENT [2117-5-21] [Month/Day/Year ]: The patient is status post tracheostomy. There is moderate left lower lobe volume loss, unchanged compared to the study from the prior day. The femoral line and brachiocephalic stent are unchanged in position. Old right humeral displaced fracture is again visualized. G-TUBE REPLACEMENT BY IR [2117-5-22] IMPRESSION 1. Successful placement of a 14 French post-pyloric [Doctor Last Name 9835] GJ tube by conversion of existing 14 French MIC G-tube access. 2. The tube is ready for immediate use for tube feedings and medications. CT HEAD [2117-5-23] IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. Hypodense areas as described above in the left occipital lobe and bilateral cerebellar hemispheres, partly seen on the prior study. 2. Moderate dilation of the lateral and the third ventricles, ? volume loss/NPH/narrowing at the superior portion of aqueduct. Correlate clinically to decide on the need for further workup. No significant change in the bifrontal diameter at the level of foramen of [Last Name (un) 2044], compared to the recent study. CT ABDOMEN [2117-5-23] - 1. Within the limits of this non-contrast examination, there is no evidence of bowel wall thickening to suggest ischemia. No acute intra-abdominal process. 2. Stable left lung base consolidation and small left pleural effusion. [5-24] EEG: PENDING Brief Hospital Course: 83F with complicated medical history of subdural hematoma and intracranial hemorrhage in [2114] now bedbound, ESRD, multiple serious infections including endocarditis and osteomyeltis, now admitted with fever, found to have LLL infiltrate and to be in status epilepticus. ACTIVE ISSUES BY PROBLEM # Cardiac Arrest - On the morning of [5-25], the patient had a bradycardia arrest that progress to PEA arrest that subsequently devolved to a V fib / VT arrest. She was given atropine (for bradycardic arrest), followed by epi x 2, amp of calcium, and defibrillated twice (for V fib and then VT), with ROSC after ~40 minutes of CPR. Afterward the cardiac arrest and ROSC, she rapidly requiring max doses of 3 pressors to keep her systolic blood pressure in the 90s-100s. It was unclear what was the cause of her arrest - based on the available clinical data, she appeared to have suffered a primary cardiac arrest without an obvious underlying precipitant. Post-arrest, even on max-dose pressors, her blood pressure steadily dropped throughout the day. In addition, post-arrest, the patient had no evidence of any meaninful neurologic function, with minimal brainstem reflexes (no cough, gag, corneal reflexes or pupillary reflexes, although she did still over-breath the ventilator.) In conjunction with the family's wishes (specifically, the patient's sister and HCP [Doctor First Name 5464], was decided that CPR would not be indicated in this patient given her steady drop in BP while on max dose pressors. This was repeatedly discussed with the family throughout the course of the day and all of their questions were answered. Despite maintaining vasopressor support, the patient's MAPs continued to deteriorate and after demonstrating MAPs in the 20s for several hours in the afternoon of [2117-5-25], the patient passed away at 16:50. The family was notified and declined autopsy. PCP was also notified. # Status epilepticus At baseline, HCP reports she is very minimally verbal (few words at a time), posture rigid and contracted, bedbound - all since stroke in [2114]. On HD2 sister visited and felt pt was less responsive that usual, not following commands and grunting frequently. No stereotypic movements. CT head repeated - unchanged from prior. Bedside EEG demonstrating continuous epileptiform activity. Neurology consulted and she was loaded w/fosphenytoin and ativan and transferred to the MICU for airway monitoring in the setting of nonconvulsive status epilepticus. Loaded w/fosphenytoin, keppra, and valproate + intermittent doses IV ativan. AED med management was especially difficult on/after [Year (4 digits) 2286]. By the morning of HD 6, EEG no longer showed status or seizures but continued to demonstrate epileptiform spikes. Extensive discussions were had w/HCP re: pt's goals of care, given need for multiple AEDs at high, sedating doses, making the necessity of intubation a real possibility. ICU team and neuro teams both felt intubation would likely be irreversible in this pt w/poor underlying mental status and multiple severe comorbidities. Family definitively communicated their desire to intubate if necessary. Patient was intubated as below [2-18] to pneumonia. After intubation, her EEG improved, no longer showing epileptiform activity and her AEDs were able to be weaned with discontinuation of fosphenytoin and benzodiazepines and then valproic acid. The morning of [5-25] she did have a seizure, however this was 30 minutes before her arrest and no further med changes were done. # HCAP On admission, pt c/o fever & cough x 3 weeks. Found to have LLL infiltrate vs atelectasis on chest xray, also seen on lung cuts of CT A/P. Received levofloxacin/vancomycin in the ED. Levo changed for cefepime on admission, then transitioned to ceftazidime on HD3 for ease of dosing with HD. When she was transferred to the ICU for status epilepticus management, an effort was made to avoid seizure threshold-lowering medications. Thus cefepime was stopped and tobramycin was started (chosen based upon past micro data showing multiple MDR bacteria). Cefepime added back when pt started spiking fevers in the ICU and wet productive-sounding cough evolved. When nurses were unable to suction sufficiently, decision was made to intubate following family discussion as above. Intubation was uncomplicated. Sputum cultures returned with carbapenmase producing klebsiella pneumoniae - sensitive to gentamicin. ID was consulted who felt monotherapy with gentamicin QHD would be appropriate - she should complete a 10 day course - last day on [5-28]. If there is decompensation, tigecycline could be added. Given the patient's mental status, it was felt she would not be extubated readily so a trachestomy was peformed by Interventional Pulmonology. She had some post-op bleeding that was controlled with silver nitrate. Repeat CT abd/pelvis on [5-23] in setting of worsening leukocytosis despite therapeutic-dosing gentamycin showed stable (not improved) L lung base consolidation). # TUBEFEEDS - HIGH RESIDUALS The patient was noted to have high residuals from her tube feeds as well as occasional vomiting. Her G-tube was advanced to a J-tube by IR on [5-22] to help decrease the amount of residuals. Tubefeeds restarted. # LEUKOCYTOSIS Pt noted to have acutely-worsening leukocytosis on [5-23]. Pt pan-cultured and CT head, CT abdomen/pelvis were repeated. These showed only stable L lung base consolidation - known Klebsiella pneumonia already being treated w/gentamycin. Pt did continue to have liquid bilious stools despite several days PO vanco, so dose was increased to 500 q6H. In addition, Gentamycin peaks/troughs rechecked and found to be in-range. WBC was down-trending on discharge and she was continued on vancomycin PO. #GAP ACIDOSIS Pt acutely developed a gap acidosis (AG 26) on [5-23]. Lactate checked was only 1.6. Serum acetone pending. Explanation was unclear but this was improving on labs checked morning prior to arrest. CHRONIC, INACTIVE ISSUES # ESRD Continued [Month/Day (4) 2286] per T, Th, Sa regimen. Continued sevelemer and renagel. Renal consult followed carefully. Antiepileptic dosing was particularly challenging around HD sessions, as pt's levels fell more than expected prior to HD and seizure activity spiked in that setting. The patient's line stopped working so on [5-20] she underwent replacement over a wire with IR. HD proceeded without complication thereafter. # HTN Pt was persistently hypertensive, w/SBPs ranging 150s-170s. Home amlodipine was increased from 5 to 10 mg QD. She also required intermittent 1x doses nifedipine to keep SBP <150. # Hyperthyroid TSH checked, as there was concern that hyperthroidism might contribute to AMS. However, TSH was low normal then borderline-high, neither suggestive of hypothyroidism. Continued methimazole. # GERD Continued omeprazole. Medications on Admission: Sevelamer 2.4g TID Vitamin D3 800 daily Omeprazole 40 mg daily Nephrocaps 1 mg daily Sensipar 60 mg daily Fludrocortisone 0.1 mg daily Methimazole 10 mg daily Amlodipine 5 mg daily Discharge Medications: Patient expired Discharge Disposition: Expired Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Cardiac arrest NON-CONVULSIVE SEIZURE ACUTE ENCEPHALOPATHY CHRONIC DEMENTIA END-STAGE RENAL DISEASE, [Hospital6 ] DEPENDENT Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired Completed by:[2117-5-25*]	[ "008.45", "V45.11", "345.3", "518.84", "530.81", "438.89", "403.91", "482.0", "585.6", "276.4", "V49.73", "416.8", "294.20", "785.51", "427.1", "250.00", "728.85", "518.0", "285.21", "427.41", "443.9", "242.20", "349.82" ]	icd9cm	[ [ [] ] ]	[ "46.32", "33.23", "99.60", "96.6", "03.31", "38.95", "39.95", "31.1", "96.72" ]	icd9pcs	[ [ [] ] ]	23964, 24024	16763, 23693	336, 444	24196, 24213	5567, 6310	24277, 24323	3471, 3562		23924, 23941		24045, 24175		23719, 23901			24237, 24254									3602, 5548									8210, 16740												291, 298							472, 1402																	1424, 2956	2972, 3455
16,689	129,112	25184	Discharge summary	report	Admission Date: [2127-9-29] Discharge Date: [2127-10-6] Date of Birth: [2056-2-4] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea at rest/Periodic chest discomfort Major Surgical or Invasive Procedure: [2127-9-29] CABGx3(LIMA->LAD, SVG->PDA&OM) History of Present Illness: 71 year old gentleman with history of endocarditis three years ago. Chest pain in [3-7] for which he was seen by a cardiologist. A stress echo was positive [4-5]. A Cardiac catheterization was subsequently performed which revealed left main and 3 vessel disease. He was subsequently referred for a cardiac catheterization. Past Medical History: Hyperlipidemia, hypertension, diabetes mellitus, PVD, GERD, s/p Left CEA, colon polyps Social History: Retired. 100 pack year history. Quit in [2121]. Lives significant other. Family History: Mother died of cancer at age 75 and father died of cancer at age 77. Physical Exam: HR 65 BP: (R) 195/88 (L) 171/97 GEN: No acute distress, well nourished. HEENT: PERRL, EOMI, Anicteric sclera. NECK: No JVD. Well healed left neck scar. LUNGS: CLear HEART: RRR, normal S1-S2. ABD: Soft, nontender, benign EXT: Warm, well perfused. Mild varicosities. Pulses 2+ throughout. Pertinent Results: [2127-10-3] 12:40PM BLOOD Hct-35.2* [2127-10-2] 06:20AM BLOOD Plt Ct-141* [2127-10-2] 06:20AM BLOOD Glucose-139* UreaN-16 Creat-0.8 Na-138 K-4.3 Cl-102 HCO3-27 AnGap-13 [2127-10-1] CXR 1. Interval improvement in mild congestive heart failure. 2. No pneumothorax. 3. Decreased bilateral small pleural effusions. [2127-10-2] EKG Atrial fibrillation. Non-specific flat T waves in leads I, II, aVL, V4-V6. Compared to the previous tracing of [2127-9-29] atrial fibrillation] has newly appeared. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2127-9-29] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname ] [Last Name (Titles) 5058] neurologically intact and was extubated. He was then transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for postoperative strength and mobility. He was transfused with packed red blood cells for postoperative anemia. His drains and pacing wires were removed per protocol. Mr. [Known lastname ] developed a brief, self limited episode of atrial fibrillation for which his beta blocker was increased. Mr. [Known lastname ] continued to make steady progress and was discharged home on postoperative day six. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Lipitor 80mg daily Lisinopril 20mg daily Aspirin 81mg daily Prilosec 10mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. 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: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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: CAD ^chol HTN PVD GERD Colonic polyps DM2 CEA Appy Hammer toe repair LE shrapnel removal Discharge Condition: Good. Discharge Instructions: Shower daily, wash incision with mild soap and water and pat dry. No lotions, creams, powders, or baths. No lifting more than 10 pounds or driving until folloup with surgeon. Call with temperature more than 101.4, redness or drainage from incision, or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Dr. [Last Name (STitle) ] 4 weeks Dr. [Last Name (STitle) 25786] 2 weeks Completed by:[2127-10-7]	[ "414.01", "427.31", "401.9", "250.00", "272.0", "530.81", "997.1", "443.9", "V15.82", "V12.72", "285.9" ]	icd9cm	[ [ [] ] ]	[ "36.12", "39.61", "99.04", "36.15" ]	icd9pcs	[ [ [] ] ]	4058, 4113	1926, 3088	362, 411	4246, 4254	1384, 1903	4617, 4729	991, 1061		3218, 4035		4134, 4225		3114, 3195			4278, 4594									1076, 1365																					281, 324							439, 771																	793, 881	897, 975
72,940	123,074	36046+58055+58056	Discharge summary	report+addendum+addendum	Admission Date: [2166-10-23] Discharge Date: [2166-10-28] Date of Birth: [2098-9-8] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2166-10-23] Emergent Coronary Artery Bypass Graft x 2 (Left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal) History of Present Illness: 68-year-old man with history of diabetes, hyperlipidemia, history of heavy smoking, peripheral vascular disease, status post aortofemoral bypass last [Month (only) 958] complicated with a small non ST segment elevation MI, followed by recurrent unstable angina a month later, treated with Cypher stenting of a 90% RCA stenosis, subsequent episodes of rhabdomyolsis likely in the setting of nonsteroidal abuse and kidney failure, returns feeling well. Presented to outside facility with chest pain, hypotension and VTac, found to have elevated St segment in aVR. On cath Lab here @ [Hospital1 ], found to have >90 L main, which progress from a moderate lesion back in [Month (only) 547]. RCA stent is patent with moderate distal disease. Upon encounter in Cath lab, pt denied CP, he is off any pressors, no IABP, occasional PVCs on monitor. Past Medical History: Diabetes Dyslipidemia Hypertension Heavy tobacco use (quit [3-31]) Peripheral Vascular Diseases/p Aortobifemoral bypass [2166-4-10] complicated with a small non ST segment elevation Myoacardial Infarction, treated with Cypher stenting of a 90% RCA stenosis Episodes of rhabdomyolsis likely in the setting of nonsteroidal abuse and kidney failure Social History: He is married with two grown children. He continues to smoke but does not drink. He works as a manager at the [Location (un) ] Airport. Family History: Father with CAD Physical Exam: Pulse: 62 Resp: 14 O2 sat: 100% RA B/P Left: 156/54 General: AAO x 3 in mild distress Skin: Dry [x] intact [x] [x] Right arm tatoo HEENT: PERRLA [x] EOMI [x] Exopthalmous Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] No Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right: none Left: none Pertinent Results: [2166-10-23] Cath: 1. Selective coronary angiography of this right dominant system demonstrated two vessel disease. The left main had a hazy 80% proximal stenosis. The LAD had mild diffuse disease. The LCx had a 70% distal stenosis. The RCA had a 40% proximal narrowing. The mid-RCA stent was patent without angiographically-a[[[Last Name (un) 5497] disease. 2. Limited resting hemodynamics revealed mild central aortic hypertension with SBP 150mmHg. 3. Left ventriculography was deferred. [2166-10-27] 05:30AM BLOOD WBC-3.1# RBC-2.65 Hgb-8.1* Hct-24.4* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.5 Plt Ct-187 [2166-10-23] 08:20PM BLOOD WBC-5.5 RBC-3.68* Hgb-10.7* Hct-32.3* MCV-88 MCH-29.0 MCHC-33.0 RDW-14.8 Plt Ct-216 [2166-10-24] 01:59PM BLOOD PT-13.2 PTT-29.1 INR(PT)-1.1 [2166-10-23] 08:20PM BLOOD PT-14.0* PTT-90.4* INR(PT)-1.2* [2166-10-27] 05:30AM BLOOD Glucose-144* UreaN-50* Creat-2.5* Na-143 K-4.7 Cl-107 HCO3-26 AnGap-15 [2166-10-23] 08:20PM BLOOD Glucose-121* UreaN-20 Creat-1.4* Na-142 K-4.1 Cl-111* HCO3-24 AnGap-11 [2166-10-24] 01:59PM BLOOD ALT-12 AST-33 AlkPhos-47 Amylase-63 TotBili-0.4 Brief Hospital Course: [10-23] Mr.[Known lastname 37742] was taken to the operating room for an emergent coronary artery bypass graft x 2 (Left internal mammary artery grafted to left anterior descending artery/Saphenous vein grafted to Obtuse Marginal) with Dr.[Last Name (STitle) ]. Please see operative report for surgical details. Cross clamp time= 26 minutes. Cardiopulmonary Bypass time= 33 minutes. He was intubated, sedated, and transferred to the CVICU in critical but stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. All lines and drains were removed in a timely fashion. Beta-blocker/Statin/aspirin , and diuresis was initiated. He continued to progress and was transferred to the telemetry floor for further care. Physical therapy was consulted for evaluation to increase strength and mobility.The remainder of his postoperative course was essentially uneventful. On POD#5 he was cleared for discharge to home by DR.[Last Name (STitle) ]. All follow up appointments were advised. Medications on Admission: Metoprolol 25-mg [Hospital1 ], glimepiride 2-mg [Hospital1 ], aspirin 325-mg/day, Plavix 75-mg/day, Niaspan 1000-mg qhs and vitamin D 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Coronary Artery Disease s/p Emergent Coronary Artery Bypass Graft x 2 Past medical history: Diabetes Dyslipidemia Hypertension Heavy tobacco use (quit [3-31]) Peripheral Vascular Diseases/p Aortobifemoral bypass [2166-4-10] complicated with a small non ST segment elevation Myoacardial Infarction, treated with Cypher stenting of a 90% RCA stenosis Episodes of rhabdomyolsis likely in the setting of nonsteroidal abuse and kidney failure Discharge Condition: Good Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [Telephone/Fax (1) 170]. 6)Call with any additional questions or concerns Followup Instructions: Dr. [First Name (STitle) ] in 4 weks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 1159] in [1-24] weeks Dr. [Last Name (STitle) ] in [2-25] weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2166-10-28] Name: [Known lastname 13121],[Known firstname ] J Unit No: [Numeric Identifier 13122] Admission Date: [2166-10-23] Discharge Date: [2166-10-28] Date of Birth: [2098-9-8] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 265] Addendum: Metoprolol dose changed to 37.5 mg po BID Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2166-10-28] Name: [Known lastname 13121],[Known firstname ] J Unit No: [Numeric Identifier 13122] Admission Date: [2166-10-23] Discharge Date: [2166-10-28] Date of Birth: [2098-9-8] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 265] Addendum: Mr.[Known lastname ] had acute renal failure postoperatively. [10-26] his Creatnine was 3.0, upfrom baseline 1.1. Kasix was discontinued. Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2166-12-31]	[ "412", "414.01", "403.90", "585.9", "V45.82", "411.1", "250.00", "305.1", "440.20", "584.9" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.11", "37.22", "88.56", "36.15" ]	icd9pcs	[ [ [] ] ]	8343, 8532	3764, 4807	332, 492	6287, 6293	2598, 3741	6835, 7567	1924, 1941		4999, 5707		5819, 5889		4833, 4976			6317, 6812									1956, 2579																					282, 294							520, 1373																	5911, 6266	1766, 1908
58,810	192,019	46784	Discharge summary	report	Admission Date: [2197-9-18] Discharge Date: [2197-9-26] Date of Birth: [2129-4-5] Sex: M Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 2291] Chief Complaint: hypoxia and tachycardia post-procedure Major Surgical or Invasive Procedure: video swallow/barium swallow History of Present Illness: This is a 68 year old man with esophageal cancer s/p 5 courses of 5FU/Cisplatin and radiotherapy with course complicated by neutropenic fever, who presented to IP on the day of admission for planned removal of a tracheal stent. Unfortunately, during the procedure the IP team noted necrotic tissue above the proximal edge of the stent as well as granulation vs tumor on the distal end of the stent that nearly obstructed the airway. The lower mass was debrided and afterward pt had new O2 requirement (satting low 90's on room air) and was newly w/ sinus tachycardia to the 120s. He denied symptoms and felt fine but given concern of complication he was admitted for observation overnight (plan had been to go back to rehab after procedure). On arrival to the floor the patient is denying any acute issues particularly denying chest pain, palpitations, or shortness of breath. He is slightly annoyed to be readmitted as he feels there have been worries about a similar need for oxygen several times and it goes away on his own. In fact, he told me he does not want me to treat it as he thinks it will go away on his own. He reports he was doing well at rehab prior to this. Review of Systems: Positive per HPI also positive for cough and thick secretions (chronic) Notably negative for dyspnea, chest pain, fevers, chills, night sweats, abdominal pain, nausea, vomiting, or diarrhea (pt reports resolved) Otherwise full review of systems negative for pertinent symptoms. Past Medical History: Past Oncologic History: [2197-3-21] CT chest and discovery of mass [2197-3-23] Head MRI: no evidence of metastatic disease. [2197-3-23] PET: left mediastinal mass with avid FDG uptake, no definitive metastatic disease. [2197-3-27]: Upper esophageal mucosal biopsy: gastric type mucosa consistent with heterotrophic gastric tissue. Cell block showed poorly differentiated carcinoma. [Date range (2) 99290]: Admitted. Tumor felt to be unresectable. Drs. [Last Name (STitle) ] and [Name5 (PTitle) 3877] assumed primary oncology care. Decision made to treat with 5-FU/cisplatin and XRT. [2197-4-5]: Placement of 2 tracheal stents by IP. [2197-4-13]: left portacath, open G-tube, tracheal stent replacement by thoracic surgery. [2197-4-17]: Cycle #1 cisplatin/5FU, radiation initiated. [2197-5-17]: Cycle #2 cisplatin/5FU. [2197-5-30]: XRT finished. [2197-6-4] Pt admitted for aspiration pneumonia with hypoxia. [2197-7-6]: Cycle #3 cisplatin/5FU. [2197-8-3]: Cycle #4 cisplatin/5FU. Other Past Medical History: - ADHD. - [Doctor Last Name 9376] syndrome. - Tracheostomy at 3 years of age for PNA. - Appendectomy [2162]. - ORIF Right ankle [2168]. Social History: Was a small business owner. Smoked 20-25 pack years of cigarettes but quite in [2180]. Previous history of [1-8] alcoholic beverage consumption per day but stopped when he developed dysphagia. No history of illicits. Family History: Mother- Died 97, [Name2 (NI) ], breast CA. Father- Died 76, PNA. Sister - breast CA. Niece - thyroid CA. Physical Exam: VS: T 100.3, BP 110/92, P 120's, RR 20, O2 90% on 4L Appearance: Very thin and slightly disheveled middle aged man in NAD Eyes: EOMI, Conjunctiva Clear ENT: Moist, no ulcers or erythema CV: Regular, tachycardic, normal S1 and S2 without murmurs, rubs, or gallops/ no lower extremity edema; port in left chest is accessed; no JVP elevation appreciated Respiratory: Breathing comfortably without distress or accessory muscle use, bilateral soft rales throughout the lung fields with excellent air movement; no wheezing or rhonchi. GI: Soft, Nontender, Non-distended, Bowel Sounds positive, no hepomegaly or splenomegaly appreciated; +PEG MSK: Globally diminished bulk, No cyanosis, No clubbing, No joint swelling Neuro: CNII-XII intact, Normal attention, Fluent speech Integument: Warm, Dry, diffuse, confluent erythematous rash on back Psychiatric: Slightly confrontational and odd affect, somewhat jovial at disagreeing with examiner Hematologic / Lymphatic: No Cervical [Doctor First Name ], Thyroid WNL Pertinent Results: CXR [9-19]=IMPRESSION: Marked improvement of previously identified bilateral basalparenchymal infiltrates as seen on chest examination of [2197-8-15]. New parenchymal infiltrates mostly occupying the right upper lobe are seen and may be related to recent performed removal of tracheal stent. No pneumothorax is identified on either side. CXR [9-21]: Multifocal lung consolidations consistent with multifocal pneumonia and aspiration are stable in the right upper lobe, worsened in the right lobe, and improved in the left lower lobe. Cardiomediastinal contours are unchanged. There is no evident pneumothorax or large pleural effusion. Left Port-A-Cath is in a standard position. [9-22] The extensive progression of multifocal consolidation in both right upper, right lower, and left lower lobe. The Port-A-Cath catheter tip is at the level of cavoatrial junction. Small amount of pleural effusion cannot be excluded. . Video swallow [9-20]-IMPRESSION: Marked aspiration and penetration of multiple consistencies of barium including ice chips, thin liquids, and nectar thick liquids. No evidence of marked esophageal obstruction. . EKG [9-21]-Sinus tachycardia. Normal tracing except for rate. Compared to tracing #1 the heart rate is increased. Atrial premature beats are not seen on the current tracing. TRACING #2 . pathology [9-18]-DIAGNOSIS: Tracheal mass, endobronchial biopsy: Extensive squamous metaplasia with granulation tissue and subepithelial fibrosis, see note. Note: The biopsy specimen shows squamous metaplasia with polypoid growth and extension into subepithelial salivary gland ducts. The underlying stroma demonstrates fibrosis with a chronic inflammatory infiltrate. Although some areas show pronounced cytologic atypia, they most likely represent reactive epithelial changes. Re-biopsy is suggested if clinically suspicious for tumor involvement of airway. Cytology (and cell block) slides from the prior esophageal mass EBUS-TBNA (C11-9124S and S11-11998S from [2197-3-27]) have been reviewed. . bronchoscopy [9-18]-Impression: 68 year-old man with esophageal cancer in remission and telescoping tracheal stents placed in [Month (only) 958] and [2197-4-7] returns for stent removal. Rigid bronchoscopy was performed with intent of stent removal, however a proximal posterior membrane ulceration and necrosis was visualized above the stent causing concern for tracheal rupture if manipulation of the stents were undertaken. A lesion at the distal edge of the stent causing 90% obstruction was debrided. Therapeutic aspiration of secretions was performed. none . MICROBIOLOGY-Date 6 Lab # Specimen Tests Ordered By [2197-9-23] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2197-9-21] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2197-9-21] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2197-9-21] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2197-9-21] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2197-9-19] URINE URINE CULTURE-FINAL INPATIENT. . [2197-9-24] 04:39AM BLOOD WBC-6.2 RBC-2.91* Hgb-8.5* Hct-25.4* MCV-88 MCH-29.4 MCHC-33.5 RDW-15.4 Plt Ct-136* [2197-9-23] 09:01AM BLOOD Hct-25.8* [2197-9-23] 06:42AM BLOOD WBC-6.8 RBC-2.48* Hgb-7.4* Hct-21.7* MCV-87 MCH-29.8 MCHC-34.1 RDW-15.4 Plt Ct-105* [2197-9-22] 01:36PM BLOOD Hct-23.8* [2197-9-22] 03:56AM BLOOD WBC-7.8 RBC-2.84* Hgb-8.5* Hct-24.7* MCV-87 MCH-29.8 MCHC-34.2 RDW-15.5 Plt Ct-123* [2197-9-21] 05:24AM BLOOD WBC-13.4* RBC-3.47* Hgb-10.4* Hct-29.9* MCV-86 MCH-30.0 MCHC-34.8 RDW-15.4 Plt Ct-175 [2197-9-20] 05:19AM BLOOD WBC-11.8* RBC-3.25* Hgb-9.8* Hct-28.0* MCV-86 MCH-30.2 MCHC-35.0 RDW-15.1 Plt Ct-171 [2197-9-19] 06:06AM BLOOD WBC-15.2* RBC-3.25* Hgb-9.8* Hct-28.1* MCV-87 MCH-30.2 MCHC-34.8 RDW-15.6* Plt Ct-144* [2197-9-18] 09:53PM BLOOD WBC-18.3# RBC-3.43 Hgb-10.7* Hct-29.1* MCV-85 MCH-31.2 MCHC-36.7* RDW-15.3 Plt Ct-164 [2197-9-18] 09:53PM BLOOD PT-14.1* PTT-27.0 INR(PT)-1.2* [2197-9-24] 04:39AM BLOOD Glucose-140* UreaN-17 Creat-0.4* Na-132* K-3.9 Cl-97 HCO3-31 AnGap-8 [2197-9-23] 06:42AM BLOOD Glucose-137* UreaN-16 Creat-0.3* Na-137 K-3.0* Cl-106 HCO3-25 AnGap-9 [2197-9-22] 03:56AM BLOOD Glucose-152* UreaN-16 Creat-0.5 Na-131* K-3.6 Cl-98 HCO3-29 AnGap-8 [2197-9-21] 05:24AM BLOOD Glucose-149* UreaN-21* Creat-0.5 Na-127* K-3.6 Cl-90* HCO3-30 AnGap-11 [2197-9-20] 05:19AM BLOOD Glucose-118* UreaN-30* Creat-0.5 Na-131* K-3.4 Cl-92* HCO3-29 AnGap-13 [2197-9-19] 06:06AM BLOOD Glucose-121* UreaN-23* Creat-0.6 Na-131* K-4.0 Cl-94* HCO3-31 AnGap-10 [2197-9-18] 09:53PM BLOOD Glucose-124* UreaN-24* Creat-0.7 Na-131* K-4.5 Cl-93* HCO3-31 AnGap-12 [2197-9-19] 06:06AM BLOOD proBNP-470* [2197-9-24] 04:39AM BLOOD Vanco-17.2 [2197-9-26] 04:41AM BLOOD WBC-7.8 RBC-3.24* Hgb-9.4* Hct-27.5* MCV-85 MCH-29.0 MCHC-34.2 RDW-15.0 Plt Ct-186 [2197-9-26] 04:41AM BLOOD Glucose-133* UreaN-19 Creat-0.5 Na-131* K-3.8 Cl-96 HCO3-30 AnGap-9 [2197-9-26] 04:41AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9 [2197-9-25] 05:41AM BLOOD Vanco-19.5 Brief Hospital Course: Assessment and Plan: Mr. [Known lastname ] is a 68 year old man with esophageal cancer s/p 5 courses of 5FU/Cisplatin and radiotherapy with course complicated by neutropenic fever, who presented to IP on the day of admission for planned removal of a tracheal stent after which he was admitted for observation and then after initial recovery of hypoxia noted to be acutely hypoxemic with foul sputum and RLL infiltrate consistent with aspiration pneumonia. . #Aspiration pneumonia:Pt admitted for monitoring after IP attempt at stent removal for hypoxia. Pt initially improved and was back to his baseline of 90% on RA. Pt was admitted for a GI work up of dysphagia per IP and pt and his family. Therefore, pt underwent a videoswallow combined with a barium study and was found to have significant aspiration. The following morning, pt became acquirely hypoxic requiring NRB, had altered mental status and tachypnea. Pt was DNR/DNI on admission, however upon discussion of this current state, pt desired to be transferred to the ICU and stated he was full code. However, upon arrival to the ICU, after his discussion with his HCP, pt decided that he would like to be DNR/DNI. CXR showed pneumonia and pt was started on vanco/cefepime/flagyl with improvement in his symptoms. He was on 4L upon transfer out of the ICU. Currently patient has been tapered to minimal oxygen (1liter) alternating with room air. Pt is unsafe to take and food/drink by mouth and must be strictly NPO. This was reinforced this admission after S+S/barium showing aspiration. Plan for 10 day course of antibiotic therapy, which he will complete on [9-30]. Pt was given nebs as needed. Sputum cultures were contaminated with respiratory flora. Pt was told that he should not refuse mouth care. . #Tachycardia: sinus. In setting of infection/hypoxia; patient has had previously as well. Improved. Ritalin initially held. . #Esophageal cancer/dysphagia-s/p treatment course. Recent PET negative for malignancy. Rigid bronch showing necrosis vs. mass-s/p debridement. Dysphagia likely due to post-radiation changes. Pt with significant promixal dysphagia and aspiration. Discussed current presentation and radiology and swallow studies with both of [Initials (NamePattern4) 228] [Last Name (NamePattern4) 2759] [Name (NI) ] and [Name (NI) 401] in detail. Discussed that pt will/may always have risk of aspiration and dysphagia. Dysphagia related to radiation. Can perform GI assessment for dysphagia after pharyngeal dysphagia is addressed in the outpatient setting. Path consistent with metaplasia (ICU team discussed with Onc - nothing further to do). PT continued on scopolamine for secretions as well as fentanyl patch for pain. Pt should continue speech and swallow therapy at rehab. . #normocytic anemia-likely due to chronic illness. Stool was guaiac positive in ICU, but Stable currently on the medical floor. Continued PPI. . #thrombocytopenia-likely due to acute illness. Improved. . #hyponatremia-chronic. Likely due to recent pulmonary process. Na remained stable around 130-132 . #adhd-can restart methylphenidate upon discharge. . #depression-SSRI . #h.o C.diff-s/p PO vanco course. No diarrhea this admission. . FEN: NPO, Tube feeds . Lines: port . CODE: DNR/DNI Transitional Issues: 1. The patient will need to continue a course of IV antibiotics till [9-30] for treatment of his aspiration pneumonia. 2. He will need to continue with speech therapy, and be re-evaluated with speech/swallow for possibility of PO intake, otherwise he is currently NPO indefinitely. 3. His final blood culture results from ([9-21]) will need to be followed up. Currently his cultures show no growth. Medications on Admission: Omeprazole 20 mg PO BID Fentanyl 17 mcg/hr Q72 hrs Citalopram 10 mg PO daily Methylphenidate 20 mg PO QAM Trazodone 50 mg PO QHS [Month/Year (2) 32316] 0.4 mg PO Q24 hr Lactobacillus 100 mg PO BID Scopolamine base 1.5mg/72 hr pat Q72 hrs Ondansetron 4 mg PO TID Bismuth subsalicylate 262 mg/ 15 ml 30 mL QID MVI daily Discharge Medications: 1. fentanyl 75 mcg/hr Patch 72 hr [Month/Year (2) ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. methylphenidate 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO once a day. 3. trazodone 50 mg Tablet [Month/Year (2) ]: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 4. [Month/Year (2) ] 0.4 mg Capsule, Ext Release 24 hr [Month/Year (2) ]: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 5. lactobacillus acidophilus 100 million cell Capsule [Month/Year (2) ]: One (1) Capsule PO twice a day. 6. scopolamine base 1.5 mg Patch 72 hr [Month/Year (2) ]: One (1) Patch 72 hr Transdermal Q72HRS (). 7. bismuth subsalicylate 262 mg/15 mL Suspension [Month/Year (2) ]: Thirty (30) ML PO QID (4 times a day). 8. miconazole nitrate 2 % Powder [Month/Year (2) ]: One (1) Appl Topical QID (4 times a day) as needed for fungal rash. 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. citalopram 10 mg/5 mL Solution [Last Name (STitle) ]: Ten (10) mg PO DAILY (Daily). 11. therapeutic multivitamin Liquid [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 12. cefepime 2 gram Recon Soln [Last Name (STitle) ]: One (1) Recon Soln Injection Q8H (every 8 hours) for 4 days: to complete course of antibiotics on [9-30]. 13. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback [Month/Year (2) ]: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 4 days: to complete course of antibiotics on [9-30]. 14. vancomycin in D5W 1 gram/200 mL Piggyback [Month/Year (2) ]: One (1) gram Intravenous Q 12H (Every 12 Hours) for 4 days: to complete course of antibiotics on [9-30]. 15. ondansetron HCl (PF) 4 mg/2 mL Solution [Month/Year (2) ]: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: esophageal cancer s/p chemo and xrt dysphagia hypoxia leukocytosis hyponatremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for monitoring after your tracheal stent was attempted to be removed. The pulmonary team was unable to remove this stent as it was felt to be unsafe. In addition, you had a area of concern biopsied which showed reactive changes, but you will should follow-up with your oncologist to have this monitored for the possibility of malignant changes in the future. You were noted to have low oxygen levels after your procedure but this improved. In additon, you had a video swallow and barium swallow performed and results show that it is too dangerous for you to take food or liquids by mouth at this time. You will need to have speech therapy, then reevaluation of a swallowing study. . Unfortunately, you developed low oxygen levels and were initially transferred to the ICU. You were found to have another aspiration pneumonia and started on antibiotics with improvement. . Medication changes: 1.antibiotics-Vancomycin, Cefepime, flagyl for 4 more days . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2197-10-5] at 11:30 AM With: [Name6 (MD) ] [Name8 (MD) 831], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2197-10-5] at 11:30 AM With: DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [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: HEMATOLOGY/ONCOLOGY When: THURSDAY [2197-12-7] at 10:00 AM With: [Name6 (MD) ] [Name8 (MD) 831], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "311", "787.20", "799.02", "518.81", "285.22", "V49.86", "507.0", "V15.82", "287.5", "314.01", "276.1", "V10.03", "277.4", "519.19" ]	icd9cm	[ [ [] ] ]	[ "31.42", "31.5", "96.6", "96.04" ]	icd9pcs	[ [ [] ] ]	15701, 15771	9691, 12965	310, 341	15895, 15895	4511, 9668	17168, 18050	3350, 3460		13770, 15678		15792, 15874		13424, 13747			16080, 16970									3475, 4492																12986, 13398			1570, 1849	16990, 17145	232, 272							369, 1551												15910, 16056					2939, 3088	3104, 3334
26,869	165,706	52046	Discharge summary	report	Admission Date: [2196-12-30] Discharge Date: [2197-1-6] Date of Birth: [2140-10-11] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: PICC line placed History of Present Illness: The patient is a 56 year old female with a history of depression who presents with dyspnea and desaturations to the 80's. 11 days ago ([12-24]), the patient developed diffuse myalgias, fatigue, fevers to 102, a non-productive cough, nausea and non-bloody non-bilious vomiting. She also experienced decreased appetite and had one episode of non-bloody diarrhea. She reports that she gets this constellation of symptoms annually and attributes it to "the flu", although this year her symptoms were significantly worse. Her recent sick contacts include a coworker with similar symptoms, and she denies any recent travel. She presented to the ED 8 days ago ([12-27]) where she had a negative CXR and CT chest, and she was discharged with a suspected viral infection. However, her symptoms persisted and she developed worsening dyspnea over the coming days. She saw her PCP 5 days ago ([12-30]) where she was found to be hypoxic to 85% on [Last Name (LF) ], [First Name3 (LF) ] she was subsequently referred back to the ED. . In the ED, the patient was febrile to 100.6 and had an O2 sat of 95% on 4L NC. She had a CXR which showed a multifocal pneumonia, especially in the RML. She was given nebulizers, and started on levofloxacin ([12-30]) and vancomycin ([12-31]). On [1-2], the patient felt worn out and was found to have an O2 saturation of 87% on 2L NC, so she was put on a non-rebreather and transferred to the MICU. ABG at that time was 7.55/33/64 and lactate was measured at 1.7. Blood cultures grew out [Last Name (LF) 8974], [First Name3 (LF) ] she was changed to nafcillin and levofloxacin. She denies any history of IVDU, osteomyelitis or prostheses. During her stay in the MICU, the patient showed steady clinical improvement. ECHO was unchanged from [2191], and sputum gram stain was significant for gram positive rods and cocci in pairs and clusters. On [1-4] the patient was weaned to 2L NC, saturating 92-94% with desaturations with exertion to the high 80's but with quick recovery. She was transferred to the general medicine service, where she denies feeling short of breath unless she has to talk a lot. She continues to suffer from laryngitis and a non-productive cough, although she denies sore throat, and her myalgias, fatigue, nausea, vomiting and diarrhea have resolved. The patient refused nasopharyngeal aspirate because she is "grossed out" by the description of the procedure. She did not receive a flu shot this year. . Past Medical History: Annual Flu-like symptoms Depression Insomnia Alcohol abuse - sober since [2174] Pneumonia - 1 episode 20 years ago Social History: [Known firstname ] works as an administrative assistant to [Initials (NamePattern4) ] [Last Name (NamePattern4) ] at [University/College ] [Location (un) ]. She is in a lesbian relationship and she lives with her partner of 22 years, who serves as her health care proxy. They live together in a small house [Location (un) 6409] with a dog and a cat. She has a history of alcohol abuse but has been sober since [2174]. She smoked 2 PPD for 25 years, but quit in [2181]. She has experimented with marijuana, but denies history of IVDU or other illicit drug use. Family History: Non-contributory Physical Exam: (on hospital admission) Vitals: T 99.1, BP 130/60, HR 76, RR 22, O2sat 95% on 3L NC, wt 87.1 kg and 5'4" General: sitting up in bed. NAD with NC on HEENT: PERRL, EOMI, MMM, CV: RRR no m/r/g appreciated Lungs: bilateral rhonchi. no wheezing currently. diminished BS on right base and laterally. Abdomen: +BS, soft NTND Ext: no e/c/c Neuro: CNIII-XII in tact, gait normal. strength 5/5 in the distal and proximal muscle groups bilaterally in the upper and lower extremities . (on transfer from MICU to floor) VITALS: T: 99.4 BP: 120/76 P: 79 RR: 20 O2 sat: 93-94% on 2L NC GENERAL: labored breathing, comfortably lying flat in bed, NAD HEENT: Sclera anicteric, oral mucosa pink. PERRL, EOM intact, oropharynx clear, no cervical lymphadenopathy. RESPIRATORY: decreased bibasilar, R decreased more than L, expiratory wheezes diffusely CVS: RRR, normal S1, S2, no murmurs ABDOMEN: Soft, non-distended, non-tender, normoactive bowel sounds, no palpable masses or organomegaly EXTREMITIES: Warm, well perfused, 2+ DP pulses bilaterally, no edema, clubbing or cyanosis SKIN: No rashes, no needle track marks NEURO: AO x 3, no focal deficits Pertinent Results: [2196-12-30] 03:40PM WBC-6.8 RBC-4.15* HGB-12.0 HCT-36.0 MCV-87 MCH-29.0 MCHC-33.5 RDW-13.3 . Micro: [12-30] Blood cx 2/4 bottles + for [Month/Day (4) 8974] [1-1], [1-2] Blood cx NGTD Legionella urinary antigen neg X 2 . Studies: [1-2] Port CXR: IMPRESSION: Improved upper lobe opacities; low lung volumes with bilateral lower lobe atelectasis, worsening. . [12-27] CTA Chest IMPRESSION: 1. No pulmonary embolism. 2. Moderate-sized hiatal hernia. 3. Mildly enlarged right hilar and AP window mediastinal lymph nodes, non-specific, but may be reactive. 4. Redemonstration of numerous hepatic cysts. Brief Hospital Course: Ms. [Known lastname 174] is a 56 year old female who presented with dyspnea and hypoxemia one week after onset of diffuse myalgias, non-productive cough, fatigue, fevers, nausea and vomiting, most likely due to influenza leading to secondary bacterial pneumonia. . 1) Hypoxemia: Most likely due to Staph pneumonia superinfection in the setting of influenza virus infection. In the ED, her vitals were T 100.6, BP 118/61, HR 68, RR 20, O2sat 95% on 4L NC. She has a CXR showed a mulitfocal pna especially in the RML. She was treated with nebulizers, levofloxacin and azithromycin in the ED and admitted. On the floor, she was started on Vanc/Levo ([12-30]). Blood cultures grew out [Month/Day (4) 8974] so was changed to Nafcillin/Levofloxacin on [1-2]. She had been satting 92-98% on 2L NC and became suddenly more hypoxic on [1-2] w/desaturation to 80s so she was put on a NRB -> satting 90% on 2 L. ABG 7.55/33/64 on 5L NC, was transferred to MICU for respiratory distress. She responded well to nebulizer treatments and nafcillin and she was transfered to the floor, a PICC line was placed and she was discharged on nafcillin to complete a two week course. . 2)[Month/Day (4) 8974] Bacteremia: She had [1-2] blood culture bottles positive for [Month/Day (4) 8974]. Most likely source is her bacterial pneumonia. She was treated as above with two week course of nafcillin. Surveillance cultures were negative. . 3) depression: She was continued on her outpatient regimen of wellbutrin, ritalin and lexapro. 4)Code: full Medications on Admission: Ritalin 20mg [Hospital1 ] Trazodone 50-100mg PRN for insomnia Wellbutrin 150mg QD Lexapro 20mg QD Ambien - prescribed by PCP, [Name10 (NameIs) ] patient never used it Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. Tablet(s) 2. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:1 6. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 inahler Refills:1 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 8. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) as needed for [Name10 (NameIs) 8974] Bacteremia for 11 days. Disp:66 2g/100ml piggybacks Refills:0 9. PICC line care saline and heparin flushes per NEHT protocol Discharge Disposition: Home With Service Facility: [Location (un) ] home services Discharge Diagnosis: PRIMARY: Pneumonia [Location (un) 8974] Bacteremia . SECONDARY: Influenza Depression Discharge Condition: Afebrile, vital signs stable, breathing comfortably on room air at rest Discharge Instructions: You were admitted with a pneumonia which is most likely a complication of having the flu. While you were here, your oxygen levels dropped, so you were transferred to the intensive care unit. We also found some infection in your blood. The infection in your blood most likely came from the pneumonia. We have treated your infections with intravenous antibiotics, and you will need to continue these at home. We advise you to get the annual flu shot in the future. The visiting nurses will come to your house to assist with your IV antibiotics. No other changes were made to your home medications. Please call your doctor or return to the hospital if you develop any concerning symptoms including worsening shortness of breath, fevers, chills or night sweats. Followup Instructions: Please ask your primary care doctor [First Name (Titles) ] [Last Name (Titles) 107742] a chest xray in 6 weeks to verify resolution of pneumonia. You have an appointment to follow up with [Doctor Last Name 402] Senkier, who works with Dr. [Last Name (STitle) ], on [2197-1-11] at 12:10.	[ "303.93", "790.7", "780.52", "487.1", "482.49", "041.19", "311" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	8372, 8437	5511, 7074	322, 340	8570, 8644	4854, 5488	9458, 9769	3655, 3673		7299, 8349		8458, 8549		7100, 7276			8668, 9435									3688, 4835																					275, 284							368, 2885																	2907, 3027	3043, 3639
76,546	195,458	53921	Discharge summary	report	Admission Date: [2191-10-30] Discharge Date: [2191-11-6] Date of Birth: [2113-9-23] Sex: M Service: MEDICINE Allergies: Darvon / Percocet Attending:[First Name3 (LF) 1253] Chief Complaint: Abdominal pain. Reason for MICU transfer: urosepsis. Major Surgical or Invasive Procedure: none. History of Present Illness: Mr. [Known lastname ] is a 78-year-old gentleman with history of systolic CHF (LVEF 35%), atrial fibrillation on coumadin, and prostate CA s/p radical [Hospital 110597] transferred from OSH to the [Hospital Unit Name 153] for treatment of possible cholecystitis with CTAP concerning for ureteral obstruction with pyelonephritis. He originally presented to OSH with complaint of groin pain radiating to the left flank x1 day. There was associated urinary incontinence, nausea, dry heaves, shortness of breath, and diaphoresis. At OSH, he was found to be hypotensive. He was treated with ampicillin, given 4 liters of IVF, and started on peripheral dopamine. He was then transferred to [Hospital1 18] for further treatment. In the [Hospital1 ] ED, initial vital signs were HR 88, BP 88/53, RR 20, satting 92% on 2L. Labs notable for white count of 19.2 with 18% bands, ALT/AST of 70/70, normal Tbili, lpase was 16, INR 3.5 (patient takes coumadin as outpatient). UA showed many bacteria, white count of 21-50 with positive leuk esterase and negative nitrite. Patient underwent non-contrast CT of the abdomen/pelvis that demonstrated left ureteral stone with partial obstruction and perinephric stranding suggestive of pyelonephritis. There was gallbladder wall thickening, and thus the patient then underwent ultrasound that showed gallbladder wall thickening and no other changes to suggest cholecystitis. The patient received vancomycin and ciprofloxacin, was started on 5 mcg/kg/min dopamin, and RIJ CVL was placed. In addition, the patient was seen by Urology and his Cardiologist was [Name (NI) 653], Dr. [Last Name (STitle) 110598], who agreed that his coumadin anticoagulation was for AF and could be reversed as necessary, so the patient 2 units FFP and was admitted to the [Hospital Unit Name 153] for further management. . Currently, the patient is complaining of mild left flank pain radiating to his groin. He also endorses shortness of breath and orthopnea. . ROS: As above, otherwise negative. Past Medical History: - CAD s/p CABG ([2177]) and PCI ([2180]) - CHF (EF 35% '[89]) - non-sustained VT s/p BiV ICD - A fib s/p ablation on coumadin - hyperlipidemia - prostate cancer s/p radical prostatectomy - hypogonadism with low testosterone - hernia repair - hydrocele repair - tonsillectomy Social History: -Retired apparel salesman -Tobacco history: denies -ETOH: denies -Illicit drugs: denies Family History: no hx of CAD Physical Exam: Admission: VS: 95.5 74 117/65 27 89%6L nc Gen: Age appropriate male in respiratory distress HEENT: MM dry. CV: S1+S2 Pulm: Bilateral crackles throughout the lung fields. Abd: S/NT/ND +bs. +CVA tenderness on left. Ext: 1+ pitting edema bilaterally. Neuro: AOx3. . Discharge: Afebrile. 100/50 p69 18 96%RA RESP: CTA with very minimal basilar rales. Good AE. EXT: 1+ peripheral edema LE B, to mid-shin. Pertinent Results: Admission Results: . [2191-10-30] 08:23AM BLOOD WBC-19.2# RBC-3.70 Hgb-12.0* Hct-35.5* MCV-96 MCH-32.5* MCHC-33.9 RDW-14.2 Plt Ct-97* [2191-10-30] 08:23AM BLOOD Neuts-79* Bands-18* Lymphs-2* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2191-10-30] 08:23AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [2191-10-30] 08:23AM BLOOD PT-34.2* PTT-39.2* INR(PT)-3.5* [2191-10-30] 04:11PM BLOOD Fibrino-616* [2191-10-30] 04:11PM BLOOD FDP-0-10 [2191-10-30] 08:23AM BLOOD Glucose-180* UreaN-52* Creat-2.1* Na-138 K-4.4 Cl-103 HCO3-26 AnGap-13 [2191-10-30] 08:23AM BLOOD ALT-70* AST-70* AlkPhos-68 TotBili-0.6 [2191-10-30] 04:11PM BLOOD LD(LDH)-259* TotBili-0.8 [2191-10-30] 08:23AM BLOOD cTropnT-<0.01 [2191-10-30] 08:23AM BLOOD Lipase-16 [2191-10-30] 04:11PM BLOOD Calcium-9.2 Phos-4.8# Mg-2.1 [2191-10-30] 04:11PM BLOOD D-Dimer-2571 . EKG ([2191-10-30]): A-V sequential pacing. Compared to the previous tracing of [2191-8-11] no change. . Portable CXR ([2191-10-30]): 1. Interval development of mild-to-moderate pulmonary congestion. 2. For better assessment, recommend repeating with PA and lateral views and better inspiration efforts. . CXR s/p Line Placement ([2191-10-30]): Interval placement of a right IJ CVL, but with the tip being obscured by the overlying pacemaker/ICD catheter. If clinical concern remains high for potential malposition, recommend repeating the radiograph with double opaque views. . Portable CXR ([2191-10-30]): Indeterminate termination point of the new right IJ CVL. Recommend repeat lateral view for better assessment. . CT Abdomen and Pelvis ([2191-10-30]): 1. A 5 mm stone within the left mid ureter without hydronephrosis, though there is increase in perinephric stranding on this side. Recommend clinical correlation with UA for presence of pyelonephritis. 2. Gallbladder wall thickening. Recommend further correlation with right upper quadrant ultrasound. 3. Volume loss in the left chest with elevation of left hemidiaphragm and consolidation of the posterior portion of the left lower lobe likely infection. . RUQ U/S ([2191-10-30]): Gallbladder wall thickening without sludge or stones, with a normal appearing common bile duct. These findings may be related to CHF, systemic inflammation, or hepatitis. Recommend clinical correlation. . CXR ([2191-10-30]): The previous dictation requested oblique views if possible to evaluate the position of the right IJ catheter, since it is superimposed by pacemaker leads. The current study is again a frontal view that is essentially identical to the previous study. Unfortunately, it is again difficult to precisely document the tip of the IJ catheter, which could be either in the lower SVC or possibly within the right atrium. Oblique views or, if possible, lateral projection would be helpful for precisely documenting the tip of the tube. . AXR ([2191-11-1]): Previously seen left ureteral stone is not clearly visualized in this radiograph. . CXR ([2191-11-2]): Previous mild pulmonary edema has improved but severe left lower lobe atelectasis has not. Heart is still moderately enlarged. No pneumothorax or appreciable pleural effusion. Transvenous right atrial pacer, right ventricular pacer defibrillator lead and a third lead probably right ventricular as well are unchanged in their respective positions. Previous right jugular line has been removed. No pneumothorax. . Renal U/S ([2191-11-2]): Mild residual focal caliectasis in the lower pole calyx of the left kidney without evidence of calculus. . Discharge labs: WBC 7.8 Hgb 10.5 HCT 31.2 PLT 129 143 104 30 / 89 4.4 32 1.4 \ Date [11-3] 12/10 [11-6] INR 1.2 1.4 1.8 (on Warfarin 4 mg) Micro: Urine culture: ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S BCx Neg x 2 UCx pending [2191-11-6] Brief Hospital Course: 78 y/o male with history of systolic CHF (LVEF 35%), atrial fibrillation on coumadin, and prostate cancer s/p radical [Hospital 110597] transferred from OSH to the [Hospital Unit Name 153] for treatment of possible cholecystitis with CTAP concerning for ureteral obstruction with pyelonephritis. . #. Pyelonephritis with Sepsis: Patient presented from an OSH with hypotension on peripheral Dopamine, leukocytosis of 19 with a left-shift, and a urinalysis positive for leukocyte esterase, 21-50 WBCs and many bacteria. Blood and urine cultures were taken. A CXR was unconcerning for a pneumonia. A CT scan revealed a non-obstructing 5 mm stone in the ureter of the left kidney without hydronephrosis. Patient was seen by Urology in the ED, and recommended conservative management with IV antibiotics and Tamsulosin given size of stone and lack of hydronephrosis. Given the septic physiology, a central line was placed, the patient received intravenous fluids to maintain a CVP of [7-7] and was started on Norepinephrine to maintain MAP > 65. The patient was started on Vancomycin and Ceftriaxone. Urine culture eventually grew out pan-sensitive E. coli. A KUB was ordered and no stone was detected. As the patient had been afebrile since admission he was transitioned to Cefpodoxime 200 mg Q12 to complete a full 14-day course (to be completed on [11-12]). Ultimately, the patient's UTI was attributed to an infected renal stone that was believed to have passed. Patient should follow up with Urology as an outpatient with a probable CT at that time to assess for residual stones. . #. Acute Renal Failure: Patient presented with serum creatinine of 2.1, up from a known baseline of approximately 1.2 (although tends to fluctuate). Despite the unobstructive nature of the renal stone there was concern for post-obstructive failure vs. pre-renal failure given CHF. Urine electrolytes were consistent with a pre-renal etiology (FENa 0.22%) but the patient appeared hypervolemic on exam. Given hypotension, the patient's Lasix were held. Several days into admission the patient's renal function abruptly improved and his urine output increased with subsequent improvement in his creatinine. . #. Pulmonary Edema and CHF: Patient was initially hypoxic and satting 92% on 2L. CXR was unconcerning for infection but did reveal pulmonary congestion. Patient has known systolic dysfunction with an LVEF 35% with CHF complicated by NSVT s/p AICD placement. Unfortunately the patient was also hypotensive on arrival so his Carvedilol, Valsartan, and Lasix were held. The patient was slowly weaned off of pressors. Cardiology was consulted and recommended reintroduction of his home Lasix, Amiodarone and Aldactone on the day of transfer to the medicine service. Valsartan was restarted the following day ([11-4]) and Carvedilol the next day ([11-5]). . #. Thrombocytopenia: Patient had platelet count of 97 on admission. Given septic physiology there was concern for possible DIC. DIC labs were negative with a fibrinogen of 616 and FDP of 0-10 (unable to use INR as patient on Coumadin). Thrombocytopenia was attributed to sepsis. Platelet counts were monitored closely throughout the ICU course and remained stable. His platelet count was improving prior to discharge. . #. CAD: Aspirin was initially held given concern for DIC picture. Statin was also held given mild transaminitis. Carvedilol was held as per above. His aspirin, valsartan, and carvedilol were resumed during the hospitalization, which he tolerated well. His Lipitor was resumed at the time of discharge. . #. Atrial Fibrillation s/p Ablation: Patient's INR was 3.5 on admission and Coumadin was held as INR was supratherapeutic and there was concern for DIC and possible procedural intervention (nephrostomy) for stone removal. Coumadin was restarted without bridge, and his INR gradually increased. He remains subtherapeutic at the time of discharge (1.8); he will follow up with [Hospital 197] Clinic within the next 1-2 days for INR check and dose titration as needed. . # Hyperlipidemia: Patient's lipitor dose was held during the admission due to mild transaminitis, however this was resumed at the time of discharge. . Code: Full Contact: [Name (NI) ] [Name (NI) ] (wife/hcp) [Telephone/Fax (1) 110599] Dispo: ICU level of care. Medications on Admission: amiodarone 200 mg po q day lipitor 80 mg po q day carvedilol 25 mg po BID Lasix 10-20 mg po q day spironolactone 12.5 mg po q day Valsartan 160 mg po BID Coumadin 4 mg po q1600 Aspirin 81 mg po q day Caltrate-600 plus Vit D Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): 30 minutes - 1 hour prior to lasix. 6. valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. warfarin 4 mg Tablet Sig: One (1) Tablet PO q 4 pm: Please follow up with your coumadin clinic within the next 2 days. 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Caltrate-600 Plus Vitamin D3 Oral 10. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:0 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation: may purchase over the counter. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: may purchase over the counter. 13. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 8 days. Disp:16 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: # E.coli UTI with septicemia # acute on chronic systolic CHF # acute renal failure # CAD s/p CABG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted in transfer from another hospital with a severe urinary tract infection in the setting of a kidney stone which was preventing the drainage of urine. You were initially managed in our ICU, and were treated with antibiotics. You also developed heart failure. You have improved from your infection, but you will need to complete a course of antibiotics. Your heart failure has resolved, and you will need to follow up with your cardiologist. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [2191-11-8] at 3:00 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: TUESDAY [2191-11-8] at 3:30 PM With: [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 126], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: TUESDAY [2191-11-29] at 1 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "790.92", "574.10", "995.92", "V45.02", "590.80", "427.31", "257.2", "041.4", "414.00", "V45.81", "287.5", "427.89", "428.23", "E934.2", "790.4", "518.81", "584.9", "592.1", "038.9", "272.4", "V10.46", "428.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "38.93" ]	icd9pcs	[ [ [] ] ]	13461, 13467	7615, 11956	332, 339	13609, 13609	3294, 6935	14244, 15089	2842, 2856		12231, 13438		13488, 13588		11982, 12208			13760, 14221			6951, 7592						2871, 3275																					240, 294							367, 2409												13624, 13736					2431, 2720	2736, 2826
63,628	131,994	37160	Discharge summary	report	Admission Date: [2176-6-10] Discharge Date: [2176-6-17] Date of Birth: [2118-4-13] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2009] Chief Complaint: Cough Major Surgical or Invasive Procedure: Ultrasound Guided Pericardiocentesis ([2176-6-13]) Endobronchial Ultrasound and Node Aspiration ([2176-6-17]) History of Present Illness: The patient is a 58 year old Vietnamese male presenting with cough x 5-6 months. Went to PCP complaining of chronic cough, PCP ordered CXR. On way home from CXR his PCPs office called and told him to go to the ED, as there was concern for a possible mass. . Cough is dry, going on for 5-6 months, reports losing [5-10] kg in same time. Denies fevers, vomiting, diaphoresis. He complains also of chest pressure every night while lying flat x 6 months, partially relieved by standing and antacids. No history of TB, no known exposure to TB. . In the ED, initial VS were: T 98.5, HR 97, BP 125/74, RR 16, SpO2 99% on RA. CXR today with concern for mass vs TB. Patient was unable to produce sputum sample in the ED. Vitals in ED prior to transfer to floor were: T 97.5, HR 82 NSR, BP 116/81, RR 16, and SpO2 97% on RA. . Upon transfer to the floor, he is asymptomatic and his VS are stable. . 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: # GERD # H. pylori infection Social History: Vietnamese, immigated in [2173]. No travel outside US since. Current smoker 10 cig/day x 30 years. No ETOH, no illicits. Family History: Noncontributory Physical Exam: PHYSICAL EXAM ON ADMISSION: VS - T 96.6F, BP 120/70, HR 80, RR 16, SpO2 98% on RA GENERAL - cachectic man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - flat, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary LAD NEURO - awake, A&Ox3, moves all extremities . PHYSICAL EXAM ON DISCHARGE: VS: T 97.9, BP 104/72, HR 92, RR 18, SpO2 94% on RA ....Ht 65 in, Wt 84 lbs on admission Gen: Cachexic male in NAD. Alert and oriented x3. Mood and affect anxious. Pleasant and cooperative. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign. Neck: Supple. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. No M/R/G appreciated. Chest: Respiration unlabored, no accessory muscle use. Lungs CTAB. No wheezes, rhonchi, or rales. Abd: BS present. Soft, thin, NT, ND. No HSM detected. Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Skin: No rashes, ecchymoses, or other lesions noted. Neuro: Moving all four limbs. Pertinent Results: LAB RESULTS ON ADMISSION: [2176-6-10] 02:40PM BLOOD WBC-7.0 RBC-4.13* Hgb-12.7* Hct-37.8* MCV-92 MCH-30.8 MCHC-33.6 RDW-13.2 Plt Ct-362 [2176-6-10] 02:40PM BLOOD Neuts-61.5 Lymphs-28.3 Monos-6.4 Eos-2.3 Baso-1.5 [2176-6-10] 02:40PM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-135 K-4.3 Cl-97 HCO3-27 AnGap-15 [2176-6-10] 03:07PM BLOOD Lactate-1.7 . LAB RESULTS ON DISCHARGE: [2176-6-17] 07:50AM BLOOD WBC-6.0 RBC-4.33* Hgb-12.8* Hct-39.3* MCV-91 MCH-29.5 MCHC-32.5 RDW-13.2 Plt Ct-364 [2176-6-17] 07:50AM BLOOD PT-12.1 PTT-31.1 INR(PT)-1.0 [2176-6-17] 07:50AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-136 K-4.5 Cl-97 HCO3-30 AnGap-14 [2176-6-17] 07:50AM BLOOD Calcium-9.8 Phos-3.8 Mg-2.2 UricAcd-3.8 [2176-6-17] 07:50AM BLOOD LD(LDH)-225 . OTHER RELEVANT LABS: [2176-6-12] 07:15AM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.8 Mg-2.1 [2176-6-12] 07:15AM BLOOD ALT-9 AST-20 LD(LDH)-284* AlkPhos-130 TotBili-0.3 . URINALYSIS: [2176-6-10] 03:50PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 [2176-6-10] 03:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG . PERICARDIAL FLUID: [2176-6-13] 04:00PM OTHER BODY FLUID WBC-2863* Hct,Fl-7.0* Polys-17* Lymphs-78* Monos-3 Eos-1 Other-1* [2176-6-13] 04:00PM OTHER BODY FLUID TotProt-4.6 Glucose-90 LD(LDH)-449 Amylase-46 Albumin-3.3 . IMAGING / STUDIES: # CHEST (PA & LAT) ([2176-6-10] at 10:23 AM): IMPRESSION: PA and lateral chest reviewed in the absence of prior chest radiographs: Lobulation and enlargement of the left hilus is best explained by adenopathy, conceivably with some calcification but malignant until proved otherwise. There is fullness in the aortopulmonic window and suggestion of the indentation on the origin of the left main bronchus as well as in the right lower paratracheal station, probably adenopathy as well. Although the left hilar bronchial anatomy is not entirely clear, there could be occlusion of the left upper lobe bronchus. There is heterogeneous opacification in the left upper lobe, both anterior and posterior to the tracheal plane as seen on the lateral view. Generalized hyperinflation is due to emphysema. There is no left pleural effusion. There may be a small right pleural effusion. Heart size is normal. Differential diagnosis would depend upon clinical history and prior radiographic appearance. It includes bronchogenic carcinoma and tuberculosis. . # ECG ([2176-6-10] at 1:51:26 PM): Sinus rhythm with a right axis deviation. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 93 142 88 [Telephone/Fax (2) 83707] 85 . # Portable TTE ([2176-6-11] at 1:07:52 PM): The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (3). There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion with some stranding. There is mild right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . # CT CHEST W/O CONTRAST ([2176-6-11] at 12:01 AM): FINDINGS: An irregularly marginated mass is present in the superior segment of the left lower lobe, crossing the fissure into the adjacent posterior portion of the left upper lobe. The mass measures about 3.6 x 2.1 cm (image 93, series 4). It is associated with contiguous nodular thickening of the interstitium as well as multiple satellite nodules in both the adjacent left upper and left lower lobes. Multiple additional nodules are identified throughout both lungs, the majority of which are round, well circumscribed, and less than or equal to 6 mm in diameter, such as a 6-mm right lower lobe nodule (image 154, series 4). However, in other regions, there are clustered peribronchovascular nodules such as in the lateral aspect of the right lower lobe (image 174, series 4) and in the anterior portion of the right lower lobe (image 138, series 4). A combined ground-glass and solid nodular opacity is identified in the periphery of the right upper lobe (image 83, series 4). A few tiny calcified granulomas are incidentally noted in the lungs as well. Lungs are otherwise remarkable for biapical scarring and upper lobe predominant centrilobular emphysema. Extensive mediastinal and left hilar lymphadenopathy are present, with conglomerate nodes throughout the right and left sides of the mediastinum with the largest nodal mass centered in the region of the aorticopulmonary window. This nodal mass is difficult to measure due to absence of intravenous contrast, but is at least 3.3 x 4.2 cm and appears centrally necrotic. Other nodes in the mediastinum also have relatively low density suggesting necrosis. These are located in the prevascular and bilateral paratracheal nodal stations. There is also suggestion of enlarged nodes in the left supraclavicular region, not ideally assessed without contrast. Mildly enlarged subcarinal nodes are also present, as well as bulky left hilar lymphadenopathy. The aorticopulmonary window and left hilar nodes result in narrowing of the left main and upper lobe bronchi which have an irregular configuration. Heart is normal in size. Moderate pericardial effusion is present as well as a 1.4 x 3.0 cm mass extrinsic to the heart and likely within the pericardium. There is no significant pleural effusion. Examination of the upper abdomen is limited as the study was not tailored to evaluate this region. With this limitation in mind, no concerning abdominal abnormality is identified in this limited assessment. Skeletal structures demonstrate a small sclerotic focus in a lower left lateral rib, which is probably a benign bone island. IMPRESSION: 1. Large spiculated left lung mass and associated bulky necrotic mediastinal and left hilar lymphadenopathy, bilateral pulmonary nodules, pericardial effusion and pericardial mass. Constellation of findings is most suggestive of advanced nonsmall cell lung cancer. Tuberculosis is considered less likely. 2. Bronchial narrowing and irregularity on the left, which may be due to a combination of extrinsic compression and potential intrinsic airway involvement. Correlation with bronchoscopy could be performed if warranted clinically. 3. Limited assessment of soft-tissue structures due to absence of intravenous contrast. For complete staging purposes, a PET-CT could be considered if warranted clinically. . # PERICARDIOCENTESIS ([2176-6-13]): Subxyphoid pericardiocentesis with removal of 140cc of bloody fluid. Drain left in place. Echo shows minimal residual effusion. First 3 sticks punctured RV with 4th stick successful. COMMENTS: 1. Successful pericardiocentesis 2. CCU 3. Plan to remove drain in 24-36 hours FINAL DIAGNOSIS: 1. Pericardial effusion . # Portable TTE (Focused views) ([2176-6-13] at 4:00:00 PM): This study was compared to the prior study of [2176-6-11]. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV systolic function. PERICARDIUM: Trivial/physiologic pericardial effusion. Conclusions Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. There is a trivial/physiologic pericardial effusion. IMPRESSION: Focused study. Limited views. Trivial pericardial effusion without echocardiographic evidence of tamponade. Compared with the prior study (images reviewed) of [2176-6-11], the previously seen small to moderate pericardial effusion with echocardiographic evidence of tamponade has markedly decreased in size and is now trivial without the presence of tamponade physiology. Given the limited nature of the current study, comparison with other aspects of the previous, comprehensive echocardiogram was not performed. . # Portable TTE (Focused views) ([2176-6-14] at 11:30:00 AM): There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2176-6-13], the pericardial effusion has slightly increased. . # ECG ([2176-6-16] at 11:45:44 AM): Sinus rhythm. Peaked P waves and rightward P wave axis, as well as right axis deviation, are consistent with pulmonary pathalogy. Compared to the previous tracing of [2176-6-10] no diagnostic interim change. TRACING #1 Rate PR QRS QT/QTc P QRS T 99 134 88 322/390 81 95 85 . # MR HEAD W & W/O CONTRAST ([2176-6-16] at 6:59 PM): FINDINGS: There is no infarction, hemorrhage, mass or mass effect. The [Doctor Last Name 352]-white matter differentiation is normal. The ventricles and sulcal configuration are age appropriate. There is a cavum septum pellucidum and septum vergae. There is no abnormal parenchymal, leptomeningeal or pachymeningeal enhancement. Mild mucosal thickening is seen in the paranasal sinuses. The extracranial structures appear normal. Both orbits demonstrate no mass lesion. IMPRESSION: No evidence of metastatic disease or acute intracranial pathology. . # ECG ([2176-6-17] at 7:46:58 AM): Sinus rhythm. Right axis deviation. Peaked P waves and rightward P wave axis consistent with right atrial abnormality and pulmonary pathology. Compared to the previous tracing of [2176-6-16] no diagnostic interim change. TRACING #2 Rate PR QRS QT/QTc P QRS T 99 134 90 328/396 82 95 81 . # BRONCHOSCOPY ([2176-6-17]): Findings: There was endobronchial tumor that was not obstructive involving proximal and distal LMS. There was tumor infiltration of the LUL. Hyperemic mucosa at distal trachea, main carina and RMS.There were enlarged nodes at stations 4R, 7, 4L, 11L. All abnormal lymph nodes were sampled by EBUS-TBNA. Impression: There was endobronchial tumor that was not obstructive involving proximal and distal LMS. There was tumor infiltration of the LUL. Hyperemic mucosa at distal trachea, main carina and RMS.There were enlarged nodes at stations 4R, 7, 4L, 11L. All abnormal. . # CHEST (PORTABLE AP) ([2176-6-17] at 11:58 AM): FINDINGS: The lungs are hyperexpanded without focal consolidation. The left upper lobe mass and left hilar enlargement due to known adenopathy are stable. The cardiac and mediastinal silhouettes are normal. The right hilar contour is normal. There is no pleural effusion or pneumothorax. IMPRESSION: 1. No pneumothorax. 2. Stable left upper lobe mass and left hilar lymphadenopathy. . # CT ABD & PELVIS ([2176-6-17] at 4:52 PM): CONTRAST-ENHANCED CT OF THE ABDOMEN: There are small bilateral pleural effusions. The previously noted pericardial effusion is not well visualized on this study. The liver, spleen, gallbladder, and pancreas are normal in appearance. Stomach and duodenum are unremarkable. The adrenal glands and kidneys are normal in appearance. There is no hydronephrosis or hydroureter. There is no intra- or extra-hepatic biliary duct dilation. There is no mesenteric or retroperitoneal lymphadenopathy. There is some minimal calcified plaque noted in the abdominal aorta. The portal and splenic veins are widely patent. Small and large bowel loops are normal in appearance. There is no ascites. CONTRAST-ENHANCED CT OF THE PELVIS: The bladder, prostate, and rectum are unremarkable. There is no pelvic or inguinal lymphadenopathy. There is no pelvic ascites. Bowel loops in the pelvis are normal in appearance. OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic changes. IMPRESSION: 1. No evidence of metastatic disease in the abdomen or pelvis. 2. Small bilateral pleural effusions. . Cytology [6-17]: Lymph node biopsy POSITIVE FOR MALIGNANT CELLS. Poorly differentiated carcinoma consistent with small cell carcinoma. See cell block (S11-[Numeric Identifier 83708]). Brief Hospital Course: The patient is a 58 year old Vietnamese male with significant smoking history who presented to his PCP with chronic cough and weight loss, found to have LUL mass and left hilar adenopathy on CXR. . # Lung Masses: The initial differential included a primary lung cancer, metastatic cancer, and tuberculosis. His cough was nonproductive and an induced sputum could not be obtained. He remained afebrile, had no elevated WBC count, and was not hypoxic. CT chest was performed shortly after admission and was highly concerning for either a primary or metastatic lung malignancy. A large LUL mass and multiple smaller nodules and opacities were seen, as well as a pericardial effusion and possible pericardial mass. He was initially kept in respiratory isolation, but this was discontinued given the low likelihood of TB based on his history and imaging findings. IP was consulted for bronchoscopic biopsy, but early tamponade physiology was then noted on echo, and drainage of his pericardial effusion was considered more urgent. Bronchoscopy was deferred until results from his pericardiocentesis were available, since the results could have been be sufficient to establish a diagnosis without bronchoscopy if positive for malignancy. Initial pericardial fluid cytology was negative for malignant cells, however, and bronchoscopy was performed on [2176-6-17] once the patient returned to the general medical floor. Multiple abnormal nodes were biopsied on EBUS, and endobronchial lesions were seen involving the proximal and distal LMS. Prior to discharge, additional staging workup was performed with MRI brain and CT abdomen/pelvis. . # Pericardial Mass / Effusion: In addition to the lung lesions, a pericardial mass and effusion were seen on CT chest. Subsequent TTE on [2176-6-11] showed a small to moderate effusion with stranding and evidence of early tamponade physiology. He remained hemodynmaically stable and his pulsus was normal at [6-12]. Cardiology was consulted and recommended drainage of the pericardial effusion, which was performed on [2176-6-13]. Subxiphoid pericardiocentesis was performed with removed of 140 ml of serosanguinous fluid with the procedure complicated by three unsuccessful needle sticks of the right ventricle. Pericardial pressure feel from six to zero with pericardial fluid removal. Post-pericardiocentesis TTE showed minimal residual effusion. A pericadial drain was placed, and he was transferred to the CCU. He remained hemodynamically stable, and the drain put out 250 ml of serosanguinous fluid. The drain stopped putting out at 9am on [2176-6-14], and repeat TTE showed a very small pericardial effusion. The drain was pulled around 7pm that night without incident. He was monitored in the CCU and then transferred back to the medical floor. Results from the pericardial fluid were nondiagnostic. . # GERD: He reports a history of facial swelling after taking a medication for GERD in past, but was uncertain which medication. He was not acutely symptomatic during his stay and no GERD medication was provided. . # Transitional Care: -- Multiple lymph node biopsy results pending at time of discharge -- Follow up in Thoracic [Hospital ] Clinic to be arranged . Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Lung Masses Pericardial Mass Hilar Lymphadenopathy Pericardial Effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for cough, chest discomfort, and shortness of breath. A chest X-ray prior to admission showed a mass concerning for lung cancer. You had a chest CT which showed several lung nodules and enlarged lymph nodes which were also concerning for lung cancer. The CT scan also showed fluid around the heart called a pericardial effusion. You had an echocardiogram (ultrasound of the heart) to evaluate this fluid. There was concern that the fluid might make it difficult for your heart to pump properly, so the fluid was drained and you were briefly monitored in the Cardiac Care Unit. You had a bronchoscopic lung biopsy in order to obtain a sample of the abnormal lymph nodes and make a definite diagnosis. The results from these biopsies are still pending. Several other studies including a brain MRI and CT scan of the abdomen and pelvis were performed. These are to help determine whether there are any abnormal lymph nodes or masses in other parts of the body. You will need to follow up in the Thoracic [Hospital ] Clinic after discharge. This has been discussed with your Primary Care Doctor, and appointments are being set up for you. You will also need to follow up with your Primary Care Doctor [First Name (Titles) ] [Last Name (Titles) ]e. Details are below. Followup Instructions: The following appoinment has been scheduled for you with your PCP. [Name10 (NameIs) ] will try to arrange an earlier appointment for you. Name: [Last Name (LF) 59927],[First Name3 (LF) 1730] C. Location: [Hospital3 8233] Address: [State 8234], [Location (un) ],[Numeric Identifier 8235] Phone: [Telephone/Fax (1) 8236] Appointment: Wednesday, [6-26], 1:30	[ "783.21", "162.3", "305.1", "V85.0", "785.6", "530.81", "423.9", "196.1" ]	icd9cm	[ [ [] ] ]	[ "40.11", "37.0", "33.24" ]	icd9pcs	[ [ [] ] ]	18852, 18858	15514, 18766	310, 430	18993, 18993	3230, 3242	20491, 20888	1818, 1836		18822, 18829		18879, 18972		18792, 18799		10572, 15491	19144, 20468									1851, 1865													2521, 3211		3616, 10555						265, 272							458, 1606										3256, 3602		19008, 19120					1628, 1659	1675, 1802
55,973	157,542	4036	Discharge summary	report	Admission Date: [2182-10-16] Discharge Date: [2182-10-21] Date of Birth: [2120-10-31] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Ampicillin / Lactose / Neomycin / metoclopramide / Doxepin Attending:[First Name3 (LF) 3624] Chief Complaint: chills, low grade temp Major Surgical or Invasive Procedure: Femoral CVL Removal of Femoral CVL History of Present Illness: 61 year old female with T1DM s/p pancreatic transplant [2173], CABG, prior NSTEMIs, CHF, ESRD with failed renal transplants and now on peritoneal HD, CHF, orthostatic hypotension on midodrine and fludrocortisone, presented to ED with chills, low grade temp and poor temperature who was noted to be hypoxic and hypotensive. Upon review of her records, she is always hypotensive and she is very at her baseline upon present. Of note, she was seen by Dr. [Last Name (STitle) 724] in [2182-5-24], at which point an immunologic workup was performed, revealing CD4 lymphopenia. She had normal IgA and IgM as well as IgG levels at that time. She was started on pneumocystis prophylaxis as well as [Doctor First Name ] prophylaxis and reported negative HIV testing at the rehab center. She was seen by ID on [9-24] at which point she was switched from pentamidine to mepron for PCP [Name Initial (PRE) 1102] (verify with pt). Her CD4 count was rechecked and found to be 165. In the ED, initial vitals were 98.8 70 85/60 22 98%. Labs were notable for normal CBC and chem7 except for Cr of 6.1 (at baseline). CXR was notable for no acute process. She was started on vanc, levo, and flagyl for presumed septic process. She was noted to have a temp of 101.4. She also got tylenol for fever and levophed for hypotension to the 60s systolic. A right femoral CVL was placed. Vitals on transfer: 77 86/49 16 99%. On arrival to the [Hospital Unit Name 153], her vitals were 106/57, 85, 97% on 3L. The pt reports that last night she began shivering incessantly and had a low grade temp of 99 (she normally runs 96-97). She has also been feeling very drowsy and weak. In the ED, they were having to tell her to take her medications multiple times before she would finally respond. She denies pain anywhere except for her sacrum, which is baseline. She frequently has diarrhea with on and off positive C.diff cultures. She reports that her last c. diff infection was 6-8wks ago. She did have diarrhea about 2 nights ago, but it was mainly loose, soft stool - nothing like her normal c. diff diarrhea. She took an immodium and it resolved like usual. She is not having and chest or abdominal pain or trouble breathing. No dizziness or lightheadedness, just weakness. In addition, this morning she was nauseated but did not vomit. She feels that her blood pressure may be low because the rehab facility took off too much fluid during peritoneal dialysis. Past Medical History: # Ischemic cariomyopathy/CHF; EF 35% in [4-/2182]-> 30% [5-/2182] # h/o severe MR s/p repair in [1-/2182] # NSTEMI [7-/2181], s/p [Year (4 digits) ] to LAD [9-/2181] # CABGX5 vessel [1-/2182] # 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. Has been in and out of hospitals in the last 9 months. Was longest at [Hospital3 ], most recently at [Hospital ] LivingCenter - [Hospital1 8218] - [Location (un) ]. Mobile with wheelchair but unable to do transfers. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: Father with MI at 57. No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals: T:98.7, BP:106/57 , P:87 , R: 18, O2: 100% 3L NC General: Alert, oriented, malnourished chronically ill appearing female in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: soft rales diffusely over anterior chest, no wheezes/rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, PD site intact/clean/dry [Location (un) ]: Femoral CVL in R groin, limbs warm, well perfused, 2+ pulses, pitting edema to knees DISCHARGE EXAM: VS: 98.5 98/56 (85-100/45-68) 69 20 100%RA GEN: WD WN F appropriate, comfortable in NAD HEENT: NCAT, pupils equal, EOMI, OP clear, missing left upper molar NECK: supple, no JVD, no LAD CV: RRR, S1,S2, III/VI systolic murmur, no r/g LUNGS: normal respiratory effort, no accessory muscle use, rhonchi and crackles present in bases, no wheezes ABDOMEN: soft, distended, peritoneal catheter present in RLQ, NT, no r/g, +BS EXTREM: left [Location (un) 6024], 1+ dp pulse, 2+ radial pulse R femoral central line, nails thickened and NEURO: Awake, alert, oriented x3, CNII-CNXII grossly intact, no focal neurologic deficits Pertinent Results: ADMISSION LABS [2182-10-16*] 01:13PM BLOOD WBC-8.5 RBC-2.91 Hgb-11.2* Hct-36.2 MCV-125* MCH-38.5* MCHC-30.9* RDW-17.2* Plt Ct-159 [2182-10-16] 01:13PM BLOOD Neuts-83.8* Lymphs-10.4* Monos-3.3 Eos-2.0 Baso-0.4 [2182-10-16] 01:13PM BLOOD PT-34.4* PTT-35.1 INR(PT)-3.2* [2182-10-16] 01:13PM BLOOD Glucose-77 UreaN-80* Creat-6.1* Na-139 K-4.3 Cl-99 HCO3-25 AnGap-19 [2182-10-16] 10:47PM BLOOD ALT-4 AST-41* LD(LDH)-342* AlkPhos-61 TotBili-0.2 [2182-10-16] 10:47PM BLOOD Calcium-8.3* Phos-5.1* Mg-1.6 [2182-10-16] 04:38PM BLOOD Lactate-1.4 MICRO [2182-10-16] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT [2182-10-16] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2182-10-16] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY EMERGENCY [Hospital1 ] IMAGING [10-16] CXR: IMPRESSION: Left pleural effusion with overlying atelectasis, underlying consolidation is difficult to exclude. [10-17] ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with inferior and inferolateral, as well as distal septal akinesis. There is mild hypokinesis of the remaining segments (LVEF = 25-30%). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated with normal gradient. Moderate to severe (3+) transvalvular mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Moderate to severe regional and global left ventricular systolic dysfunction, c/w multivessel CAD. Well-seated mitral annuloplasty ring with moderate to severe residual regurgitation. Mild aortic regurgitation. Pleural effusions. Compared with the prior study (images reviewed) of [2182-9-3], mitral regurgitation is more prominent (may be secondary to increased volume). The other findings are similar. [10-17] CXR: Portable AP radiograph of the chest was reviewed in comparison to [2182-10-16]. Post-sternotomy wires and replaced most likely mitral valve are unchanged in appearance. No progression of interstitial pulmonary edema is demonstrated and might reflect need for dialysis. Bilateral pleural effusions, right more than left, have developed in the interim, most likely small to moderate in size. No new focal consolidation to suggest infectious process is seen with re-assessment after dialysis is required. DISCHARGE LABS [2182-10-21] 09:30AM BLOOD WBC-4.0 RBC-2.62* Hgb-9.6* Hct-31.4* MCV-120* MCH-36.6* MCHC-30.5* RDW-16.3* Plt Ct-175 [2182-10-21] 09:30AM BLOOD Glucose-87 UreaN-80* Creat-6.6* Na-134 K-4.5 Cl-91* HCO3-28 AnGap-20 [2182-10-21] 09:30AM BLOOD Calcium-7.9* Phos-5.0* Mg-1.7 Brief Hospital Course: 61y F with T1DM s/p pancreatic transplant [2173], CABG, prior NSTEMIs, CHF, ESRD with failed renal transplants and now on peritoneal HD, orthostatic hypotension on midodrine and fludrocortisone who presented with hypotension and low grade fever from rehab facility. ACTIVE ISSUES: # Hypotension: Patient's baseline SBP is in the 80's (on fludrocortisone and midodrine as outpatient) and she presented with SBP's as low as 60's. She is known to have severe orthostatic hypotension. She was started on Levophed in the ED but weaned off in the [Hospital Unit Name 153]. Her hypotension was concerning for sepsis given her low grade fever in ED and empiric antibiotics were administered in ED to cover broadly. Peritonitis was unlikely based on peritoneal fluid cell counts. In addition patient has been compliant with PCP [Name9 (PRE) ] currently taking atovaquone. Another possible etiology for hypotension was over dialysis, as patient is on PD and very sensitive to fluid shifts. A lactate of 1.4 was reassuring. A random cortisol was checked and peritoneal and blood cultures were sent and came back without growth. A b-glucan and galactomannan were sent and results are pending on discharge. Patient continued PD with a conservative volume removal strategy. #Fever: Patient initially presented with low grade fevers, which were concerning for evolving sepsis given hypotension. She was initially treated with vancomycin, levofloxacin and metronidazole for broad prophylactic coverage. Her blood, urine, and peritoneal cultures were all negative and so antibiotics were stopped. #CD4 lymphopenia: Possibly related to prior ATG therapy for previous transplants or myelosuppressive effects from the MMF (discontinued 7/[2181]). Patient's last CD4 count was 165 on [2182-9-24], up from 66 in [2182-5-24] at which point she was started on PCP [Name Initial (PRE) ]. Currently on acyclovir, fluconazole, and Mepron. Patient was continued on acyclovir, fluconazole, and atovaquone prophylaxis. # ESRD: Patient is on peritoneal dialysis. We discussed possible volume depletion as a cause of hypotension with the nephrology team, who recommended the lowest concentration of PD fluid to avoid further hypotension. Rehab PD settings had been: ccpd if SBP <80 use one 6L 1.5% bag with one 6L 2.5% bag. If SBP>80 use two 6 liter 2.5% bag 2000cc fills x 4. On discharge her PD regimen was: 4 exchanges per 24 hours, 3 hours dwell time per exchange, 2L volume per dwell, with 4 cycles of 1.5% dextrose daily, one cycle of 2.5 % dextrose as needed for patient comfort or signs of volume overload. # S/p renal/pancreatic transplant: Patient stopped MMF in [Month (only) 205] due to anemia. She was continued on tacrolimus and prednisone. # CAD: Patient has an extensive cardiac history including CABG. She was formerly on [Last Name (LF) ], [First Name3 (LF) ] and warfarin. Now on aspirin and warfarin with supra therapeutic INR (anticoagulated for global hypokinesis of LV). Most recent TTE 09/[2181]. Patient was continued on aspirin and Coumadin was held given supra therapeutic INR. # Pulmonary edema: Patient's chest x-ray and clinical exam were concerning for pulmonary edema. She had an echo showing an EF that was unchanged at 25-30% and increased mitral regurgitation. We contact[Name (NI) ] her cardiologist Dr. [Last Name (STitle) 171] who will see her as an outpatient for further evaluation for her severe MR. # Coccygeal pain: Patient was repositioned frequently and a pad support was used to decrease pressure # Scleral injection and photophobia: Patient's scleral injection and photophobia were concerning for worsening glaucoma vs. viral conjunctivitis, though lack of exudates makes conjunctivitis less likely and lack of eye pain was reassuring. She was seen by ophthalmology, who recommended continuing current eye drop regimen. # Macrocytosis: Patient has longstanding macrocytosis. We contact[Name (NI) ] her outpatient hematology team, who thought it might be secondary to erythropoietin-stimulating agents given that it has persisted after discontinuation of CellCept. Transitional Issues: 1. Pt will need to follow up with Dr. [Last Name (STitle) 171] in Cardiology as an outpatient for her severe mitral regurgitation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Acetate 667 mg PO TID W/MEALS 2. Docusate Sodium 100 mg PO DAILY:PRN constipation 3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES DAILY 4. Creon 12 2 CAP PO TID W/MEALS 5. Cyanocobalamin 1000 mcg IM/SC QMONTH 6. Epoetin Alfa 12,000 units SC MWF Start: HS 7. Oxymetazoline 1 SPRY NU TID:PRN dry nares Duration: 3 Days 8. Ferrous Sulfate 325 mg PO BID 9. Fluconazole 100 mg PO MWF 10. Fludrocortisone Acetate 0.1 mg PO BID 11. FoLIC Acid 1 mg PO DAILY 12. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes 13. lactase NF 1000 units Oral UNK 14. Levothyroxine Sodium 150 mcg PO DAILY 15. Atorvastatin 80 mg PO HS 16. Loperamide 2 mg PO QID:PRN diarrhea 17. Atovaquone Suspension 1500 mg PO DAILY 18. Methazolamide 50 mg PO TID 19. Preparation H NF (phenyleph-shark liv oil-mo-pet) UNK Rectal daily 20. Midodrine 15 mg PO Q 8H hold for SBP >130 21. Gabapentin 100 mg PO QOD 22. Omeprazole 40 mg PO DAILY 23. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K >5 24. PredniSONE 5 mg PO DAILY 25. Restasis NF (cycloSPORINE) 0.05 % OU [Hospital1 ] 26. Simethicone 80 mg PO QID:PRN gas 27. Sodium Chloride 500 mg PO DAILY 28. Tacrolimus 1 mg PO Q12H administered at 800 and [2169] 29. Travatan Z NF (travoprost) 1 drop OU QHS 30. Ondansetron 4 mg PO Q4H:PRN nausea 31. Ureacin-20 NF (urea) UNK Topical [Hospital1 ] on palms, nails 32. Aspirin 81 mg PO DAILY 33. Acyclovir 400 mg PO Q12H 34. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 35. Amiodarone 200 mg PO DAILY 36. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 37. Calcitriol 0.25 mcg PO MWF 38. Warfarin 0.5 mg PO DAILY16 Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Calcium Acetate 667 mg PO TID W/MEALS 3. Docusate Sodium 100 mg PO DAILY:PRN constipation 4. Ureacin-20 NF (urea) 0 UNK TOPICAL [Hospital1 ] on palms, nails 5. Creon 12 2 CAP PO TID W/MEALS 6. Cyanocobalamin 1000 mcg IM/SC QMONTH 7. Oxymetazoline 1 SPRY NU TID:PRN dry nares Duration: 3 Days 8. Ferrous Sulfate 325 mg PO BID 9. Fluconazole 100 mg PO MWF 10. Epoetin Alfa 12,000 units SC MWF 11. Fludrocortisone Acetate 0.1 mg PO BID 12. FoLIC Acid 1 mg PO DAILY 13. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes 14. lactase NF 1000 units Oral UNK 15. Levothyroxine Sodium 150 mcg PO DAILY 16. Atorvastatin 80 mg PO HS 17. Loperamide 2 mg PO QID:PRN diarrhea 18. Atovaquone Suspension 1500 mg PO DAILY 19. Methazolamide 50 mg PO TID 20. Preparation H NF (phenyleph-shark liv oil-mo-pet) 0 UNK RECTAL DAILY 21. Midodrine 15 mg PO Q 8H hold for SBP >130 22. Gabapentin 100 mg PO QOD 23. Omeprazole 40 mg PO DAILY 24. PredniSONE 5 mg PO DAILY 25. Restasis NF (cycloSPORINE) 0.05 % OU [Hospital1 ] 26. Simethicone 80 mg PO QID:PRN gas 27. Sodium Chloride 500 mg PO DAILY 28. Tacrolimus 1 mg PO Q12H administered at 800 and [2169] 29. Travatan Z NF (travoprost) 1 drop OU QHS 30. Ondansetron 4 mg PO Q4H:PRN nausea 31. Aspirin 81 mg PO DAILY 32. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 33. Amiodarone 200 mg PO DAILY 34. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 35. Calcitriol 0.25 mcg PO MWF 36. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES DAILY 37. Warfarin 1 mg PO DAILY16 38. Mepilex NF (foam bandage) 4 X 4 Topical as needed skin breakdown on sacrum RX foam bandage [Mepilex] 4" X 4" one pad as needed Disp #30 Unit Refills:0 Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - [Location (un) ] Discharge Diagnosis: orthostatic hypotension 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 17759], It was a pleasure caring for you during your hospitalization at [Hospital1 18]. You came to the hospital because your blood pressure was low and you were having fevers and chills. Your blood pressure was low due to removal of too much fluid while on peritoneal dialysis. Reassuringly we did not find any sources of infection in your blood, urine, peritoneal fluid, or in your lungs. Furthermore you have not had any more fevers while in the hospital. The following changes were made to your medications: Changed: 1. Increase warfarin to 1 mg Daily (this dose may be adjusted according to your INR) Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: The following appointments have been scheduled for you: Department: TRANSPLANT CENTER When: WEDNESDAY [2182-11-6] at 11:30 AM With: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: WEDNESDAY [2182-11-6] at 2:20 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: TRANSPLANT CENTER When: MONDAY [2182-12-23] at 1:20 PM With: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629*]	[ "V42.83", "288.51", "287.5", "424.0", "V45.11", "733.00", "285.21", "412", "244.9", "458.0", "337.1", "585.6", "996.81", "E878.0", "799.02", "787.91", "V49.75", "780.60", "250.61", "V45.81", "428.0", "403.91", "428.43" ]	icd9cm	[ [ [] ] ]	[ "54.98", "38.97" ]	icd9pcs	[ [ [] ] ]	16896, 16974	9094, 9365	429, 465	17042, 17042	5950, 9071	17973, 19067	4530, 4658		15151, 16873		16995, 17021		13427, 15128			17218, 17950									4673, 5292						5308, 5931										13265, 13401					366, 391		9381, 13244					493, 2962												17057, 17194					2984, 4174	4190, 4514
4,138	113,764	10835+10836	Discharge summary	report+report	Admission Date: [2159-1-15] Discharge Date: [2159-1-23] Date of Birth: [2093-8-8] Sex: M Service: CARDIAC SURGERY CHIEF COMPLAINT: Three-vessel disease. HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with a [5-12] month history of exertional dyspnea and shortness of breath. The patient had an ETT in [2158-7-31] which was positive and was treated medically at that time, but the exertional angina persisted, and the patient had a cardiac catheterization that showed three-vessel disease with a normal ejection fraction. PAST MEDICAL HISTORY: Status post right knee surgery. Hypercholesterolemia. Coronary artery disease. SOCIAL HISTORY: He is retired and lives alone. He denied tobacco. Occasional alcohol, approximately [5-7] drinks per week. FAMILY HISTORY: Uncle had a history of myocardial infarction in his 60s. Brother died in his 50s from diabetes. ALLERGIES: PERCOCET. MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Atenolol 25 mg p.o. q.d., Lorazepam 0.5 mg q.h.s. p.r.n., Nitroglycerin p.r.n. CATHETERIZATION RESULTS: Left anterior descending with subostial occlusion, left circumflex proximal 30%, 70% in obtuse marginal 2, and 70% in obtuse marginal 3. Right coronary artery with high-rising posterior descending artery 80% ostial, 70% proximal posterior lateral. ETT showed 70% maximal PHR. Electrocardiogram showed [Street Address(2) 4793] depression inferior in V4-6, resolved at rest. Anterior septal and apical ischemia. Ejection fraction of 60%. REVIEW OF SYSTEMS: The patient denied diabetes, cerebrovascular accident, transient ischemic attack, seizures, and hypertension. He denied asthma, chronic obstructive pulmonary disease, upper respiratory infection, cough, orthopnea. The patient did complain of dyspnea on exertion. He denied peptic ulcer disease, hematochezia, melena, blood in stool. He denied claudication, edema, peripheral vascular disease, vein stripping. He denied nausea, vomiting, diarrhea, or constipation. He denied voiding difficulties, benign prostatic hypertrophy, or hematuria. LABORATORY DATA: On [1-9] white count was 6.1, hematocrit 42.7, platelet count 170; sodium 140, potassium 5.1, chloride 103, bicarb 28, BUN 14, creatinine 0.7; INR 1.0, PT 12.5. Electrocardiogram showed sinus rhythm at 72, there were T-waves in III, Q-waves in AVF and III. Chest x-ray showed no pulmonary congestion, infiltrates, or nodules, no effusions. PHYSICAL EXAMINATION: Vital signs: Heart rate 78 in sinus rhythm, blood pressure 122/72, respirations 18, oxygen saturation 96% on room air. General: The patient was resting in bed in no apparent distress. He was alert and oriented times three. The patient followed commands. Neurological: Grossly intact. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Anicteric. Noninjected eyes. Moist mucous membranes. Normal mucosa. Nasopharynx: Supple. No lymphadenopathy. No bruits. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. No masses. Extremities: Warm and well perfused extremities. No clubbing, cyanosis, or edema. No varicosities. Pulses: Carotid 2+ bilaterally, dorsalis pedis and posterior tibial were 2+ bilaterally. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery Service and underwent coronary artery bypass grafting times four with LIMA to left anterior descending, saphenous vein graft to obtuse marginal 2 and obtuse marginal 3, and saphenous vein graft to posterior descending artery. The patient had a mean arterial pressure of 68, CVP of 8, and atrial paced at 88 on Propofol drip and Neo-Synephrine at 0.5 pressure support. The patient was transferred to the CSRU on postoperative day #1. The patient had a dose of Lasix for a low urine output, and the patient was extubated. The patient was continued on Neo-Synephrine drip at 0.5 for pressure support and was on prophylactic antibiotics. The patient's T-max was 101.8??????. He had good blood pressure and good pulse. He was in normal sinus rhythm. He was positive at 1.6 L. White count was 15.3, hematocrit was 31.5, creatinine 0.8. He otherwise was doing well. The patient was started on Lasix b.i.d., and the patient's medial chest tube was removed. On postoperative day #2, the patient was on the floor. The patient remained afebrile with a heart rate of 104 in sinus rhythm. Blood pressure was 140s/80s. The patient otherwise had good p.o. intake and making good urine. The patient's chest tube was removed, and JP was removed. He was placed on Lopressor 25 b.i.d. to control his blood pressure. On postoperative day #3, the patient was paranoid in the hospital and became confused. The patient locked himself in the bathroom and refused all services. Psychiatry was [Name (NI) 653], and the patient was given Haldol which relieved the symptoms. The patient remained afebrile with a pulse of 106, white count 23.3. The patient was pancultured, and ABG and chest x-ray was obtained, as well as contacting [Name (NI) ] for elevated blood sugar. Psychiatry stated that the patient had an acute episode of confusion and paranoia and was consistent with delirium, and they recommended to minimize narcotics, which were subsequently stopped, and to obtain a head CT, which was obtained. Head CT showed no acute infarction, hemorrhage, or masses. The Haldol was started on a standing dose at night and p.r.n. dose and to monitor the patient for alcohol withdraw symptoms. On postoperative day #4, the patient had a temperature of 101.4??????. He otherwise was doing well. White count came down to 15.5. The patient's paranoia had slightly improved, and the patient was more cooperative with the staff and was less confused. On postoperative day #5, the patient had continued to improve. The patient's T-max was 100.9??????. He was in sinus rhythm and tachycardiac up to 140-150s. Lopressor was increased to control blood pressure and the heart rate. The patient's white count went down to 10.8. Psychiatry recommended adding Trazodone p.r.n. and at night for sleep, and the patient was also placed on Metformin for blood glucose control and to stop the Insulin [First Name8 (NamePattern2) ] [Last Name (un) ]. On postoperative day #6, the patient had a temperature of 102.4??????. He otherwise was doing well. The patient complained of increased breathing. The patient's ABG was 7.48, 35, 70, 27, and 2, in room air. The patient was taking good p.o. and making good urine. The patient continued to have a white count of 10.6. No other cultures came back positive. The patient continued to improve. On postoperative day #7, the patient had a low-grade temperature of 100.4??????, but otherwise was taking good p.o., making good urine, and the patient's white count continued to stay low at 10.4 On postoperative day #7, Psychiatry recommended that the patient obtain an Occupational Therapy consult for safety at home. They also recommended to stop the Haldol. On postoperative day #8, the patient continued to improve. The patient had a white count of 11.9, which had been stable. Occupational Therapy cleared the patient to go home, and Psychiatry felt that the patient was safe to go home. CONDITION ON DISCHARGE: Good. DISPOSITION: Home with VNA. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Delirium. 3. Hypercholesterolemia. 4. Status post right knee surgery. 5. Status post coronary artery bypass grafting times four. FOLLOW-UP: Please follow-up with Dr. [Last Name (STitle) 70] in six weeks; please call for a follow-up appointment. Follow-up with Dr. .................. in [12-1] weeks. Follow-up with endocrinologist in [12-1] weeks. Follow-up with cardiolgoist in [12-1] weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 3118] MEDQUIST36 D: [2159-1-23] 11:48 T: [2159-1-23] 12:22 JOB#: [Job Number 35334] Admission Date: [2159-1-15] Discharge Date: [2159-1-23] Date of Birth: [2093-8-8] Sex: M Service: CARDIAC SURGERY CHIEF COMPLAINT: Three-vessel disease. HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with a [5-12] month history of exertional dyspnea and shortness of breath. The patient had an ETT in [2158-7-31] which was positive and was treated medically at that time, but the exertional angina persisted, and the patient had a cardiac catheterization that showed three-vessel disease with a normal ejection fraction. PAST MEDICAL HISTORY: Status post right knee surgery. Hypercholesterolemia. Coronary artery disease. SOCIAL HISTORY: He is retired and lives alone. He denied tobacco. Occasional alcohol, approximately [5-7] drinks per week. FAMILY HISTORY: Uncle had a history of myocardial infarction in his 60s. Brother died in his 50s from diabetes. ALLERGIES: PERCOCET. MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Atenolol 25 mg p.o. q.d., Lorazepam 0.5 mg q.h.s. p.r.n., Nitroglycerin p.r.n. CATHETERIZATION RESULTS: Left anterior descending with subostial occlusion, left circumflex proximal 30%, 70% in obtuse marginal 2, and 70% in obtuse marginal 3. Right coronary artery with high-rising posterior descending artery 80% ostial, 70% proximal posterior lateral. ETT showed 70% maximal PHR. Electrocardiogram showed [Street Address(2) 4793] depression inferior in V4-6, resolved at rest. Anterior septal and apical ischemia. Ejection fraction of 60%. REVIEW OF SYSTEMS: The patient denied diabetes, cerebrovascular accident, transient ischemic attack, seizures, and hypertension. He denied asthma, chronic obstructive pulmonary disease, upper respiratory infection, cough, orthopnea. The patient did complain of dyspnea on exertion. He denied peptic ulcer disease, hematochezia, melena, blood in stool. He denied claudication, edema, peripheral vascular disease, vein stripping. He denied nausea, vomiting, diarrhea, or constipation. He denied voiding difficulties, benign prostatic hypertrophy, or hematuria. LABORATORY DATA: On [1-9] white count was 6.1, hematocrit 42.7, platelet count 170; sodium 140, potassium 5.1, chloride 103, bicarb 28, BUN 14, creatinine 0.7; INR 1.0, PT 12.5. Electrocardiogram showed sinus rhythm at 72, there were T-waves in III, Q-waves in AVF and III. Chest x-ray showed no pulmonary congestion, infiltrates, or nodules, no effusions. PHYSICAL EXAMINATION: Vital signs: Heart rate 78 in sinus rhythm, blood pressure 122/72, respirations 18, oxygen saturation 96% on room air. General: The patient was resting in bed in no apparent distress. He was alert and oriented times three. The patient followed commands. Neurological: Grossly intact. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Anicteric. Noninjected eyes. Moist mucous membranes. Normal mucosa. Nasopharynx: Supple. No lymphadenopathy. No bruits. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. No masses. Extremities: Warm and well perfused extremities. No clubbing, cyanosis, or edema. No varicosities. Pulses: Carotid 2+ bilaterally, dorsalis pedis and posterior tibial were 2+ bilaterally. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery Service and underwent coronary artery bypass grafting times four with LIMA to left anterior descending, saphenous vein graft to obtuse marginal 2 and obtuse marginal 3, and saphenous vein graft to posterior descending artery. The patient had a mean arterial pressure of 68, CVP of 8, and atrial paced at 88 on Propofol drip and Neo-Synephrine at 0.5 pressure support. The patient was transferred to the CSRU on postoperative day #1. The patient had a dose of Lasix for a low urine output, and the patient was extubated. The patient was continued on Neo-Synephrine drip at 0.5 for pressure support and was on prophylactic antibiotics. The patient's T-max was 101.8??????. He had good blood pressure and good pulse. He was in normal sinus rhythm. He was positive at 1.6 L. White count was 15.3, hematocrit was 31.5, creatinine 0.8. He otherwise was doing well. The patient was started on Lasix b.i.d., and the patient's medial chest tube was removed. On postoperative day #2, the patient was on the floor. The patient remained afebrile with a heart rate of 104 in sinus rhythm. Blood pressure was 140s/80s. The patient otherwise had good p.o. intake and making good urine. The patient's chest tube was removed, and JP was removed. He was placed on Lopressor 25 b.i.d. to control his blood pressure. On postoperative day #3, the patient was paranoid in the hospital and became confused. The patient locked himself in the bathroom and refused all services. Psychiatry was [Name (NI) 653], and the patient was given Haldol which relieved the symptoms. The patient remained afebrile with a pulse of 106, white count 23.3. The patient was pancultured, and ABG and chest x-ray was obtained, as well as contacting [Name (NI) ] for elevated blood sugar. Psychiatry stated that the patient had an acute episode of confusion and paranoia and was consistent with delirium, and they recommended to minimize narcotics, which were subsequently stopped, and to obtain a head CT, which was obtained. Head CT showed no acute infarction, hemorrhage, or masses. The Haldol was started on a standing dose at night and p.r.n. dose and to monitor the patient for alcohol withdraw symptoms. On postoperative day #4, the patient had a temperature of 101.4??????. He otherwise was doing well. White count came down to 15.5. The patient's paranoia had slightly improved, and the patient was more cooperative with the staff and was less confused. On postoperative day #5, the patient had continued to improve. The patient's T-max was 100.9??????. He was in sinus rhythm and tachycardiac up to 140-150s. Lopressor was increased to control blood pressure and the heart rate. The patient's white count went down to 10.8. Psychiatry recommended adding Trazodone p.r.n. and at night for sleep, and the patient was also placed on Metformin for blood glucose control and to stop the Insulin [First Name8 (NamePattern2) ] [Last Name (un) ]. On postoperative day #6, the patient had a temperature of 102.4??????. He otherwise was doing well. The patient complained of increased breathing. The patient's ABG was 7.48, 35, 70, 27, and 2, in room air. The patient was taking good p.o. and making good urine. The patient continued to have a white count of 10.6. No other cultures came back positive. The patient continued to improve. On postoperative day #7, the patient had a low-grade temperature of 100.4??????, but otherwise was taking good p.o., making good urine, and the patient's white count continued to stay low at 10.4 On postoperative day #7, Psychiatry recommended that the patient obtain an Occupational Therapy consult for safety at home. They also recommended to stop the Haldol. On postoperative day #8, the patient continued to improve. The patient had a white count of 11.9, which had been stable. Occupational Therapy cleared the patient to go home, and Psychiatry felt that the patient was safe to go home. CONDITION ON DISCHARGE: Good. DISPOSITION: Home with VNA. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Delirium. 3. Hypercholesterolemia. 4. Status post right knee surgery. 5. Status post coronary artery bypass grafting times four. FOLLOW-UP: Please follow-up with Dr. [Last Name (STitle) 70] in six weeks; please call for a follow-up appointment. Follow-up with Dr. .................. in [12-1] weeks. Follow-up with endocrinologist in [12-1] weeks. Follow-up with cardiolgoist in [12-1] weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 3118] MEDQUIST36 D: [2159-1-23] 11:48 T: [2159-1-23] 12:22 JOB#: [Job Number 35335]	[ "414.01", "780.6", "293.9", "272.0", "413.9", "998.89" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "36.13" ]	icd9pcs	[ [ [] ] ]							9090, 9211				15770, 16525		9238, 9840	11689, 15687																							10796, 11671							9860, 10773		8428, 8451							8480, 8838																	8861, 8942	8959, 9073	15712, 15749
13,305	154,300	14238	Discharge summary	report	Admission Date: [2176-12-18] Discharge Date: [2176-12-25] Date of Birth: [2123-3-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1493] Chief Complaint: hypotension (referred from liver clinic) hyperglycemia Major Surgical or Invasive Procedure: Persantine MIBI [2176-12-10] L Subclavian Central Line Insertion [2176-12-19] History of Present Illness: HPI: 53-yo-man w/ end stage cirrhosis was referred from clinic for hypotension. He was feeling well until 3 days ago, when he began to feel lethargic. His fatigue continued until today, when he presented to Liver Clinic for evaluation and had SBP 67/30, prompting referral to the ED. He denies any recent fever, chills, chest pain, palps, dyspnea, abd pain, dysuria, polyuria, polydipsia, melena, and hematochezia. He does c/o non-productive cough since this AM. . In [Name (NI) ], pt appeared clinically dehydrated w/ temp 97.4, BP 83/45, HR 62, O2 sat 97% RA. CXR demonstrated RML/RLL infiltrates concerning for PNA. He was treated w/ levaquin 500mg IV, flagyl 500mg IV, hydrocortisone 100mg IV, and 5L IV NS. BP remained in the 80s/40s, w/ nadir 66/45 despite IV fluids. He was started on dopamine gtt through peripheral IV to maintain MAP>60, and MICU was called for eval. . On Transfer to the floor: While in the MICU, pt was on Dopamine gtt until [12-22] and hydrocortisone 100 mg IV q 8hr from [2181-12-18]. Echo revealed nl EF, r/o cardiac cause of hypotension. FeNa was 0.07%, thus it was felt pt likely had dehydration. The pt had glucose of 500s on admission (no prior h/o DM) and was started on insulin gtt, later titrated to glargine and SSI with [Last Name (un) ] input. The pts Na of 119 on admission corrected after fluids. . Today pt denies SOB, CP, n/v. States he has had 2 BM today. No BRBPR. No f/c/s. No cough. Denies dizziness upon standing. Past Medical History: post-traumatic vertigo depression End stage liver disease secondary to alcohol cirrhosis w/ ascites onset [4-/2166] elevated ferritin level umbilical hernia hepatic encephalopathy hepatic coma DT GI bleeding lung mass followed on lung CT chronic tob abusedisorder chronic pancreatitis Social History: lives alone, no drink since [4-13], smoke [2-11] ppd Family History: father died of cirrhosis Physical Exam: On admission to MICU: PE: T 97.4, HR 67, BP 95/47 in dopamine 5mcg/kg/m, RR 14, O2 sat 99% 3L/m Gen: jaundiced man lying flat in bed, speaking in full sentences in NAD HEENT: icteric, EOMI w/ lateral nystagmus B, PERRL, OP clear w/ dry MM, JVP 8cm CV: reg s1/s2, no s3/s4/m/r Pulm: crackles at bases B, no wheezes Abd: +BS, soft, NT, moderately distended, no fluid wave Ext: cool feet, 2+ DP B, 1+ pitting edema to ankles B Neuro: a/o x 3, CN 2-12 intact, no asterixis, strength 5/5 throghout UE/LE B, sensation to fine touch intact throughout except decreased over L ant tibia Pertinent Results: [2176-12-18] 05:52PM LACTATE-2.9* [2176-12-18] 05:46PM URINE HOURS-RANDOM CREAT-122 SODIUM-12 [2176-12-18] 05:46PM URINE OSMOLAL-449 [2176-12-18] 05:12PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.015 [2176-12-18] 05:12PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-LG UROBILNGN-8* PH-6.5 LEUK-NEG [2176-12-18] 05:12PM URINE RBC-[7-19]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2176-12-18] 03:54PM GLUCOSE-517* UREA N-39* CREAT-0.9 SODIUM-119* POTASSIUM-3.7 CHLORIDE-84* TOTAL CO2-22 ANION GAP-17 [2176-12-18] 03:54PM ALT(SGPT)-22 AST(SGOT)-30 LD(LDH)-222 ALK PHOS-156* TOT BILI-21.6* DIR BILI-14.0* INDIR BIL-7.6 [2176-12-18] 03:54PM CK-MB-2 cTropnT-<0.01 [2176-12-18] 03:54PM ALBUMIN-2.6* [2176-12-18] 03:54PM AMMONIA-13 [2176-12-18] 03:54PM OSMOLAL-290 [2176-12-18] 03:54PM WBC-13.7# RBC-3.68 HGB-13.3* HCT-37.8* MCV-103* MCH-36.2* MCHC-35.2* RDW-14.0 [2176-12-18] 03:54PM NEUTS-88* BANDS-0 LYMPHS-3* MONOS-7 EOS-0 BASOS-1 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-1* [2176-12-18] 03:54PM PLT SMR-VERY LOW PLT COUNT-28# LPLT-3+ [2176-12-18] 03:54PM PT-17.5 PTT-35.9* INR(PT)-2.1 . ECG: NSR at 66, LAD (no change from prior), nl intervals, no ST/T changes . CXR ([2176-12-18]): 1. New bilateral patchy opacities concerning for multifocal pneumonia/aspiration. 2. Findings concerning for fluid overload. . RUQ US ([2176-12-18]): 1) Patent left TIPS. 2) Occluded right TIPS (old). 3) No intrahepatic biliary ductal dilatation. 4) Stable/large amount of ascites. 5) Cirrhosis without mass lesions 6) No gallstones, no evidence of cholecystitis 7) Low portal flow velocities, likely [3-13] low systemic BP . Chest CT ([2176-10-31]): 1. Rounded atelectasis in the right lower lobe, which has increased slightly in the interval. 2. Stable appearance of pancreatic cystic lesion. 3. Cirrhosis and small amount of ascites in the left pericolic gutter. Findings consistent with known cirrhosis. . MIBI ([2176-12-10]): Normal myocardial perfusion with normal wall motion and ejection fraction at lower limit of normal at 44%. Of note, the visual inspection of the gated images demonstrate a normal ejection fraction. . Echo [2176-12-21]: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60-70%). The ascending aorta is mildly dilated. 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. . Blood cx [12-19] and [12-21] pend Urine cx [12-18] neg Brief Hospital Course: Brieflyl, this is a 53 yo M w/ h/o EtOH cirrhosis on the transplant list, chronic pancreatitis with DM, anemia, admitted w/ hypotension refractory to fluids, hyperglycemia, hyponatremia, and thrombocytopenia. . #Hypotension: Likely due to hypovolemia and infection. Initially it was felt that the most likely etiology of the pts hypotension was his cirrhosis, but possible other etiologies of acute change included distributive (septic), cardiogenic and hypovolemic. There was initial suggestion of infection with CXR findings and lactate of 2.9, but the pt was afebrile with only mild nonproductive cough and good UOP. The pt had no signs of SBP, and per hepatology services the pt did not meet criteria to require paracentesis. The pt was started on levofloxacin and flagyl on [12-18] in the case of pneumonia (given new CXR infiltrates). Again, in the workup of his hypotension, TTE on [12-21] revealed good EF. A component of hypovolemia/dehydration was also suspected, supported by clinical exam and FeNa of 0.07%. The pt received a dose of steroids in the ED. While in the MICU, pt was on Dopamine gtt until [12-22] and hydrocortisone 100 mg IV q 8hr from [2181-12-18]. The pts dopamine gtt was discontinued prior to transfer to the floor. The pts diuretics and nadolol were held throughout his stay. . # PNA: Given the pts new cough, elevated WBC, and CXR infiltrates, the pt was started on levofloxacin and flagyl IV on [12-18]. The pt was discharged with levofloxacin and flagyl po to complete a 14 day course in the case of a postobstructive etiology (given the pts RLL lung mass). . #RLL lung mass: Followed as outpt. Identified on CT initially in [12-12]. PET scan pending as outpt on [12-30]. . #. Cirrhosis/ascites: The pt has end-stage cirrhosis [3-13] EtOH, on transplant list but deferred pending w/u of lung mass. Hepatology services followed the pt throughout his stay. The pts bilirubin was elevated throughout this admission (21 on admission, baseline 3)w/ no evidence of obstruction; but RUQ US did not have good view of CBD. The pt is extremely jaundiced. Alk phos, ALT/AST were wnl. The pt has chronic ascites [3-13] cirrhosis. UNa was less than 10 with U osm 577 c/w low intravascular volume. The pt was continued on rifaxamin 400 mg tid and lactulose 30 cc TID. He did not show signs of encephalopathy during his stay on the floor. . #. Diabetes: No prior h/o DM but presenting glucose >500, suspect due to chronic pancreatitis. No gap metabolic acidosis or ketonuria. The pt was initiated on insulin gtt from [2183-12-20] while in the MICU. [Last Name (un) ] was consulted and the pt was subsequently started on lantus 20 U qhs, increased to 45 Uqhs prior to discharge. The pt was also placed on a tight humalog sliding scale. The pt was taught proper insulin administration by our nursing staff and was observed to self-administer insulin on the day of discharge. The pt is to have VNA after discharge to ensure compliance. He will f/u with the [Last Name (un) ] clinicl. . #. Thrombocytopenia: Platelets decreased from baseline plt 70-100 ([3-13] cirrhosis) with no evidence of bleeding. He received 1 unit FFP and 3 x platelets prior to central line placement in the MICU. The pts plts were in the 40s at the time of discharge. . #. Anemia: Iron studies c/w anemia of chronic disease. . #. Hyponatremia: The pt had hyponatremia on admission of Na 119 (baseline 31) likely due to cirrhosis with decreased EAV. His hyponatremia resolved with IVF. Medications on Admission: nadolol 20 mg QD furosemide 40 mg QD spironolactone 100 mg QD rifaximin 400 mg TID lactulose 3 times QD magnesium oxide 400 mg QD MVI 1 tablet QD Protonix 40 mg QD trazodone 50 mg QHS Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. 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 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:2700 ML(s) Refills:2 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:21 Tablet(s) Refills:0 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:7 Tablet(s) Refills:0 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lantus 100 unit/mL Solution Sig: Forty Five (45) units Subcutaneous at bedtime. Disp:1 month supply Refills:2 8. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous as directed by your insulin sliding scale. Disp:1 month supply Refills:2 9. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscell. as directed. Disp:150 lancets Refills:2 10. BD Insulin Syringe 1 mL 28 x [2-11] Syringe Sig: One (1) syringe Miscell. as directed. Disp:150 syringes Refills:2 11. One Touch Ultra Test Strip Sig: One (1) strip Miscell. as directed. Disp:150 test strips Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Post-obstructive pneumonia End stage cirrhosis New onset diabetes Anemia of chronic disease Thrombocytopenia Hypotension--related to infection Discharge Condition: stable, blood pressure stable, blood glucose under better control Discharge Instructions: 1) Please take all medications as prescribed. Please follow up with all of your doctor's appointments 2) Please follow a 2 gram sodium restricted diet (carefully monitor sodium intake) 3) Check your daily weights. If you gain 3 or more pounds, please call your doctor 4) Please call your doctor or return to the ER if you experience chest pain, shortness of breath, or any other concerning symptoms 5) Please check your fingersticks 4 times a day and keep a record of your blood sugar levels to bring to all of you doctor visits Followup Instructions: 1) Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2177-1-1] at 11:00 AM 2) Dr. [Last Name (STitle) ], [Hospital ] [Hospital 982] Clinic--[1-20] at 10 AM--[Telephone/Fax (1) 9472] (please call for location and directions) 3) Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 42325]: Monday [1-6] at 9:15 AM 4) Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] ,Date/Time:[2177-2-14] 10:10 5) Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 612] Date/Time:[2177-2-14] 10:30	[ "785.52", "287.4", "572.8", "995.92", "303.90", "577.1", "251.8", "239.1", "486", "789.5", "276.1", "038.9", "571.2", "285.29" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.05", "99.07", "00.17" ]	icd9pcs	[ [ [] ] ]	10884, 10942	5772, 9321	371, 459	11129, 11197	3033, 5749	11775, 12484	2386, 2412		9556, 10861		10963, 11108		9347, 9533			11221, 11752									2427, 3014																					277, 333							487, 1978																	2000, 2291	2307, 2370
28,789	162,553	48661	Discharge summary	report	Admission Date: [2124-12-25] Discharge Date: [2124-12-26] Date of Birth: [2056-10-26] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Maxitrol / Pilocarpine / Quinine / Lactose Attending:[First Name3 (LF) 2704] Chief Complaint: Elective carotid artery stent Major Surgical or Invasive Procedure: Placement of left internal carotid stent History of Present Illness: 68 year old woman has a history of hypertension, hyperlipidemia, Sjogren??????s syndrome and known carotid artery disease. On [2124-11-28] the patient [Date Range 1834] repeat carotid ultrasound which revealed progression of her disease. On the left, she was noted to have an 80-99% stenosis. The right had a 60-69% stenosis. She denies amaurosis fugax or any specific neurologic changes. She is now referred for carotid angiography and probable stenting. . Prior testing included: [2124-11-28] carotid series: 60-69% right ICA stenosis, 80-99% left ICA stenosis. [2124-11-28] LE arterial study: no evidence of lower extremity arterial occlusive disease noted at rest. [2124-12-8] Persantine ETT: no anginal symptoms or ischemic ST changes. Normal perfusion study. LVEF 69%. . Patient received a L common carotid artery stent in the cath lab. Upon arrival to the CCU, patient complains of HA which she feels is related to her BP, worse with lower BPs. She continues on neosynephrine to maintain SBPs >110. She otherwise denies any lightheadedness, dizziness, vision changes, numbness, tingling, weakness, chest pain, SOB, N/V, abdominal pain, or any other complaints currently. She does endorse claudication symptoms at baseline as well as chronic myalgias which have been stable. Past Medical History: Cardiac Risk Factors: Dyslipidemia, Hypertension . Cardiac History: No h/o CABG, PCI, or EPS . Other PMHx: # Sjogren??????s syndrome # Carotid artery disease # hypothyroidism # History of partial complex seizures # Hx of herniated discs, s/p back surgery # Prior right ankle fracture s/p surgery # [Doctor Last Name 7820] syndrome of the left eye # Bilateral lens implants # History of hematuria (unknown source) # Intermittent GERD # Urinary frequency # Interstitial pneumonitis Social History: Patient lives with her long time friend [Name (NI) ] [Name (NI) 102340] [Telephone/Fax (1) 102341]. Ms. [Known lastname 102342] is a retired nurse. Family History: Mother had congestive heart failure, aortic valve disease and diabetes. She passed away in her early 70??????s. Several family members on her maternal side had strokes. Father died at age [Age over 90 ] from old age. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.0, BP 109/44, HR 59, RR 18, O2 100% RA Gen: WDWN female in NAD. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with No JVD CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: +BS. soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. R groin site CDI w/o hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: ADMISSION LABS: [2124-12-25] 10:43AM BLOOD WBC-10.9 RBC-4.66 Hgb-14.9 Hct-42.9 MCV-92 MCH-31.8 MCHC-34.6 RDW-12.1 Plt Ct-395 [2124-12-25] 10:43AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0 [2124-12-25] 10:43AM BLOOD Plt Ct-395 [2124-12-25] 10:43AM BLOOD Glucose-90 UreaN-24* Creat-0.8 Na-141 K-4.6 Cl-105 HCO3-27 AnGap-14 [2124-12-26] 07:00AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0 EKG [2124-12-25] demonstrated NSR @ 80 w/ nl axis and intervals. [2124-12-25] Cardiac Catheterization (see report for further details) Successful PTCA and stenting of the left internal carotid artery with a Protege Rx 8-->6mm taper and was post dilated to 4.5mm. Final angiogrpahy revealed 10% residual stenosis, no angiographically apparent dissection and robust flow. The patient left the lab pain free, neurologically unchanged and in stable condition. Brief Hospital Course: Ms. [Known lastname 102342] [Last Name (Titles) 1834] placement of a left internal carotid artery stent on [2124-12-25]. She was hypotensive after the procedure, briefly requiring neosynephrine and IV fluid boluses. When she was discharged, her systolic BP was ~90 and she denied HA/lightneadedness/CP. She was told to hold her Procardia until advised to restart it by her cardiologist, Dr. [First Name (STitle) ]. She is scheduled to see him on [2124-12-29] for follow-up and BP check. She also had a headache following the procedure, which had resolved by the time of discharge. Neurologic exam was non-focal when she had the headache. She was discharged on clopidogrel 75 mg PO QD and aspirin 325 mg PO QD, as well as simvastatin 40 mg PO QHS. In addition, Ms. [Known lastname 102342] was counseled about smoking ceasation. She was continued on her home synthroid, ibuprofen, famotidine, plaquinel and eye drops. Medications on Admission: Aggrenox 25mg-200mg one capsule twice a day Procardia XL 60mg one tablet daily every morning Simvastatin 40mg one tablet daily Aspirin 81mg daily Pepcid AC as needed Beclomethasone Dipropionate 80mcg 1 puff as needed Brimonidine 0.1% one drop to OU twice a day Zyrtec 10mg one tablet by mouth as needed Plaquenil 200mg one tablet twice a day Ibuprofen 800mg one tablet three times a day Ketoconazole 2% as needed Zaditor 0.025% one drop to each eye four times a day Levothyroxine 50mcg one tablet daily Oxycodone 5mg 1-3 tablets four times a day as needed Travoprost 0.004% one drop OU once a day Triamcinolone Acetonide Flaxseed Oil [Last Name (un) 7139] 128 5% one drop OU twice a day Saline nasal spray as needed Genteal eye gel Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H (Every 12 Hours). 5. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO Qday prn (). 6. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Zaditor Ophthalmic 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sodium Chloride 5 % Drops Sig: One (1) Ophthalmic [Hospital1 ] (2 times a day). 10. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic DAILY (Daily). 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 12. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home Discharge Diagnosis: Primary 1. Left carotid stenosis s/p left common carotid stent Discharge Condition: SBPs in 90s, walking around floor withour symptoms Discharge Instructions: You were admitted to the hospital for a carotid artery stent. If you develop dizziness, visual changes, headache, problems with your speech, chest pain, shortness of breath, pain or bleeding from your procedure site, or any other concerning symptoms, call your doctor or come to the emergency room. Some changes were made to your medications. (1) You should no longer take Aggrenox. (2) You should not take Procardia until advised by your cardiologist to start taking this again. This is because your blood pressures were low in the hospital. (3) You were started on clopidogrel (Plavix). Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 4022] Call tomorrow to make an appointment for this week. You should plan to see Dr. [First Name (STitle) ] in the cath lab on Friday [2124-12-29] on [Hospital Ward Name ] 4. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 43], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 541] Date/Time:[2125-2-5] 12:30 Provider: [Last Name (NamePattern5) 7224], [MD Number(3) 1240]:[Telephone/Fax (1) 62] Date/Time:[2125-2-6] 11:00	[ "433.10", "515", "305.1", "458.9", "530.81", "710.2", "401.9", "244.9", "272.4" ]	icd9cm	[ [ [] ] ]	[ "00.45", "00.63", "00.61", "00.40", "88.41" ]	icd9pcs	[ [ [] ] ]	7066, 7072	4413, 5363	359, 401	7179, 7232	3534, 3534	7872, 8479	2441, 2663		6149, 7043		7093, 7158		5389, 6126			7256, 7849									2703, 3515																					290, 321							429, 1736							3550, 4390										1758, 2244	2260, 2425
30,348	170,535	33079	Discharge summary	report	Admission Date: [2185-12-28] Discharge Date: [2185-12-31] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Ciprofloxacin Attending:[First Name3 (LF) 492] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: [2185-12-28] - Flexible bronchoscopy with therapeutic aspiration. [2185-12-28] - Bronchoscopy with insertion of Y stent, trach change History of Present Illness: 89F with ESRD on hemodialysis, chronically on home ventilatory, and with history of tracheomalacia, admitted to OSh with vent dissynchrony, thick secretions, and increasing peak pressures. At OSH she was found to have Pseudomonas in sputum and started on Aztreonam. [Initials (NamePattern4) ] [Last Name (NamePattern4) 295] trach was inserted by Interventional Pulmonology at [Hospital1 18] to bypass the area of tracheomalacia and the patient was returned to OSH. She now returns from the OSH with hypoxia and hypotension requiring pressors. Past Medical History: Past Medical History: Respiratory failure requiring mechanical ventilator support Tracheal stenosis Chronic kidney disease on hemodialysis Diabetes mellitus (per OSH H+P, daughter denies) COPD (per OSH H+P, daughter denies) Hypertension, but now requires midodrine to maintain BPs s/p CVA (per OSH H+P, daughter denies) Aortic stenosis s/p aortic valve replacement in [2181] Hypothyroidism per OSH record however pt. recently on methimazole Paroxysmal atrial fibrillation CAD Dementia (given med list although daughter denies) Hyperlipidemia CHF Osteoarthritis . Past surgical history: CABG in [2181] w/ AVR; mosaic porcine valve AVR [2181] Hip surgery Hemodialysis catheter placement placed [10/2184] at [Hospital 1281] Hosp,[Location (un) ], MA Social History: No smoking, no alcohol, no drug use. Lives with daughter, bed bound. Family History: Non-contributory Physical Exam: On Admission: VS: Temp 96, BP 100/70, RR 18, HR 90, PO2 99% on 15L trach mask. Gen: NAD, responds to voice HEENT: Anicteric, PERRLA Neck: Supple, No LAD, + tracheostomy Chest: CTA B/L, good air intake B/L CV: S1S2 RRR, 2/6 SEM Abd: Soft, NT/ND, + PEG tube Ext: No C/C/E, + mild rash on back of arms/legs/back Pertinent Results: [2185-12-28] 02:15PM WBC-13.9# RBC-4.06 HGB-10.7* HCT-34.8* MCV-86 MCH-26.4* MCHC-30.8* RDW-19.3* [2185-12-28] 02:15PM GLUCOSE-138* UREA N-15 CREAT-1.8* SODIUM-142 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-33* ANION GAP-12 [2185-12-28] 06:34PM TYPE-ART PO2-62* PCO2-40 PH-7.42 TOTAL CO2-27 BASE XS-0 [2185-12-28] 08:29PM PT-14.7* PTT-27.0 INR(PT)-1.3* *** MICRO: [2185-12-28] Blood cultures: No growth to date [2185-12-28] BAL: Coag + Staph aureus, ID pending [2185-12-28] Urine culture: No growth to date [2185-12-28] Catheter tip culture: No growth to date. * [2185-12-28] XRAY CHEST: INDICATION: Reevaluate trach and question pneumothorax. COMPARISON: [2185-12-17]. There is no pneumothorax. The tracheostomy tube is 4.9 cm from the carina. There is a right IJ line that follows the course of the double-lumen right subclavian catheter projecting 1 cm below the carina. The left subclavian line appears to have coiled back within the subclavian vein. The lung parenchyma is difficult to evaluate due to bilateral overlying effusions which appear worse particularly on the left, with likely underlying atelectasis. IMPRESSION: Left subclavian line with tip coiled. Other lines and tubes in standard position. Worsening effusion particularly on the left, which is obscuring the lung fields. No pneumothorax. Findings discussed with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 780], M.D. at the time of dictation. * [2185-12-29] ECHOCARDIOGRAM: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. There is moderate bioprosthetic aortic valve stenosis (area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.; the mitral regurgitation may be severe; if clinically indicated, a transesophageal echocardiogram would more accurately quantitate the mitral regurgitation] The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Mrs. [Known lastname 4318] was admitted to the Trauma ICU on [2185-12-28]. She was restarted on levophed for hypotension for a brief period of time, and her antibiotics were changed to Vancomycin/Meropenem/Gentamicin for broader spectrum coverage. Her central line was remove and cultured, and a new left subclavian line was placed. That evening she underwent flexible bronchoscopy by Dr. [Last Name (STitle) ], which revealed severe tracheomalacia obstructing her tracheostomy tube, so she was taken to the OR for insertion of a Y stent across the area of tracheomalacia, and her tracheostomy was replaced as well. She subsequently returned to the ICU in stable condition, was weaned off pressors, and restarted on her tube feeds. She passed a bedside swallow evaluation on [2185-12-29] and was started on a clear liquid diet. On [2185-12-30] her PEG tube was replaced as the old one was leaking, and she was hemodialyzed. Since she was afebrile and her culture data was negative, all antibiotics were stopped. As she was saturating well on 15L trach mask, was hemodynamically stable, and was tolerating tube feeds and PO diet, the decision was made to discharge the patient to a rehab facility. Medications on Admission: 1. Lipitor 10 mg PEG daily 2. Aztreonam 750 IV Q12H 3. Calcium carbonate 1000 mg TID 4. Combivent 6 puffs Q6h via vent 5. Donepezil 5 mg PEG daily 6. Calmoseptine TP [Hospital1 ] 7. Folate 1 mg PEG daily 8. Lansoprazole 30 mg PEG daily 9. Memantine 5 mg PEG [Hospital1 ] 10. Midodrine 10 mg PEG TID 11. Nephrocaps 1 cap PEG daily 12. Nystatin TP TID 13. Propafenone 150 mg PEG [Hospital1 ] 14. Tylenol 650 PEG Q6h PRN headache/fever 15. Ativan 0.5-1mg PEG q4h PRN anxiety Discharge Medications: 1. Donepezil 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 2. Midodrine 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO TID (3 times a day). 3. Nystatin 100,000 unit/g Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 4. Atorvastatin 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule [Last Name (STitle) ]: One (1) Cap PO DAILY (Daily). 7. Propafenone 150 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q12H (every 12 hours). 8. Chlorhexidine Gluconate 0.12 % Mouthwash [Last Name (STitle) ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Memantine 5 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 11. Zolpidem 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 12. Calcium Carbonate 500 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO Q 8H (Every 8 Hours). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Tracheomalacia 2. ESRD on hemodialysis 3. Aortic stenosis s/p porcine valve replacement 4. CAD s/p CABG 5. Paroxysmal atrial fibrillation 6. Hyperlipidemia Discharge Condition: Stable. Discharge Instructions: You were admitted to the [Hospital1 18] on [2185-12-28] for respiratory failure and tracheomalacia. Dr. [Last Name (STitle) *] performed a bronchoscopy and inserted a stent into your trachea to help keep it open, and you subsequently did much better. Please call or return to the Emergency Department if you have any of the following: Persistent temperature > 101 degrees or chills * Difficulty breathing or managing your ventilator * Production of colorful or excessive sputum * Any other symptoms which concern you. Medications: Resume taking your medications as directed. Diet: Continue your tube feeds via the PEG tube Followup Instructions: Please followup with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 3020]) as needed. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494] Completed by:[2185-12-30]	[ "V42.2", "427.31", "428.0", "403.91", "244.9", "518.83", "V55.1", "V46.11", "V45.81", "250.00", "496", "519.09", "272.4", "585.6" ]	icd9cm	[ [ [] ] ]	[ "97.23", "39.95", "33.24", "96.05", "38.93", "96.6" ]	icd9pcs	[ [ [] ] ]	8018, 8097	5006, 6231	265, 409	8300, 8310	2257, 4983	8999, 9236	1894, 1912		6765, 7995		8118, 8279		6257, 6742			8334, 8976								1607, 1790	1927, 1927																					206, 227							437, 995										1941, 2238							1039, 1584	1806, 1878
70,005	198,575	40565	Discharge summary	report	Admission Date: [2176-7-20] Discharge Date: [2176-7-22] Date of Birth: [2154-3-12] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 21193] Chief Complaint: bilateral leg weakness and dysesthesia (ED transfer: "r/o spinal abscess") Major Surgical or Invasive Procedure: none History of Present Illness: [Known firstname ] [Known lastname 88805] is a 22y F with no significant PMH who p/w fever, diarrhea, and one day of progressive lower extremity paresthesias and weakness to the point that now she cannot stand. She was in her USOH until 3d PTA, when she developed persistent LLQ abdominal pain, which has continued through the day of admission. It gets worse in waves. There was no diarrhea initially, but today she has had diarrhea x9. No one else she knows has experienced these symptoms. Last night, she became febrile to 103F and she developed a mild HA and her legs began feeling "achy." She also developed mild low back pain over the last 2-3 days. This morning, she awoke with paresthesias, this morning her legs felt tingly like after they've been asleep in her words, and mild weakness, that progressed rapidly to the point that she could not walk. She went to an OSH ED where she was given Vancomycin and Ceftriaxone IV; an abdominal CT with PO+IV contrast was reportedly unremarkable. She was transferred to [Hospital1 18] ED for "r/o spinal abscess." She arrived in our ED with temp 98.4F HR 138 and BP 118/57. RR 16 and SaO2 99%. The ED thought her exam was notable for profound symmetric LE weakness with absent patellar tendon reflexes and symmetric LE sensory loss. She was also c/o her "eyelids are tired" and mild intermittend SOB. Sick contacts include only her two children, 2.5y daughter and 11mos son, both of whom had a febrile illness (+lethargy, but no diarrhea or other symptoms), self-limited, lasting a few days and resolving in the last 1-3d. No toxic exposures, specifically no known tickbites or exposure to wooded/tick-infested areas. No FH of vasculitis. On ROS, the pt loss of vision, blurred vision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies bowel or bladder incontinence or retention, although a Foley was placed at the OSH ED due to inability to get up and use commode independently. No recent weight loss or gain. Denies cough. only mild shortness of breath. Mild pharyngitis. Denies chest pain or tightness. +feels heart racing (HR 120-130s). Denies nausea, vomiting. +diarrhea, abd pain. No recent constipation. No recent change in bladder habits or UTIs. No dysuria. Denies rash. Legs are painful. Past Medical History: 1. G2P2, both spontaneous vaginal deliveries with epidurals and uncomplicated/uneventful, healthy kids. Social History: Lives at home in Glouchester with 2kids and sister and mother and father. [Name (NI) 1403] at a Candy store in [Location (un) 28318] and Raises her kids. Lives in a non-wooded area. Two dogs that do not visit wooded/tick-containing areas to her knowledge (only their backyard/deck and indoors. Denies EtOH except rarely. Denies tobacco or illicit drug use. No recent immunizations, no recent flu vaccine. Family History: No Hx of autoimmune/[Last Name (un) 18183]/vasculitic disease. No FH of Neurologic disease. +Cancer Hx (colon-mom's aunt; breast; prostate-[Doctor Last Name 22583]) + paternal GPA died 56 of "heart problems", and paternal uncle of the same at 36y/o. Physical Exam: < ON ADMISSION: > General: Lying in bed in moderate distress, tachypneic, tachycardic. +Rigors. 4th, then 5th L of NS running, with steady clear UOP (900cc at that time) HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous membranes are moist. No lesions noted in oropharynx, but poorly visualized. Neck: Supple, with full range of motion and no nuchal rigidity. No lymphadenopathy was appreciated. Pulmonary: Lungs CTA bilaterally. Voice is soft and patient's respirations seem mildly labored (but No retractions). Cardiac: Tachy, loud S1/S2, no M/R/G. Abdomen: Moderately overweight. Soft, non-distended, hypoactive BS. Tender to palpation over LLQ, but not jumping off the bed with decent pressure. Extremities: Cool (vs. trunk) and somewhat dusky. No clubbing, cyanosis, or edema. 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted except + stretch marks at lower abdomen from pregnancies, and small scabs/dots at lower shins (?shaving injuries). *************** Neurologic examination: Mental Status exam: Grossly normal MS -- AOx3. Able to relate history without difficulty. Attentive, and able to name [Doctor Last Name 1841] backward without difficulty. Speech was soft, but not dysarthric. Language is fluent with intact repetition and comprehension, normal prosody, and normal affect. There were no paraphasic errors. There was no evidence of apraxia or neglect -Cranial Nerves: I: Olfaction not tested. II: PERRL, 4 to 2mm and brisk. No RAPD Visual fields are full on gross bedside exam. No papilledema, exudates, or hemorrhages on fundoscopic examination. III, IV, VI: EOMs full and conjugate. No nystagmus. V: Facial sensation intact and subjectively symmetric to light touch V1-V2-V3. VII: Symmetric, but weak facial movements. No ptosis, no flattening of either nasolabial fold. Brow elevation is symmetric. Eye closure is symmetrically weak. Symmetric facial elevation with smile. Weak buccinators (cheek puffing). Can purse/whistle, but weak. VIII: Hearing intact and subjectively equal to finger-rub bilaterally. IX, X: Palate elevates symmetrically with phonation. [Doctor First Name 81]: 4+/5 equal strength in trapezii bilaterally. XII: Tongue protrusion is midline. -Motor: Bilateral step-wise pronator with rigors. Rigors in arms/chest/jaw. Normal to slightly decreased tone bilaterally in UEs, LEs. Delt Bic Tri WE FF FE IO \| IP Q Ham TA [Last Name (un) 938] Gastroc L 4- 4+ 4- 5 4+ 4 4 2 4- 3 3 3 4 R 4- 4+ 4- 5 4+ 4 4 2 4- 3 3 4 4 -Sensory: - Patient reports complete anesthesia to pinprick, temperature sensation, light touch, and vibration in both lower extremities up to a somewhat inconsistent sensory level at the groin/inguinal ligament. Normal/intact sensation above this level in the trunk and arms/hands/face. - The aforementioned area of sensory anesthesia, however, spares the inner [2-12] of both calves (symmetrically), wrapping around to the medial portion of the popliteal fossa, where she says she can perceive pinprick, light touch, and cold metal. Also, she can perceive vibration 128Hz at the medial malleoli of each ankle, but not at the MTPs and not at either knee. -Reflex examination (left; right): Biceps (+++;+++) (+distal spread from pec/delt bilaterally) Triceps (++;++) Brachioradialis (++;++) Quadriceps / patellar (++;++) Gastroc-soleus / achilles (+;+) Plantar response was indeterminate bilaterally. -Coordination: Finger-nose-finger testing was slow, but no dysmetria or tremor. Slowed finger tapping bilaterally, and very slow/weak toe-tapping. Mirroring finger/hand behavior was normal, with no overshoot. -Gait: Not tested; patient required assistance just pulling to a seated position, and cannot stand to walk. Pertinent Results: [2176-7-19*] 02:30AM BLOOD WBC-7.3 RBC-3.95 Hgb-12.1 Hct-36.0 MCV-91 MCH-30.6 MCHC-33.6 RDW-12.6 Plt Ct-164 [2176-7-19] 02:30AM BLOOD Neuts-85.0* Lymphs-11.0* Monos-3.7 Eos-0.2 Baso-0.1 [2176-7-19] 02:30AM BLOOD PT-15.3* PTT-26.7 INR(PT)-1.3* [2176-7-19] 02:30AM BLOOD Glucose-122* UreaN-10 Creat-0.6 Na-138 K-3.3 Cl-106 HCO3-21* AnGap-14 [2176-7-19] 02:30AM BLOOD ALT-9 AST-14 AlkPhos-68 TotBili-0.3 [2176-7-19] 02:30AM BLOOD Albumin-4.0 Calcium-7.3* Phos-2.7 Mg-1.8 [2176-7-19] 02:30AM BLOOD CRP-44.0* [2176-7-19] 02:30AM BLOOD CRP-44.0* [2176-7-19] 11:14PM BLOOD Lactate-1.0 [2176-7-20] 03:48AM BLOOD GQ1B IGG ANTIBODIES-PND [2176-7-20] 03:48AM BLOOD CAMPYLOBACTER JEJUNI ANTIBODY, [Doctor First Name ]-PND [2176-7-20] 01:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-18 GLUCOSE-66 [2176-7-20] 01:30AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-0 LYMPHS-43 MONOS-57 [2176-7-20] 12:10AM URINE UCG-NEGATIVE [2176-7-20] 12:10AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.030 [2176-7-20] 12:10AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2176-7-20] 12:10AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 TRANS EPI-<1 [2176-7-20] 12:10AM URINE MUCOUS-RARE [2176-7-19] 11:14PM LACTATE-1.0 [2176-7-19] 02:30AM SED RATE-16 [2176-7-19] 02:30AM LIPASE-23 MRI of the C/T/L spine (with and without IV gadolinium contrast dye) -FINDINGS: The alignment, configuration and signal intensity throughout the cervical, thoracic and lumbar vertebral bodies appears normal. The signal intensity throughout the cervical and thoracic spinal cord appears unremarkable with no evidence of focal or diffuse lesions. The conus medullaris is normal and terminates at the level of T12. There is no evidence of spinal canal stenosis or neural foraminal narrowing. With gadolinium contrast, there is no evidence of abnormal enhancement to indicate leptomeningeal disease. The visualized paravertebral structures are grossly unremarkable. - IMPRESSION: Essentially normal MRI of the cervical, thoracic and lumbar spine with no evidence of spinal canal stenosis, neural foraminal narrowing or nerve root impingement, there is no evidence of abnormal enhancement to indicate leptomeningeal disease. The signal intensity throughout the spinal cord is normal. Brief Hospital Course: [Known firstname ] [Known lastname 88805] is a 22y F, G2P2 with no significant PMH and taking no home medications who was admitted in the midst of a febrile illness with LLQ discomfort and diarrhea. During the same day she developed fever and diarrhea she also complained of aching/tingling in both legs, followed by numbness and weakness. She was admitted to the Neurology service with complaints of leg weakness and sensory changes, out of concern for possible GBS or paraspinal abscess. Her exam on admission was in part poorly localizing, and there was primarily give-way weakness in the morning following admission, when her rigors and fever had subsided and her HR and BP had normalized after 5L of IVF between the OSH and our ED. She had no intensive care needs, and was breathing comfortably shortly after admission, so was transferred from the ICU to the floor. She remained afebrile and HDS and in NAD throughout her stay here at [Hospital1 18]. An MRI of the full spine was normal, with no e/o paraspinal abscess. LP in the ED resulted in normal CSF routine studies (see above). Her vital signs and laboratory studies were largely normal with the exception of a low Ca++ of 7.3 (normal albumin 4.0), which normalized by the day of discharge (iCa on [7-22] was 1.18). Lyme serology was negative. Rapid strep throat test was negative. UA was normal. Urine, blood, and CSF cultures were NG at the time of discharge. Her calcium level was slightly low on arrival to the ED, but by the time you left the hospital, it returned to a normal level (ionized calcium 1.18) after fluids and food and rest. Her General examination was normal on the day of discharge (her abdominal tenderness and tachycardia resolved) and she only had one more episode of diarrhea the day before (evening of [7-21]). Her Neurological examination remained difficult to interpret, with a non-localizing pattern of complete sensory anesthesia in the lower extremities (see below) and a hesitant gait (Romberg negative) and give-way weakness in the hamstrings and TAs. Physical Therapy evaluated her and decided that she was safe to return home (with support from family), but that she should use a walker on discharge until her gait normalizes. She also c/o intermittent lightheadedness and headache, for which we encouraged fluid intake and acetaminophen PRN. Follow-up was arranged in [Hospital 878] clinic [8-1] ([Month/Year (2) 54849]/[Doctor Last Name 1206]). Tests pending at discharge: 1. Gq1b, clostridium jejuni serum antibodies. 2. West Nile virus CSF antibody. 3. Final reports on blood and CSF cultures. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: 1. viral gastroenteritis/diarrheal illness 2. non-localizing sensory changes with mild weakness of uncertain etiology Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Stands with good balance; takes hesitant steps. Neurologic examination still with subjective loss of all sensation in bilateral LEs except for patchy/inconsistent region of inner thighs, medial calves. Still some give-way weakness in TAs, EHLs, FEs and intrinsic finger muscles. Discharge Instructions: You were admitted to [Hospital1 18] out of concern for leg weakness and sensory changes. You had a diarrheal illness with fever, which was probably a viral (vs. possibly bacterial) gastrointestinal infection. During the same 24-36 hour period that you developed fever and then diarrhea, you also developed aching/tingling, and then numbness, in your legs, and you began feeling weak in your legs. We admitted you to the hospital on our Neurology service in order to test you for serious or life-threatening conditions. One such condition (an infection that presses on your spinal cord or spinal nerve roots) was ruled out by MR imaging of your spinal cord, which was normal. Another condition ([Last Name (un) 4584]-[Location (un) ] syndrome) is unlikely due to the rapid progression and then regression of your symptoms as well as the preservation of your knee and ankle reflexes and the prominent sensory changes (not just weakness) already present when you arrived. To err on the safe side, we also obtained cerebrospinal fluid (CSF, by spinal tap) in addition to routine bloodwork, laboratory studies, and cultures. Your initial tests are largely normal. The CSF and labs and cultures are normal. A test for strep throat was negative. A blood test for exposure to Lyme disease (from tickbites) was negative. Your calcium level was slightly low on arrival to the ED, but by the time you left the hospital, it returned to a normal level (ionized calcium 1.18) after fluids and food and rest. Our physical therapists evaluated you and they agree it is safe for you to return home if you use a walker initially for your unsteady gait. You still had intermittent lightheadedness and headache, so please drink plenty of fluids (at least six glasses of fluid, along with salty foods) to replace the volume you lost during your diarrheal illness. If your headaches persist, please use over-the-counter acetaminophen (Tylenol) for pain relief as needed, at a dose of 500-650mg with doses spaced apart by 6 hours or more (use as directed). It was a pleasure taking care of you here at [Hospital1 18]. Best of luck in the future, Ms. [Known lastname 88805]! Followup Instructions: Plan to follow up with Dr. [Last Name (STitle) 54849] and Dr. [Last Name (STitle) 1206] [8-1] in [Hospital 878] clinic ([Hospital1 18] [Hospital Ward Name ], [Hospital Ward Name 23] Clinical Center). Please call [Telephone/Fax (1) 2756] and ask for [Hospital 878] clinic to confirm appointment scheduling for this day. [Name6 (MD) 3523] [Name8 (MD) 3524] MD [MD Number(2) 21196] Completed by:[2176-7-22]	[ "356.9", "008.8", "781.2", "729.89", "782.0" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]	12590, 12596	9872, 12368	381, 388	12758, 12758	7423, 9849	15374, 15861	3341, 3600		12561, 12567		12617, 12737		12532, 12538			13176, 15351						5041, 7404			3615, 3617														12382, 12506							267, 343							416, 2768										3631, 4613		12773, 13152				4638, 5024	2790, 2895	2911, 3325
2,639	193,734	26790	Discharge summary	report	Admission Date: [2113-10-14] Discharge Date: [2113-10-20] Date of Birth: [2048-10-3] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 9157] Chief Complaint: hypoxia, syncope Major Surgical or Invasive Procedure: Chest tube placement and removal History of Present Illness: Ms. [Known lastname 53899] is a 65 year old female, with history of CAD s/p NSTEMI [2108], STEMI [9-16] with proximal LAD occlusion treated with BMS, systolic heart failure with EF 25%, LV hypertrophy and hypertension, current LLE DVT and multiple pulmonary emboli. The patient had a recent admission for multiple syncopal episodes when she was found to be in cardiogenic/septic shock with Strep pneumo pneumonia with admission complicated by PE, DVT and right-sided penumothorax, and was discharged to [Hospital 100] Rehab MACU yesterday evening with plan to return [2113-10-17] for ICD placement. Today, patient became unresponsive and unable to follow commands. Per report from EMS, she was hypoxic to the 60%s. ED course: 97.6 92 105/73 20 99%RA. EKG showed NSR at 90 bpm with Q waves in V1-V3, slight ST elevations in V3-V4 and prolonged QT, which were all unchanged from before. Labs notable for BNP 2398, K 3.1 and WBC 12.2 with 82% PMNs. Troponin was 0.01 and lactate 1.7. Blood cultures were drawn. Given cefepime and vancomycin. EKG in the ED showed NSR at 90 bpm with Q waves in V1-V3. CT head did not demonstrate any evidence of intracranial lesions/hemorrhage/masses, but there is sinus opacification. - Chest x-ray shows mild-mod pneumothorax at the right base, ?small PTX at apex too. Patient had a chest tube in which was discontinued yesterday without any post x-ray. RIJ terminating in mid-SVC - CT w/ & w/o contrast: 1. Moderate right basal pneumothorax, increased since the prior study; 2. No interval increase in Bilateral pulmonary embolism in the LLL, RUL. No right heart strain; 3. Bibasal consolidations, atelectasis/infection. - Central line [10-11] still in place - Bedside cardiac ultrasound shows poor ejection fraction, no pericardial effusion no obvious right-sided heart strain - CTA: 1. Moderate right basal pneumothorax, increased since the prior study. 2. No interval increase in Bilateral pulmonary embolism in the LLL, RUL. No right heart strain. 3. Bibasal consolidations, atelectasis/infection. On admission to the CCU, she is afebrile, 93% on 2L NC, with no specific complaints. She remembers being SOB earlier today, and says this has now resolved. She does not remember further details and does not remember syncopizing. She denies any current SOB, cough, chest pain, palpitations, LH, dizziness. She has not had a BM in 2 days. No dysuria, urgency, or frequency. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: CAD with NSTEMI [2108], STEMI [9-/2112] -PCI: BMS to LAD -Ischemic cardiomyopathy with LVEF of 20-25% on OSH TTE [4-/2113] 3. OTHER PAST MEDICAL HISTORY: COPD GERD Migraine headaches Osteroarthritis Chronic lower back pain Depression Social History: Patient is married, lives with husband. Family stress due to death of her son from heroin overdose. Also has daughter w/ current substance abuse problems. [Name (NI) ] a 60 pack year history and currently smokes about one pack per day, but has plans to quit. Family History: Mother had CHF, died from [Name (NI) 11964] at age 80. Father died from lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T= 96.9; BP 139/91; HR 108; RR 25; O2 sat 93% 2L nc GENERAL: Cachectic caucasian female in NAD. Oriented x1. Mood, affect appropriate, although she seems distant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Has dentures. NECK: Supple; unable to assess JVP as IJ line in place on right side. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. [2-12] holosystolic murmur best heard at LSB. There is a mild lift to her left chest. No thrills. No S3 or S4. LUNGS: Has kyphosis. Resp were unlabored, no accessory muscle use, although mildly tachypnic. Lung sounds are decreased in the right base. There are crackles in both bases, L>R. No wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Her skin does appear to hang off her body, consistent with her overall cachectic appearance NEURO: A+Ox1, CN2-12 intact, 5/5 strength in all extremities PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ DISCHARGE PHYSICAL EXAM VS: 96.8 102/54 94 20 95% on 2L GEN: cachectic, chronically ill appearing, comfortable, appropriate CV: RRR no m/r/g LUNGS: CTA b/l, decreased respiratory effort ABD: soft, NT ND. small amount of bleeding from chest tube site EXT: no edema SKIN: warm and dry Pertinent Results: ADMISSION LABS [2113-10-13] 05:43AM BLOOD WBC-11.5* RBC-4.05* Hgb-13.4 Hct-40.5 MCV-100* MCH-33.2* MCHC-33.2 RDW-15.1 Plt Ct-481* [2113-10-14] 03:05PM BLOOD WBC-12.2* RBC-4.33 Hgb-13.7 Hct-41.9 MCV-97 MCH-31.7 MCHC-32.7 RDW-15.2 Plt Ct-536* [2113-10-14] 03:05PM BLOOD Neuts-82.0* Lymphs-12.4* Monos-4.2 Eos-1.1 Baso-0.3 [2113-10-13] 05:43AM BLOOD PT-13.1 PTT-91.4* INR(PT)-1.1 [2113-10-13] 05:43AM BLOOD Glucose-131* UreaN-10 Creat-0.4 Na-138 K-3.8 Cl-98 HCO3-30 AnGap-14 [2113-10-13] 05:43AM BLOOD ALT-354* AST-232* AlkPhos-154* TotBili-0.7 [2113-10-14] 03:05PM BLOOD proBNP-2398* [2113-10-14] 03:05PM BLOOD cTropnT-0.01 [2113-10-15] 08:00AM BLOOD CK-MB-5 cTropnT-<0.01 [2113-10-13] 05:43AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.9 Mg-2.4 [2113-10-14] 03:19PM BLOOD Lactate-1.7 DISCHARGE LABS [2113-10-20] 05:18AM BLOOD WBC-8.9 RBC-3.41* Hgb-11.0* Hct-34.8* MCV-102* MCH-32.1* MCHC-31.4 RDW-14.9 Plt Ct-359 [2113-10-20] 05:18AM BLOOD Glucose-94 UreaN-6 Creat-0.4 Na-137 K-3.8 Cl-105 HCO3-24 AnGap-12 [2113-10-18] 06:19AM BLOOD ALT-94* AST-34 AlkPhos-154* TotBili-0.4 IMAGING [2113-10-17] TTE: Overall left ventricular systolic function is severely depressed (LVEF= 20%). Right ventricular chamber size is normal. Trivial mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. The pulmonary artery systolic pressure could not be determined. Microbubles are seen in the left atrium. This could represent a right to left shunt through the inter atrial septum. A complete transthoracic echo looking for right-to-left shunt is recommended. IMPRESSION: Severe global left ventricular systolic dysfunction. Tricuspid regurgitation. [2113-10-14] CTA CHEST W&W/O C&RECONS, NON-CORONARY: 1. No significant interval change in the bilateral pulmonary emboli involving the lobar and segmental branches of the right upper lobe and left lower lobe. No evidence of right heart strain. 2. Possible developing infarction in the left lower lobe (superior segment). Bibasilar consolidations, due to aspiration are similar. 3. Interval increase in the moderate right pneumothorax. [2113-10-14] CT HEAD W/O CONTRAST: re is no evidence of acute intracranial hemorrhage, edema, masses or mass effect. [Doctor Last Name ]-white matter differentiation is preserved. The ventricles and sulci are mildly dilated, consistent with involutional changes. The basal cisterns are normal. Calcifications are seen in bilateral vertebral arteries and cavernous internal carotid arteries. There is near-complete opacification of the left maxillary sinus, and partial opacification of bilateral ethmoid and sphenoid sinuses. The mastoid air cells are clear. IMPRESSION: No acute intracranial abnormality. Extensive pansinus disease. CXR: [2113-10-20] As compared to the previous radiograph, the right-sided chest tube has been removed. There is no evidence of pneumothorax or other complication. A minimal right pleural effusion with a small right basal atelectasis persists. Unchanged mild to moderate left pleural effusion with subsequent atelectasis and minimal enlargement of the left pulmonary artery. Unchanged size of the cardiac silhouette. Unchanged evidence of the left lung parenchyma. The right PICC line is also unchanged. Brief Hospital Course: Ms [Known lastname 53899] is a 65yoF with h/o CAD s/p NSTEMI [2108], STEMI [2113-9-16] with proximal LAD occlusion treated with BMS, systolic CHF w/ EF 20%, and LLE DVT and multiple pulmonary embolisms. She had a recent admission for multiple syncopal episodes, complicated by cardiogenic/septic shock with Strep pneumo pneumonia, PE, DVT, and right-sided penumothorax. She returned from rehab with recurrent pneumothorax. # RECURRANT PNEUMOTHORAX - An IJ placed for her original MICU stay was the cause of her initial pneumothorax. A chest tube was placed and her lung reexpanded. She was discharged to rehab for a short stay but returned with hypoxia and was found to have a recurrent pneumo. A chest tube was placed and her lung reinflated on suction. Her chest tube was then placed to water seal, and then clamped. Followup CXRs showed lung reexpansion and the tube was removed on [10-19]. CXR on [10-20] prior to d/c showed an expanded right lung. She continued to have slight bleeding from the chest tube site due to her anti-coagulation. # AIR EMBOLISM - On [2113-10-17], her right IJ was removed. She was in trendelenburg and humming at the time. About 1 minute after tube removal, she became acutely hypoxic and tachypneic, with O2 saturation down to 45%. She was placed on a non-rebreather and code blue was called. Her O2 sat increased to 88% on NRB and she was transferred to the MICU. She was stable in the MICU, breathing at 94% on NRB. Her O2 sat continued to improved and she was transferred back to the floor. Presumptive diagnosis of air embolism. # PULMONARY EMBOLISMS - Diagnosed on prior admission. Switched to heparin drip acutely for management of pneumothorax chest tube while admitted. Transitioned to lovenox on [10-19]. Warfarin started at 4mg on [10-19]. INR 1.0 on discharge. # DELIRIUM - She was intermittently delirious throughout her hospital stay, often A+Ox1. Many of her medications had been stopped or tapered, including fluconazole (no evidence for fungal UTI), fluoxetine, wellbutrin and fexofenadine. Her gabapentin was also decreased to 200 mg [Hospital1 ]. Psychiatry was called for concerns of delirium vs. psych disorder. If symptoms of depression return, can consider restarting anti-depressants. She was [Last Name (un) 65964] and oriented to person, place and time on day of discharge. # CARDIOGENIC SHOCK - From her previous admission, likely in the setting of PEs and poor LVEF. Recommendation from cardiology was placement of an ICD for secondary prevention of sudden cardiac death, but due to her acute illness, this was deferred. EP saw the patient prior to discharge and will followup for ICD placement soon. She should remain on tele monitoring until ICD is placed. # COPD - Chronic from many years of smoking, with no indication of worsening status at this time. Continues on oxygen which may be her home requirement. Ipratropium used in house. Discharged on tiotroprium, advair and albuterol PRN. # CAD: NSTEMI [2108], STEMI [9-/2112] with BMS to LAD, stents patent on cath from [2113-10-1]. Continued aspirin. No need for plavix anymore. Statin was held due to elevated LFTs. This can be restarted as an outpatient if LFTs continue to trend down. # sCHF: LVEF = 25% on TTE from [2113-10-6]. No evidence for acute exacerbation at this time. Repeat TTE around [2113-10-26] # DEPRESSION - Stopped fluoxetine and wellbutrin to minimize polypharmacy and reduce delirium. Can restart as outpatient if necessary. # CHRONIC BACK PAIN: Decreased gabapentin to 200mg [Hospital1 ]. Also on topamax. Occasional oxycodone as needed. # GERD: Stopped pantoprazole. Restarted ranitidine as she was previously on it. TRANSITIONAL --- Pulmonary Embolisms - trend INR and discontinue lovenox when therapeutic --- ICD Placement - EP will contact [Hospital 100] rehab to arrange transfer on Wednesday [10-25] for ICD. Patient should be remain on tele until ICD placement. --- Depression - can consider restarting anti-depressants as needed Medications on Admission: 1. bupropion HCl 100 mg PO daily 2. folic acid 1 mg PO daily 3. thiamine HCl 100 mg PO daily 4. multivitamin PO daily 5. topiramate 100 mg PO BID 6. fluoxetine 60 mg PO daily 7. clopidogrel 75 mg PO daily 8. gabapentin 400 mg PO BID 9. aspirin 325 mg PO daily 10. pantoprazole 40 mg , Delayed Release (E.C.) PO daily 11. fexofenadine 60 mg PO BID 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO q6 PRN pain 13. albuterol sulfate 90 mcg/Actuation HFA 1 puff q6 PRN SOB/cough 14. ipratropium bromide 17 mcg/Actuation HFA 1 puff q6 PRN SOB/wheeze 15. enoxaparin 75 mg SC daily 16. fluconazole 100 mg PO daily for three days (first day [10-13]) 17. furosemide 10 mg/mL, continuous infusion 18. lisinopril 5 mg PO daily MEDS on TRANSFER from MICU: Acetaminophen Aspirin 81 Colace 100mg [Hospital1 ] Folate Gabapentin 400mg [Hospital1 ] Heparin drip Ipratropium Lisinopril 5mg MVI Pantoprazole 40mg Senna Thiamine Topamax 100mg [Hospital1 ] Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a day. 9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 10. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). 11. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 14. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) inh Inhalation twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: PRIMARY DIAGNOSIS Pneumothorax Air embolism SECONDARY DIAGNOSIS Cardiogenic shock 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 53899], You were admitted to the hospital with a recurrence of your pneumothorax that had been caused by the insertion of an IV in your neck. Your stay was also complicated by an air embolism caused by the removal of that line that caused difficulty with your breathing. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Medication changes: STOP buproprion, fluoxetine, fexofenadine and fluconazole, since these may have contributed to some confusion DECREASE gabapentin to 200mg twice a day for pain STOP pantoprazole START ranitidine 150mg twice a day for heartburn START albuterol four times a day as needed for shortness of breath START tiotropium daily for COPD START Advair inhalation twice a day for COPD Followup Instructions: Please contact your primary care physician to schedule [Name9 (PRE) 702] after you leave rehab. Cardiology ICD Placement: The EP lab will contact to arrange transfer for ICD placement on Wednesday [10-25]. If you do not hear from them Monday, please contact them at [Telephone/Fax (1) 35850]. Department: PULMONARY FUNCTION LAB When: THURSDAY [2113-10-26] at 12:30 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [2113-10-26] at 1 PM With: [Name6 (MD) 610] [Name8 (MD) ] RN/DR. [Last Name (STitle) 611] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "V85.0", "530.81", "412", "414.01", "E879.8", "415.19", "724.2", "293.0", "424.0", "428.22", "414.8", "401.9", "305.1", "453.6", "453.86", "410.92", "338.29", "311", "428.0", "512.1", "272.4", "261", "496" ]	icd9cm	[ [ [] ] ]	[ "34.04", "38.93" ]	icd9pcs	[ [ [] ] ]	14709, 14775	8453, 12515	323, 358	14901, 14901	5112, 8430	15882, 16766	3464, 3554		13523, 14686		14796, 14880		12541, 13500			15076, 15463									3594, 5093		2919, 3054																		15483, 15859	267, 285							386, 2825												14916, 15052		3085, 3166			2847, 2899	3182, 3448
31,405	117,441	43741	Discharge summary	report	Admission Date: [2177-2-25] Discharge Date: [2177-3-5] Date of Birth: [2114-11-4] Sex: M Service: NEUROLOGY Allergies: Infliximab / Latex / Shellfish Derived Attending:[First Name3 (LF) 2518] Chief Complaint: Bilateral leg numbness Major Surgical or Invasive Procedure: -intubation -lami T2-L2, fusion in situ without instrumentation T2-L2 History of Present Illness: The pt is a 62 year-old right-handed gentleman who presented as a transfer from an OSH with lower extremity numbness and weakness. Briefly, he was admitted to [Hospital 8] Hospital on [2177-2-19] for elective repair of a left ankle deformity. He apparently tolerated the procedure well. Yesterday, he was in his room walking with his walker and tripped. He fell onto his back and immediately noticed neck and upper back pain. He was helped back into bed. He did not notice any weakness or numbness of the legs at that point. Shortly thereafter, he was noted to become slightly hypotensive (systolic in the 80's). He was given volume resuscitation (unclear how much per the available notes) and eventually transferred to the ICU on a dopamine gtt. It was noted hours later that his urine output was minimal despite aggressive IVF. He described no sensation of a full bladder, but apparently when he was subsequently catheterized a large volume of urine was drained. Of note, he was also started on empiric antibiotics with the thought that the hypotension may be due to sepsis (though no documentation of fever, etc). Subsequent to the fall, he underwent a head CT which was normal. To the best of his knowledge, the pt believes that he was able to move his legs last evening prior to falling asleep. When he awoke this morning, he found that he was unable to move or feel his legs. He has had full strength and sensation in his arms. He has been catheterized since his bladder was decompressed as above. He has not had a bowel movement since the fall. CT scan of the spine as well as of the torso was performed at the OSH prior to transfer and demonstrated no notable abnormality. He was transferred to [Hospital1 18] this afternoon for further evaluation. At the time of my encounter, he complained of neck, upper back, and left elbow pain. He denied headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, or tinnitus. He is hard of hearing at baseline and wears hearing aids. Past Medical History: -ankylosing spondylitis -s/p bilateral knee replacements -s/p bilateral ankle surgeries with hardware, most recently [2-19] as above -history of PE, multiple DVT, thought to be secondary to clotting disorder (he is unsure exactly which one), on anticoagulation (stopped on [2-13] in preparation for recent procedure, apparently restarted [2-24]) -hypertension Social History: He denied history of tobacco, alcohol, or illicit drug use Family History: Not elicited Physical Exam: Vitals: T: 99.2F P: 73 R: 16 BP: 114/62 SaO2: 96% 3L NC General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Cervical collar in place. Pulmonary: Lungs CTA bilaterally 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. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk. VFF to confrontation. There is no ptosis bilaterally. EOMI without nystagmus. Facial sensation intact to pinprick. No facial droop, facial musculature symmetric. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically. [6-9] strength in trapezii and SCM bilaterally. Tongue protrudes in midline. -Motor: Normal bulk throughout. Tone is flaccid in the lower extremities. No pronator drift bilaterally. No adventitious movements noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 0 0 0 0 0 0 0 R 5 5 5 5 5 5 5 0 0 0 0 0 0 0 -Sensory: Absent light touch, pinprick, cold sensation to a T2 level. Lack of vibratory sense, proprioception up to iliac crests bilaterally. -Coordination: No dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 0 0 R 2 2 2 0 0 Plantar response mute on the right, could not assess left due to extensive bandaging. -Gait: Deferred given paraplegia. Pertinent Results: [2177-2-25] 02:17PM BLOOD WBC-11.1* RBC-3.27* Hgb-10.2* Hct-29.8* MCV-91 MCH-31.3 MCHC-34.4 RDW-12.8 Plt Ct-281 [2177-2-25] 02:17PM BLOOD PT-14.6* PTT-23.2 INR(PT)-1.3* [2177-2-25] 02:17PM BLOOD Glucose-128* UreaN-14 Creat-0.7 Na-141 K-4.2 Cl-109* HCO3-25 AnGap-11 [2177-2-25] 07:27PM BLOOD ALT-18 AST-30 LD(LDH)-220 CK(CPK)-694* AlkPhos-53 Amylase-20 TotBili-0.2 [2177-2-25] 07:27PM BLOOD Lipase-13 [2177-2-25] 07:27PM BLOOD CK-MB-13* MB Indx-1.9 cTropnT-<0.01 [2177-2-25] 02:17PM BLOOD Calcium-8.6 Phos-1.6* Mg-2.2 [2177-2-26] 03:39AM BLOOD Calcium-7.8* Phos-3.9# Mg-2.0 [2177-2-25] 07:27PM BLOOD calTIBC-217* Ferritn-188 TRF-167* [2177-2-25] 07:27PM BLOOD Ammonia-20 [2177-2-26] 01:29AM BLOOD Glucose-149* Lactate-1.9 Na-138 K-4.0 Cl-106 [2177-2-26] 01:29AM BLOOD Hgb-10.2* calcHCT-31 [2177-2-26] 03:54AM BLOOD freeCa-1.11* Brief Hospital Course: The pt is a 62 year-old gentleman with PMH of Ankylosing spondylitis and a known coagulopathy off coumadin for a recent L foot surgery but bridged with lovenox. He who presented with the relatively acute onset of paraplegia after a fall at an OSH. After the fall he was hypotensive and required pressors. Neurologic examination at the time of admission was notable for flaccid paraplegia and a T2 sensory level. He also related a history of a flaccid bladder and it is possible that his episodes of hypotension are also related to dysautonomia of spinal origin. Concerned for spinal cord compression in the upper thoracic region given the history and exam. The patient was intially sent for emergent CT myelogram due to recently placed plates and screws in the left ankle. CT myelogram done showed large extradural collection extending posteriorly from T2 to L2 concerning for hematoma or less likely abscess. Spine surgery was consulted & he was then sent to MRI which confirmed the the epidural hematoma and he was taken to the OR on [2-25] for emergent T2-L2 fusion and laminectomy. Please see operative report for full details of procedure. His remaining hospital course by system is as follows: Neuro: He was treated with cefazolin for 1 day post-operatively and extubated. His dexamethasone was tapered. He reported some sensation down to his calves on post-op day 1, however afterwards he had no sensation or movement below T2. Serial neurologic exams revealed persistent flaccid paraplegia, absent tendon reflexes in the lower extremities and absent sensation from T3 below. Given little improvement since surgical decompression, his prognosis for functional recovery is poor. He should remain in TLSO brace for all transfers given risks of injury if the patient were to fall. He does not need to wear the brace while in bed or sitting upright. The patient prefers to wear a soft cervical collar, but does not require the collar from a spine stability standpoint. Wound staples should be removed in 2 weeks ([2177-3-17]). He should follow up with the orthopedic spine surgeon (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1352]) in 2 weeks following discharge. CV: His hypotension was treated with neosynephrine which was gradually tapered. He did not have any further blood pressure lability or other signs of dysautonomia in the subsequent hospital course. RESP: He was extubated on [2-26] without complication. ID: He had a fever on post-op day 1 but his WBC was trending down. Blood cultures, incluiding intraop cultures were negative for growth.He was treated with cefazolin for 1 day post-operatively. HEME: 1) He had a normocytic anemia and iron studies were consistent with chronic disease. He also lost about 1200cc of blood in the OR and was transfused 750cc of PRBC. His hematocrit was stable at 28 following serial measurements. He was started on oral iron x 2 weeks given his blood loss. 2) Coagulopathy- Multiple DVT's and PE relating to prior orthopedic procedures. He was evaluated by hematology as an outpatient and told that he did not have a factor deficiecy. On admission to this hospital anticoagulation was held. His anticoagulation was restarted with Heparin on post-op day #3. Given hemodynamic stability and no evidence for further bleeding, coumadin was restarted. Daily PT/INR should be drawn at rehab and coumadin dosing adjusted accordingly for goal INR 2-2.5. INR at time of discharge was 1.8 GI: A liver lesion measuring 4 cm was noted on the MRI of the T-spine; this should be followed up as an outpatient with a liver ultrasound or CT torso. Care should be taken to monitor for regular bowel movements considering his spinal cord injury and lack of sensation. FEN: He will be discharged with a foley catheter; voiding trials should take into consideration his spinal cord injury and the possibility that he will not sense bladder fullness - timed straight catheterizations versus chronic foley would be recommended therapy if this does not recover within 1-2 weeks. Medications on Admission: Meds at time of transfer: -lovenox 100mg SQ Q12H -dopamine ggt -decadrom 10mg IV Q6H -Colace 100mg PO TID -Beconase 2 sprays nasally [Hospital1 ] -Proscar 5mg PO QHS -Flexeril 15mg PO QHS -CaCO3 500mg PO QD -Vit D 400 units PO QD -Vancomycin 1.5gm IV Q12H -Gentamycin 500mg IV Q24H Outpatient Meds: -Vit D 600 units PO BID -Finaseteride 5mg PO QHS -flexeril 50mg PO QHS -Meloxicam 15mg Qam -Tramadol 50mg PO BID -Toprol XR 100mg PO QAM -Ipratropium spray 0.03% 2 puffs in each nostril PRN -Prednisone 10mg PO BID prn arthritis flare -fluticasone 50mcg [2-5] sprays per nostril Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as needed. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily) for 14 days. 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 9. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day: check PT/INR daily for goal 2-2.5. 11. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed for constipation: please titrate bowel regimen to one bowel movement per day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Spinal compression Discharge Condition: Flaccid Paraplegia with T3 sensory level. Discharge Instructions: You were admitted following a fall that resulted in bleeding around your spinal cord. You were taken to the OR for T2-L2 laminectomy to relieve the pressure on your spinal cord. Please continue to take all medications as prescribed On an MRI of the spine, you were found to have an incidental liver lesion 4cm - a liver ultrasound or CT torso as an outpatient has been recommended. Followup Instructions: Please see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1352] (orthopedic spine surgery) for follow up, office phone: ([Telephone/Fax (1) 2007] in 2 weeks. You should have a CT torso or liver ultrasound for further evaluation of liver nodules noted incidentally on your spine studies. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2533]	[ "458.9", "V12.51", "V43.65", "720.0", "573.8", "E884.9", "285.29", "286.9", "596.8", "952.8", "401.9", "V15.07" ]	icd9cm	[ [ [] ] ]	[ "81.64", "81.05", "03.09", "99.04" ]	icd9pcs	[ [ [] ] ]	11634, 11704	5846, 9899	323, 395	11766, 11810	4943, 5823	12242, 12650	2954, 2969		10535, 11611		11725, 11745		9925, 10512			11834, 12219						3732, 4924			2984, 3418																					260, 285							423, 2465												3433, 3715					2487, 2861	2877, 2938
44,806	165,310	40535	Discharge summary	report	Admission Date: [2193-7-19] Discharge Date: [2193-8-20] Date of Birth: [2118-8-21] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1390] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2193-7-19] Laparoscopy converted to laparotomy with sigmoid colon resection and primary anastomosis. [2193-8-6] Lysis of adhesions, loop colostomy and placement of pelvic drain. [2193-8-13] Left DL PICC line History of Present Illness: 74 year old female with very limited past medical history, who was transferred here from the OSH with abdominal pain and CT scan concerning for free intraabdominal air. Patient reports abdominal pain that started at 5 pm tonight, about 6 hours ago. The pain was located in the low abdomen/ pelvis. It did not radiate. Initially, it felt as constipation, perhaps a need to pass flatus. The pain worsened and patient started experiencing some sweats. There was no nausea or vomiting. It remained in the same area. Patient has been having regular bowel movements [2-10] a day. No constipation or diarrhea. She denies any melena or hematochezia. Patient has never had a colonoscopy or any abdominal operations. She denies any fevers. Of note, patient reports chronic cough, which occurs several times during the day. It is especially bad after she gets out of bed. The cough is non-productive. She denies any shortness or breath or chest pain. She has been taking omeprazole many years ago, yet she did not think that it was helping and thus stopped it. She restarted omeprazole 2 months ago, still feels it gas not been helping and her cough has persisted. Past Medical History: Bilateral hip buritis, bilateral shoulder pain, GERD, chronic cough PSH: Endometrial biopsy Social History: Married Family History: Noncontributory Physical Exam: Upon presentation to [Hospital1 18]: VS: 96.1 92 143/71 20 94% RA CV: RRR pulm: CTA b/l abdomen: obese, soft, ND/ minimally tender in lower abdomen, no guarding, no rebound extremities: no LE edema, no cyanosis Pertinent Results: [2193-7-19] 05:45AM GLUCOSE-180* UREA N-11 CREAT-0.7 SODIUM-140 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-29 ANION GAP-13 [2193-7-19] 05:45AM CALCIUM-8.7 PHOSPHATE-4.2 MAGNESIUM-1.7 [2193-7-19] 05:45AM WBC-21.3* RBC-4.55 HGB-12.5 HCT-40.0 MCV-88 MCH-27.4 MCHC-31.2 RDW-13.5 [2193-7-19] 05:45AM PLT COUNT-338 IMAGING: [8-4]: CT Chest/Abd/Pelvis 1. Large defect in the colon within the pelvis at suspected level of surgical anastomosis. There is a large pocket of extra-luminal gas and fluid noted within the pelvis with inflamed peritoneum. Persistent pneumoperitoneum. 2. Multiple indeterminate bilateral pulmonary nodules. Interval follow-up in three months recommended to ensure stability. 3. Bilateral compressive atelectasis and pleural effusions are noted, right greater than left, which have increased slightly since prior CT [2193-7-28]. [8-6]: CXR (AP) Bibasilar atelectasis. No PTX [8-7]: CXR (AP) Slight interval progression of pulmonary edema. Small amount of b/l pleural effusion. [8-7]: CXR (AP) Hazy opacification of R mid & lower lung zones best explained by slight increase in the moderate R pleural effusion & basal atelectasis demonstrated by the torso CT on [8-4]. Pulmonary vasculature more distended today, indicating [Hospital1 ]-vent failure and/or volume overload. [Month (only) 116] be very mild edema developing in L mid lung. [8-8]: CXR (AP) Interval increase of R pleural effusion & unchanged appearance of L pleural effusion, much smaller. Bibasilar opacities might represent atelectasis, but infectious process is possible. [8-9]: CXR (AP) Moderate-to-large R pleural effusion, increased since [8-7]; Pulmonary vasc. congestion persists. Small L pleural effusion is presumed. Brief Hospital Course: She was admitted to the Acute Care team and taken to the operating room on [7-19] for laparoscopy converted to laparotomy with sigmoid colon resection and primary anastomosis. Postoperatively she recovered in the PACU and once stabilized was transferred to the regular nursing unit. Over the course of her stay on the regular unit her bowel function was very slow to return. She was given trials of sips to clears and the regular diet and was unable to tolerate these meals. She complained of intermittent nausea throughout as well. On [7-24] she underwent CT scan of he abdomen as there was concern for anastomosis leak; results revealed free air and free fluid within the abdomen, more than expected at postoperative day #5, with air-fluid levels and enlarged intrapelvic fluid collection measuring up to 8.7 cm in diameter; findings are concerning for leak or perforation. Also noted incidentally were numerous pulmonary nodules, measuring up to 8 mm in diameter which warrants close follow up with CT within three months. She underwent ultrasound guided drainage of the fluid collection where an 8 French [Last Name (un) 2823] catheter was placed within the pelvic collection. Approximately 150 mL of greenish stool was aspirated and samples were sent for microbiology growing PSEUDOMONAS AERUGINOSA. She was started on IV antibiotics which were continued for 2 weeks. These were stopped on [2193-8-20]. She will be discharged with the JP drain in place and will follow up in Acute Care Clinic in [2-10] weeks to determine if it can be removed. Her staples were taken out on [8-20]. The patient was transferred to the ICU on [2193-8-7] with concerns for sepsis. Initially the patient's SBP decreased as well as her UOP. She received multiple boluses with little improvement. Bedside ECHO was performed that showed no obvious wall motion abnormalities and she was euvolemic. Central line was placed to measure CVPs, which ranged 12-15. On [8-8], the patient was started on trophic tube feeds. Patient continued to be on pressors due to low blood pressure. On [8-9], the patient's propofol was stopped and switched to midazolam and intermittent fentanyl. Levophed was weaned off and tube feeds were advance and well tolerated. A CXR was performed that showed patient was wet, so Lasix was given with good effet. She was started on a Lasix gtt on [8-10] due to volume overload, and she continued to diurese well. On [8-11], the patient was extubated and Lasix gtt was stopped. On [8-12],the patient was transferred back to the floor in stable condition. Her mental status was concerning after transfer out of the ICU, she remained quite lethargic and delirious for a couple of days. Her narcotics were decreased and use was limited. Tylenol and Ultram were started for pain control which seemed to help with improvement of her mental status. A Dobbhoff was placed and tube feedings were initiated but unfortunately she self discontinued the Dobbhoff on the day after it was placed. Speech evaluated her at bedside and recommended that she have thickened liquids with pureed solids. At this point the screening process for LTAC was initiated. She was accepted at a facility of her choice and arrangements were made for discharge. On day that she was to leave she was noted with 3 small episodes of bilious emesis; a KUB was done showing multiple dilated air-filled loops of small bowel in a nonspecific pattern. She was made NPO and her IV fluids were restarted. Her ostomy continue to be functional throughout this. An NG tube was placed and she remained NPO for a couple of days until the nausea resolved. Once no further nausea her tube feeds were restarted and she was able to tolerate them. She has had several episodes of desaturation during the night time with shortness of breath. CXR consistent with bilateral pleural effusions and pulmonary edema. She received IV Lasix with adequate response and was started on standing IV Lasix 20 mg IV tid initially and just changed to [Hospital1 ] dosing on day of discharge. Her exams will need to be followed closely and adjustments will need to be made for ongoing diuresis. She does continue to have a nasal oxygen requirement. Her NG tube was removed on [8-19] and she was started on an oral diet. Marinol was added and she self reports improved appetite. Calorie counts should be done while at rehab. She has been followed closely by Physical and Occupational therapy and being recommended for acute rehab after her hospital stay. Medications on Admission: prilosec, tylenol Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 2. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP < 110, HR < 60 . 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 9. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day. 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 11. insulin regular human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale: see attached. 12. dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 13. Pantoprazole 40 mg IV Q12H 14. furosemide 10 mg/mL Solution Sig: Twenty (20) MG Injection twice a day. 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash: apply to affected areas as directed. 16. Metoclopramide 10 mg IV Q6H 17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q4H (every 4 hours). 18. oxycodone 5 mg/5 mL Solution Sig: Five (5) ML's PO every [5-15] hours as needed for pain. 19. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG PO BID (2 times a day). 20. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Perforated sigmoid colon Pelvic abscess Anastomotic leak Acute blood loss anemia Pulmonary edmea Sepsis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital withdiverticulitis which was complicated by a perfertion in your colon requiring that you undego an operation to repair this. Following your surgery you had a comolication requiring another operation where a colostomy was perfomed and you now have a bag on your abdomen that collects your bowel movments. You are also continuing to have bowel movements from your rectum which is normal. Following your second operation you developed a bloodsteream infection requiring that intravenous antibiotics that you are still receiving for at least anotehr week. Becasue of your prolonged hospital course it is being recommended that you go to a rehabiliation facility to work on getting your stronger so that you may return home. Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in [2-10] weeks. Completed by:[2193-8-29]	[ "292.81", "518.5", "285.1", "785.0", "428.0", "787.91", "562.11", "997.4", "560.1", "614.6", "518.89", "038.9", "E878.2", "112.89", "530.81", "998.59", "041.7", "E935.8", "V64.41", "786.2", "782.1", "614.3", "401.9", "995.91" ]	icd9cm	[ [ [] ] ]	[ "96.04", "46.03", "45.76", "38.91", "54.91", "38.97", "96.72", "38.93", "96.6", "54.59", "99.15" ]	icd9pcs	[ [ [] ] ]	10428, 10500	3953, 8502	318, 543	10647, 10647	2157, 3930	11602, 11739	1889, 1906		8570, 10405		10521, 10626		8528, 8547			10822, 11579									1921, 2138																					264, 280							571, 1732												10662, 10798					1754, 1848	1864, 1873
8,925	138,961	5055	Discharge summary	report	Admission Date: [2123-3-19] Discharge Date: [2123-3-20] Service: MEDICINE Allergies: Amoxicillin / Cephalosporins / Keflex / Nsaids Attending:[First Name3 (LF) 2485] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right Femoral line placement History of Present Illness: [Age over 90 ]F CAD, s/p NSTEMI [6-9], thoracic aneurysm w/ known compression of right and left mainstem bronchi, DNR/DNI/[Hospital 20844] nursing home resident presented to ED with substernal chest pain beginning evening prior to admission. Per nursing home note, patient found hypotensive without recordable BP, and hypoxic to 70% on RA. Given lasix and SLNTG prior to transfer to [Hospital1 18]. In ED, initial VS 99.5 109 83/47 14 99% on 4L. Despite DNR/DNI/CMO, plan made with health care proxy to allow placement of central line, fluid resuscitation and use of pressors. Pt received 6L IVF in ED and BP improved. Received levofloxacin for noted UTI on u/a. Past Medical History: NSTEM [6-9] Thoracic aortic aneurysm 7X9cm w/ compression of R/L mainstem bronchi, but not surgical candidate PEripheral vascular disease HTN Anemia CRI GIB [3-10] NSAIDS Carotid Stenosis Urinary incontinence Social History: Lives at [Hospital1 5595], no living biological family members. HCP [Name (NI) 17563] [Name (NI) 7363] [Telephone/Fax (1) 20845] Family History: NC Physical Exam: Apneic, Pulseless. No heart sounds or breath sounds. Patient was pronounced dead on hospital day 2. Pertinent Results: [2123-3-19] 11:15AM CORTISOL-76.5* [2123-3-19] 11:15AM WBC-27.1* RBC-2.80* HGB-9.1* HCT-29.5* MCV-106* MCH-32.7* MCHC-31.0 RDW-15.0 [2123-3-19] 11:15AM NEUTS-80* BANDS-15* LYMPHS-2* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2123-3-19] 11:15AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-1+ [2123-3-19] 11:15AM PLT COUNT-196 [2123-3-19] 06:15AM GLUCOSE-386* UREA N-35* CREAT-1.5* SODIUM-136 POTASSIUM-2.9* CHLORIDE-109* TOTAL CO2-20* ANION GAP-10 [2123-3-19] 06:15AM CK(CPK)-20* [2123-3-19] 06:15AM cTropnT-0.01 [2123-3-19] 06:15AM CK-MB-NotDone [2123-3-19] 06:15AM CALCIUM-7.0* PHOSPHATE-1.6* MAGNESIUM-1.5* [2123-3-19] 06:15AM CORTISOL-58.6* [2123-3-19] 06:15AM WBC-21.0# RBC-2.52# HGB-8.2# HCT-27.6# MCV-109* MCH-32.3* MCHC-29.6* RDW-15.1 [2123-3-19] 06:15AM NEUTS-78* BANDS-19* LYMPHS-2* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2123-3-19] 06:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-1+ BURR-1+ [2123-3-19] 06:15AM PLT COUNT-222 [2123-3-19] 02:00AM PT-14.4* PTT-31.0 INR(PT)-1.3 [2123-3-19] 02:00AM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.015 [2123-3-19] 02:00AM URINE RBC-[4-10]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [2123-3-19] 01:14AM TYPE-MIX TEMP-37.5 O2 FLOW-4 PO2-53* PCO2-47* PH-7.26* TOTAL CO2-22 BASE XS--5 INTUBATED-NOT INTUBA [2123-3-19] 01:14AM GLUCOSE-87 LACTATE-1.8 NA+-143 K+-3.3* CL--118* [2123-3-19] 01:14AM freeCa-1.17 [2123-3-18] 11:35PM GLUCOSE-93 UREA N-44* CREAT-1.9* SODIUM-146* POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-21* ANION GAP-19 [2123-3-18] 11:35PM CK(CPK)-19* [2123-3-18] 11:35PM CK-MB-NotDone cTropnT-0.02* [2123-3-18] 11:35PM CALCIUM-9.1 PHOSPHATE-2.9 MAGNESIUM-2.1 [2123-3-18] 11:35PM WBC-7.2 RBC-3.64* HGB-12.0 HCT-39.7 MCV-109# MCH-33.1 MCHC-30.3* RDW-15.1 [2123-3-18] 11:35PM NEUTS-91.9* BANDS-0 LYMPHS-5.9* MONOS-1.7* EOS-0.2 BASOS-0.3 [2123-3-18] 11:35PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [2123-3-18] 11:35PM PLT SMR-NORMAL PLT COUNT-209# Brief Hospital Course: [Age over 90 ]F with multiple endstage medical problems presented to [Hospital1 18] from nursing home with hypotension. Patient was successfully fluid resuscitated in ED and transferred to MICU. There after several hours, patient began to complain of feeling "badly" without a specific source of complaint, but also complained of dyspnea. Patient was given furosemide, morphine, and ativan, and dyspnea improved mildly. However, one hour following this intervention, patient became acutely bradycardic to HR 40s, and given goals of care, no further intervention was performed. Within minutes, patient was pulseless and apneic. Patient was pronounced dead on hospital day 2. Healthcare proxy was informed. Medications on Admission: N/A Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Probable Urosepsis Thoracic aortic aneurysm Congestive heart failure exacerbation Discharge Condition: Expired Discharge Instructions: n/a Followup Instructions: n/a	[ "285.9", "440.20", "411.1", "995.92", "038.9", "414.01", "412", "785.51", "401.9", "433.30", "276.4", "593.9", "441.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4689, 4698	3887, 4607	266, 296	4824, 4833	1568, 3864	4885, 4891	1428, 1432		4661, 4666		4719, 4803		4633, 4638			4857, 4862									1447, 1549																					215, 228							324, 1010																	1032, 1250	1266, 1412
44,951	169,895	42110	Discharge summary	report	Admission Date: [2150-8-14] Discharge Date: [2150-8-17] Date of Birth: [2091-10-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2901] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with drug eluting stent to the left circumflex coronary artery History of Present Illness: Patient states that yesterday he was mowing his lawn when he developed sharp substernal chest pain and pressure. He stopped working sat down and had resolution of his pain within 15 minutes. He then completed the mowing without any further pain. Later that evening he went to a bar and had [1-30] drinks without any more pain. Around 1 am the patient was awoken with significant substernal chest pain radiant to his right arm and felt like "someone was sitting on his chest". He took several tums without any improvement and had an episode of vomitting while at home. He finally called an ambulance and was taken to the ED at 530 am. . In the ER, Initial VS were HR: 52 BP: 120/48 Resp: 12 O(2)Sat: 100. EKG showed: ST elevations in II, II avF, V3-V6, and ST depressions in V1-V2. He received asa, heparin, a plavix load, and was sent emergently for cardiac catheterization. Cardiac cath showed two lesions: 100% prox LCx before obtuse marginal, 90% distal RCA. He had an export thrombectomy from LCx and [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] was placed. He was also hypotensive periprocedurally to 80s systolic and transiently bradycardic. Paitent recived a fluid bolus and atropine and was started on a dopamine gtt. He also had R heart cath which showed PCWP 25. L venous sheath is still in place. . Upon arrival to the CCU patient was stable and alert with a BP 126/84 MAP 93 on 10 of dopamine, P 79, 95% on 4L. Patient complained of nausea and had several episodes of vomitting. He endorsed slight [1-8] retrosternal chest pain, greatly improved from presentation. Denied any SOB, HA, abdominal pain. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Dyslipidemia 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: - GERD - Vertigo - Anxiety - Hernia Repair Social History: SOCIAL HISTORY - Tobacco history: none - ETOH: 3 drinks a night x3/week - Illicit drugs: none - Reccently retired electrician, worked on the [Company 2860] Yawkey building. [Month (only) 116] have had several prior exposures to asbestos. Family History: FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: DM2 - Father: Stroke at age 84 Physical Exam: VS: BP= 126/84 HR= 79 RR=15 O2 sat= 95% 4L GENERAL: 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 6 cm. 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. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. 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+ . Exam on discharge: Temp 97.4, HR 60, RR 20 BP 117/67 O2 sat 99% RA HEENT: no JVD, no LAD CV: RRR, no M/R/G Chest: CTAB, no crackles ABD: soft, NT, pos BS Ext: no edema, feet warm, pulses palp Neuro: no defects, gait nl, speech clear, A/O Right groin with minimal bluising, no bleeding Pertinent Results: [2150-8-14] 06:30AM BLOOD WBC-9.0 RBC-5.09 Hgb-16.1 Hct-44.6 MCV-88 MCH-31.6 MCHC-36.1* RDW-13.6 Plt Ct-297 [2150-8-14] 06:30AM BLOOD Glucose-174* UreaN-20 Creat-1.1 Na-139 K-3.9 Cl-102 HCO3-20* AnGap-21* [2150-8-15] 06:00AM BLOOD ALT-88* AST-303* LD(LDH)-865* CK(CPK)-1768* AlkPhos-66 TotBili-0.9 [2150-8-15] 06:00AM BLOOD CK-MB-86* MB Indx-4.9 cTropnT-5.59* [2150-8-14] 01:06PM BLOOD Calcium-8.8 Phos-2.6* Mg-2.2 . Labs on Discharge: [2150-8-17] 06:45AM BLOOD WBC-7.0 RBC-4.44* Hgb-14.1 Hct-39.8* MCV-90 MCH-31.9 MCHC-35.6* RDW-12.7 Plt Ct-215 [2150-8-17] 06:45AM BLOOD Glucose-111* UreaN-17 Creat-1.1 Na-139 K-3.8 Cl-105 HCO3-23 AnGap-15 [2150-8-17] 06:45AM BLOOD ALT-63* AST-68* AlkPhos-73 TotBili-0.7 [2150-8-17] 06:45AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.3 . Cardiac cath [8-14]: COMMENTS: 1) Selective coronary angiography of this right-dominant system demonstrated two-vessel coronary disease. The LAD had no significant disease. The LCx had 100% proximal stenosis and 70% mid-vessel stenosis, both of which had thrombus. The RCA had 50% mid-vessel stenosis and 90% distal stenosis in a small dominant vessel. 3) Limited resting hemodynamics revealed moderately-elevated left-sided pressures, with a mean PCWP of 26 mmHg; V waves were high at 44 mmHg, suggesting the possibility of mitral regurgitation. The PA pressures were moderately-elevated at 51/19 mmHg, with a mean PA pressure of 34 mmHg. The right atrial pressure was normal at 8 mmHg. 4) The patient developed hypotension (sBPs low 80s) periprocedurally; this may have been due to a vasovagal effect compounded by hypovolemia in the setting of an inferolateral MI. Dopamine at 10mcg/kg/min was begun with good effect on the blood pressures. He also received one 0.6mg dose of atropine for transient bradycardia into the low 40s. 5) Angiomax was used and angioseal for arteriotomy closure. 6) Successful export thrombectomy and PCI of thrombotically occluded proximal LCx with 2.5x28mm Promus [Name Prefix (Prefixes) ] [Last Name (Prefixes) 7930] to 3.0mm (see PTCA comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease, status post export thrombectomy followed by drug-eluting stenting of the proximal and mid-LCx. The RCA was not well suited for PCI because of its small caliber. 2. Acute inferior myocardial infarction, managed by acute PTCA of vessel. 3. Moderate left-sided filling pressures. 4. Bradycardia controlled with dopamine. 5. Successful export thrombectomy and PCI of LCx. . ECHO [8-14]: 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 severe hypokinesis of the distal half of the inferior wall and apex. The remaining segments contract normally (LVEF = 50-55 %). The estimated cardiac index is normal (>=2.5L/min/m2). 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 arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Mild mitral regurgitation. Dilated thoracic aorta. . ECG [8-15]: Sinus rhythm. Slight ST segment elevation in leads II and V4-V6 with biphasic T waves in leads V5-V6 and Q waves in the inferior leads and V6 suggesting an evolution of an inferolateral myocardial infarction. Tall R waves in leads V1-V2 suggest posterior involvement. The ST segment depression in leads V2-V3 is probably reciprocal. Low QRS voltage in the limb leads. Compared to the previous tracing of [2150-8-14] there are further evolutionary changes of an evolving myocardial infarction. Brief Hospital Course: # Hypotension: Patient transiently hypotensive to the 80s systolic peripercidurally, patient was also bradycardic received atropine arguing for a vasovagal mediated process in the setting of manipulation of the right coronary vessels. Dopamine was weaned off promptly and BP tolerating BB and ACEi without lightheadedness at the time of discharge. . # CAD: patient w/ 100% occlusion of prox LCx, 70% mid both with thrombus RCA 50% mid, 90% distal in small dominant vessel. Now with DES in LCx and mid RCA. Patient did not have any significant coronary risk factors prior to procedure. STarted on ASA and Plavix (needs total of 1 year), high dose atorvastatin, Metoprolol and Lisinopril. Tolerating these medicines well prior to discharge. . # High filling pressures: Patient with elevated Wedge pressures during cath likely from transient cardiogenic failure. Patient has new oxygen requirement and was diuresed with lasix. He did not need to be sent home on lasix as symptoms resolved after acute ischemic phase was over. ECHO showed preserved EF and no significant valve disease. Also showed mild regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the inferior wall and apex. He will need another ECHO in about a month. . # RHYTHM: normal sinus, no significant VEA. . # HTN: started on beta blocker and ace inhibitor as above, BP well controlled. . # HLD: atorvastatin 80 mg for a few months, then can decrease. LFT's initially high at presentation, thought secondary to low output state. LFT's close to normal at discharge. Will need to have LFT's checked in 6 weeks. . # GERD: will give pantoprazole 40 mg daily instead of Nexium for DES. Medications on Admission: Nexium 20 mg daily Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 5. 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 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: ST Elevation myocardial infarction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 91350], It was a pleasure caring for you. You were admitted to the hospital with chest pain due to a heart attack. We did a cardiac catheterization and placed a drug eluting stent in your left circumflex artery. It is extrememly important that you take aspirin and Plavix every day for at least one year and possibly longer to prevent the stent from clotting off and causing another heart attack. Do not stop taking aspirin and plavix or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless your cardiologist tells you it is OK. You have some other milder blockages in other coronary arteries. You will take medicines to prevent these blockages from getting worse. Your heart function is slightly weaker than before your heart attack but it is expected that your heart will recover in the next month. Follow the activity guidelines that the physical therapist reviewed with you. . We made the following changes to your medications: - Start taking aspirin 325 mg and Plavix every day for one year to prevent the stent from clotting off. - Start taking atorvastatin (Lipitor) to lower your cholesterol - Start taking metoprolol, a beta blocker, to lower your heart rate and help your heart recover. - Start taking lisinopril, an ACE inhibitor, to help your heart pump better - Stop taking Nexium, take pantoprazole instead for your heartburn, this medicine does not interfere with Plavix. Followup Instructions: Name: [Last Name (LF) 15817],[First Name3 (LF) ] R. Location: [Hospital ] MEDICAL ASSOCIATES-[Location (un) ] Address: 325 RIVER RIDGE DR, [Location (un) ],[Numeric Identifier 8538] Phone: [Telephone/Fax (1) 8506] Appt' [Last Name (LF) 766], [8-24] at 12:45pm Department: CARDIAC SERVICES When: THURSDAY [2150-10-1] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "428.32", "272.4", "428.0", "300.00", "410.21", "530.81", "401.9", "414.01" ]	icd9cm	[ [ [] ] ]	[ "00.45", "36.07", "37.23", "88.56", "00.40", "00.66" ]	icd9pcs	[ [ [] ] ]	11118, 11124	8527, 10214	316, 405	11203, 11203	4399, 4836	12808, 13558	3078, 3237		10283, 11095		11145, 11182		10240, 10260		6512, 8504	11354, 12300									3252, 4093		2701, 2706																12329, 12785			266, 278			4855, 6495				433, 2598		4112, 4380										11218, 11330		2737, 2782			2642, 2681	2798, 3046
81,754	133,465	1892	Discharge summary	report	Admission Date: [2133-5-20] Discharge Date: [2133-5-25] Date of Birth: [2047-7-9] Sex: F Service: MEDICINE Allergies: Wellbutrin Attending:[First Name3 (LF) 2880] Chief Complaint: Fatgue, dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: 85 yo F with hx of HTN, CHF, PPM for 2 degree AV block, presents with increasing fatigue. The patient's family reports that she has been sleeping 5-7 hours per night, rather than her usual three. The patient herself reports that she has been sleepy much more often than usual. The patient's sone reports that her appetite has been dwindling over the past few weeks as well. The patient's son also think she may have had a temperature, but there is no objective data for a fever. The patient has been having difficulty breathing as well, especially when she lies flat. She has been sleeping sitting up intermittently over the last few weeks. The patient denies any chest pain or palpitations. She further reports some cough. She denies any nausea, vomiting, or GI symptoms. . In the ED, initial vitals were T 98.2, HR 84, BP 124/62, RR 22, O2Sat 95% on 2L. EKG reportedly unchanged from prior; patient in sinus rhythm. Supplemental oxygen was removed and patient had a desat to 84% on RA. After 2L NC applied her O2Sat was in the mid-90s though again had a desat to the 80s when lying flat. CXR showing pulmonary edema. BNP elevated to 5053. 18g IV placed and patient given 40 mg IV furosemide. Vitals on transfer were: HR 84 28 114/52 97% 2L NC. . On arrival to the floor, patient was comfortable in bed. The patient is profoundly deaf and required handwritten notes as part of interview. Past Medical History: 1. Hypertension, hyperlipidemia, history of tobacco abuse 2. Chronic obstructive pulmonary disease. 3. Osteoporosis. 4. H/o pacemaker insertion for 2nd degree AV block (Mobitz type I) on Holter monitor with associated symptoms of presyncope. 5. Remote history of colon carcinoma (ascending colon), s/p resection 6. Peripheral vascular disease status post aortoiliac reconstruction 7. Left ventricular hypertrophy with hypertrophic obstructive cardiomyopathy physiology. 8. Hearing loss Social History: Lives with husband. She has been retired for at least last ten years and worked previously in accounting. There is evidently some difficulty at home and patient does not get along with husband. Smoking : h/o smoking for 60 years, 1 pack/day, stopped in [December 2130] EtOH : none Illicit drugs : none She has 4 living children. HCP: [Name (NI) ] [Name (NI) 10544] [Telephone/Fax (1) 10546] Family History: Mother had diabetes and died at 77 of complications of diabetes and an MI. Father died at 52 of a massive MI. Brother died at 67 of bone cancer. Son died in [8-/2130] of meningitis. Physical Exam: Admission physical exam: VS: T = 99.6 P = 81 BP = 118/58 RR = 30 O2Sat = 93% 2L GENERAL: Frail female sitting up in bed. She is in no acute distress. HEENT: PERRL, EOMI, no scleral icterus or injection, MMM, no lesions noted in oropharynx Neck: supple, no LAD Respiratory: Crackles heard through bottom [12-22] of lungs. Back: Significantly kyphotic Cardiovascular: S1, S2, [2-22] holosytolic murmur heard at all listening sites for heart Gastrointestinal: soft, non-tender, BS+ Extremities: Radial/pedal pulses 2+, no edema noted. Mental status: Alert, oriented x 3. Able to relate history without difficulty. Very hard of hearing; other CNs grossly intact, 4/5 strength in all extremities. . Discharge physical exam: VS: Tm 98.1 HR 57-66 BP 81-136/40-70 RR 16-18 O2Sat = 95-99% on room air Wt.: 41.3 kg <-- 41.5 kg Is/Os: [Telephone/Fax (1) 10547] GENERAL: NAD, frail woman, hard of hearing HEENT: No scleral icterus or injection, MMM, oropharynx clear and without erythema Neck: Supple, no LAD Respiratory: Clear to auscultation bilaterally. Back: Significant kyphosis. Cardiovascular: S1, S2, [2-22] holosytolic murmur heard globally across auscultation sites. Gastrointestinal: Soft, non-tender, BS+ Extremities: Radial/pedal pulses 2+, no edema noted. Pertinent Results: Admission labs: [2133-5-20] 01:40PM WBC-13.0# RBC-3.71 HGB-11.5* HCT-34.2* MCV-92 MCH-31.0 MCHC-33.5 RDW-12.9 [2133-5-20] 01:40PM NEUTS-88.8* LYMPHS-5.6* MONOS-5.0 EOS-0.4 BASOS-0.3 [2133-5-20] 01:40PM proBNP-5053* [2133-5-20] 01:40PM GLUCOSE-120* UREA N-20 CREAT-1.4* SODIUM-137 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-32 ANION GAP-14 [2133-5-20] 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG . [2133-5-20] 01:40PM BLOOD proBNP-5053* [2133-5-20] 01:40PM BLOOD cTropnT-<0.01 [2133-5-21] 06:00AM BLOOD CK-MB-2 cTropnT-<0.01 [2133-5-21] 08:30PM BLOOD CK-MB-2 cTropnT-<0.01 [2133-5-22] 04:10AM BLOOD CK-MB-2 cTropnT-<0.01 [2133-5-22] 04:10AM BLOOD CK(CPK)-40 [2133-5-21] 08:30PM BLOOD CK(CPK)-37 [2133-5-21] 06:00AM BLOOD CK(CPK)-39 . Discharge labs: [2133-5-25] 07:35AM BLOOD WBC-7.0 RBC-3.12* Hgb-9.7* Hct-28.8* MCV-92 MCH-31.1 MCHC-33.7 RDW-12.9 Plt Ct-278 [2133-5-25] 07:35AM BLOOD Ret Aut-1.7 [2133-5-25] 07:35AM BLOOD Glucose-98 UreaN-24* Creat-1.3* Na-134 K-4.3 Cl-96 HCO3-29 AnGap-13 [2133-5-25] 07:35AM BLOOD Iron-50 [2133-5-25] 07:35AM BLOOD calTIBC-274 Ferritn-156* TRF-211 . [5-22] CXR: IMPRESSION: AP chest compared to [2-5] through [2133-5-21]: Pulmonary vascular congestion and mild interstitial edema has improved since [5-20]. Uniform opacification of the right lower lung is probably atelectasis. Mild cardiomegaly is chronic. Small bilateral pleural effusions are unchanged. Transvenous right atrial and right ventricular pacer leads are in standard placements. . [5-20] CXR: IMPRESSION: 1. Mild congestive heart failure superimposed on severe chronic obstructive airway disease. 2. No evidence of pneumonia. . 2D-ECHOCARDIOGRAM: [2133-5-21] The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a severe resting left ventricular outflow tract obstruction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is systolic anterior motion of the mitral valve leaflets. Moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is a very small pericardial effusion. . IMPRESSION: Mild symmetric LVH. During systole mitral valve and chordae are pulled towards the hypertrophied upper septum and a severe LVOT obstruction develops. At least moderate, posteriorly directed mitral regurgitation. Very small pericardial effusion without evidence of tamponade. . Compared with the report of the prior study (images unavailable for review) of [2133-2-6], the LVOT gradient has increased significantly. LV systolic function is not quite hyperdynamic on the current study. The estimated pulmonary artery pressures are lower. Pericardial fluid amount is probably similar. . Brief Hospital Course: The patient is an 85-year-old woman who presented with loss of appetite, lethargy, dyspnea. . # PUMP: On presentation, the patient appeared to be having an exacerbation of her diastolic CHF, based on her physical exam and the imaging taken in the emergency department. The patient reports she is compliant with her medications, but she has a complicated home life that may make compliance difficult. She may have had a dietary indiscretion (unlikely given reports of her diminished appetite) or a worsening of her heart function, although her troponins were negative. Her echocardiogram did demonstrate worsening of her left ventricular outflow tract obstruction, which may be contrinuting to this exacerbation. The patient also had suggestion of infection by white count and differential, but no source was found and leukocytosis resolved. Urinalysis not suggestive of infection; urine culture positive for G+ bacteria (alpha-strep or lactobacillus), but asymptomatic. The patient does have a foreign body (pacemaker), but did not become febrile during hospitalization. Chest X-rays not suggestive of pneumonia. Leukocystosis resolved. The original mild pulmonary congestion was likely secondary to severe MR. [First Name (Titles) ] [Last Name (Titles) 2974], [5-22], the patient had to be transferred to the CCU due to tachypnea and hypotension unresponsive to gentle boluses. In the CCU, the patient produced 500 mL over 24 hours with IV lasix 10 mg x 1 and responded well to metoprolol. She did not have a recurrence of hypotension or of tachypnea. On [2133-5-24], the patient was orhtostatic during physical therapy, but she had received an extra dose of furosemide. She received gentle hydration (250 cc) to which she responded well. By the time of her discharge, she was back on room air, and Physical Therapy had cleared her to return home. Social Work also consulted, and she will receive nursing services at home, including medicine checks, and also a visit from Elder Services with a home safety evaluation. . # CORONARIES: Patient has significant risk factors for CAD, given hypertension, peripheral vascular disease, long smoking history, hyperlipidemia, etc. EKG did not suggest acute changes. She was continued on aspirin, clopidogrel, simvastatin therapies. Continued low-dose beta-blocker (metoprolol); lisinopril held initially due to concern for acute kidney injury, but returned to regimen on discharge. . # RHYTHM: The patient has a pacemaker implanted, but has been in normal sinus rhythm. . # COPD: Likely contributing to patient's dyspnea, although the patient did not have wheezing on exam. She was provided with albuterol and ipratropium nebulizers standing and as needed and continued on home fluticasone. . # Kidney injury: Patient has had increased creatinine since early in [Month (only) 116]. Baseline appears to 1.0 for creatinine, but may well be higher. [Month (only) 116] be acute from dehydration or part of longer process. FeUrea 56%, suggestive of intrinsic process, may be from diuresis (although patient came in with elevated creatinine) or ATN secondary to episode of hypotension that sent patient to CCU. Creatinine had returned closer to baseline by discharge. She may need additional investigation as an outpatient to determine her kidney status. . # Anemia: The patient has had a slow decline in hematocrit since admission. The anemia is normocytic. The patient denies any frank blood in stool, though she has been trace guaiac positive. The patient does endorse hemorrhoids, however. Her reticulocyte index ws 1.7, which suggests a proliferative deficit as opposed to bleeding. Her MCV was within normal limits. Iron studies were not suggestive of iron deficiency. She has been ordered for a re-check of her hematocrit and hemoglobin and can be followed as an outpatient. . # Hypertension: Continued home amlodipine therapy. Held lisinopril early in hospital course. . # Hyperthyroidism: Continued methimazole therapy. Medications on Admission: alendronate [Fosamax] 70 mg Tablet One (1) Tablet by mouth once a week. aspirin 325 mg Tablet One (1) Tablet by mouth DAILY (Daily). clopidogrel 75 mg Tablet One (1) Tablet by mouth DAILY (Daily). docusate sodium 100 mg Capsule One (1) Capsule by mouth twice a day. furosemide 20 mg Tablet One (1) Tablet by mouth DAILY (Daily). lisinopril 40 mg Tablet One (1) Tablet by mouth HS (at bedtime): Please take at bed time. 30 Tablet(s) 2 methimazole 5 mg Tablet One (1) Tablet by mouth DAILY (Daily). metoprolol succinate 25 mg Tablet Extended Release 24 hr 0.5 Tablet Extended Release 24 hr by mouth DAILY (Daily): Please take at bed time. 30 Tablet Extended Release 24 hr(s) 2 multivitamin Tablet One (1) Tablet by mouth DAILY (Daily). simvastatin 40 mg Tablet One (1) Tablet by mouth DAILY (Daily). tiotropium bromide [Spiriva with HandiHaler] 18 mcg Capsule, w/Inhalation Device One (1) Inhalation once a day. Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. 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. 12. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO every other week. 13. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO once a day. Disp:15 Tablet Extended Release 24 hr(s) Refills:0 14. Outpatient Lab Work Check CBC on [2133-6-1]. Fax results to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 4004]. Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Exacerbation of diastolic congestive heart failure . Secondary: COPD Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [Known lastname 10544], . It was a pleasure participating in your care at [Hospital1 771]. . You were admitted to the hospital because of fatigue and shortness of breath. We think those symptoms were caused by an exacerbation of your chronic heart failure. We were able to remove some fluid and control your heart rate, which helped your breathing. We also gave you nebulizer treatments to improve your breathing problems caused by your COPD. It was also discovered that you were anemic during your hospitalization, which may also be contributing to your fatigue. . We will set up nursing to come check up after you and make sure that you are doing well. . You should follow up with the appointments listed below to make sure you do not become imbalanced in your fluids and that your anemia can be further worked up. Dr. [Last Name (STitle) ] is a colleague of your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. . No longterm changes were made to your medications. You should continue to take your usual medications as directed. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: [Hospital3 249] When: MONDAY [2133-6-1] at 9:20 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD/[Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] 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. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up. . Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 18] - CARDIOLOGY DIVISION Address: [Location (un) ], SL 423C, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 10548] We are working on a follow up appointment with Dr. [Last Name (STitle) ] within 2 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above. . [First Name11 (Name Pattern1) 900] [Last Name (NamePattern1) 2882] MD, [MD Number(3) 2883]	[ "V45.01", "285.9", "428.0", "584.9", "242.90", "V10.05", "458.9", "424.0", "585.9", "272.4", "496", "389.9", "276.1", "733.00", "428.33", "403.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13982, 14041	7688, 11680	286, 294	14161, 14161	4162, 4162	15542, 16826	2662, 2849		12643, 13959		14062, 14140		11706, 12620			14344, 15519			5039, 7665						2889, 3406																					231, 248							322, 1712							4178, 5023					14176, 14320					1734, 2221	2237, 2646			3593, 4143
9,036	157,563	5655	Discharge summary	report	Admission Date: [2141-7-29] Discharge Date: [2141-8-2] Date of Birth: [2092-2-18] Sex: F Service: MEDICINE Allergies: Imitrex / Iodine-Iodine Containing Attending:[First Name3 (LF) 2009] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: Extubation ([2141-7-31]) History of Present Illness: Ms. [Known lastname 22571] is a 53 year old female with type I DM with insulin pump HL, hypothyroid, dyslipidemia, hx of tracheostomy after MVC, psychiatric disorder who was found unresponsive on her couch today. Per EMS report, she was noted to have rectal temp of 90.7. Blood glucose was read as "high". She was reported to have two days of vomiting. Her insulin pump was noted to be shut off. She was subsequently taken to [Hospital3 ] where her exam was notable for arousle to pain with eyes deviated to right, BP of 99/57 and pulse of 87. ABG with PH of 6.87, UA normal except for ketones, glucose of 949, HCO3 < 5, troponin of 0.392 and WBC of 37.9. She was started on insulin gtt, 2 amps of bicarb and cefepime/vancomycin. MD notes from OSH notes he turned off the pump, prior to sending to [Hospital1 18]. Sedation shut off in transit by [Location (un) ], noted to not have response. At [Hospital1 18] ED, initial vitals were 95.0. She was started on fentanyl/versed gtt/insulin 7 units. Labs notable for ABG of 7.11/40/456 on 500 X 15 FiO2 of 100%, 5 PEEP; lactate of 4.5, HCO3 of 10, lipase of 696 and glucose of 686. She got 4L at OSH. 500 cc here at ED. She was subsequently admitted to MICU for further evaluation and management. On arrival to the MICU, she was intubated and sedated. Her ex-husband confirmed that she started having nausea and vomiting for past two days with increasing confusion. He does not report her having any sick contacts except hospital visit two weeks ago for his pulmonary edema admission. She has not eaten out though she regularly goes to casino but no alcohol intake. He reports she has not had chest pain, shortness of breath, fever or chills. He reports she has not endorsed SI to him. 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: IDDM Osteoperosis Fibromyalgia Anxiety Depression Bipolar Disorder s/p MVA [4-2] w/ multiple face/pelvic/spine fx -intubated x1 month, s/p trach Hypothyroidism Hyperlipidemia Social History: The patient reports that she quit smoking since [2137-3-26]. 20 pack year smoking history. She does not drink any alcohol. Family History: Father had lung cancer with a history of smoking, as well a coronary artery disease. No known family exposure to TB. Physical Exam: Admission Exam General: Intubated. Sedated. HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Not assessed Discharge Exam VS: T: 97.4 BP: 129/47 P: 85 R: 16 18 O2: 98% on RA Gen: NAD, AAOx3 HEENT: EOMI, MMM CV: RRR, normal S1/S2, no m/r/g Lungs: CTAB, no wheezes, rhonchi or rales Abdomen: soft, non-tender, non-distended Ext: 2+ radial and DP pulses Neuro: Motor and sensory grossly intact in upper and lower extremeties, bilaterally Pertinent Results: Labs on Admission: [2141-7-29] 08:20PM BLOOD WBC-35.9* RBC-4.30 Hgb-13.1 Hct-43.4 MCV-101* MCH-30.5 MCHC-30.3* RDW-14.1 Plt Ct-272 [2141-7-30] 05:11AM BLOOD WBC-8.6# RBC-4.24 Hgb-12.6 Hct-38.9 MCV-92# MCH-29.7 MCHC-32.4 RDW-14.3 Plt Ct-226 [2141-7-31] 05:00AM BLOOD WBC-10.3 RBC-3.93* Hgb-12.0 Hct-36.0 MCV-92 MCH-30.6 MCHC-33.4 RDW-14.7 Plt Ct-144* [2141-8-1] 04:00AM BLOOD WBC-7.8 RBC-3.72* Hgb-11.1* Hct-34.2* MCV-92 MCH-29.8 MCHC-32.4 RDW-15.0 Plt Ct-106* [2141-7-29] 08:20PM BLOOD Neuts-76.2* Lymphs-13.7* Monos-8.9 Eos-0.5 Baso-0.8 [2141-7-29] 08:20PM BLOOD PT-10.2 PTT-22.9* INR(PT)-0.9 [2141-7-30] 05:11AM BLOOD Fibrino-330 [2141-7-29] 08:20PM BLOOD Glucose-686* UreaN-36* Creat-1.5* Na-151* K-4.2 Cl-110* HCO3-10* AnGap-35* [2141-7-30] 05:11AM BLOOD Glucose-307* UreaN-29* Creat-1.1 Na-158* K-4.2 Cl-128* HCO3-24 AnGap-10 [2141-7-31] 05:00AM BLOOD Glucose-112* UreaN-11 Creat-0.7 Na-146* K-3.3 Cl-116* HCO3-21* AnGap-12 [2141-8-1] 02:01PM BLOOD Glucose-252* UreaN-7 Creat-0.5 Na-142 K-3.8 Cl-112* HCO3-23 AnGap-11 [2141-7-29] 08:20PM BLOOD ALT-29 AST-39 CK(CPK)-147 AlkPhos-92 TotBili-0.2 [2141-7-29] 08:20PM BLOOD Lipase-696* [2141-7-31] 05:00AM BLOOD Lipase-54 [2141-7-29] 08:20PM BLOOD Albumin-3.8 [2141-8-1] 02:01PM BLOOD Calcium-8.0* Phos-2.2* Mg-2.5 Iron-87 [2141-8-1] 02:01PM BLOOD calTIBC-246* Hapto-175 Ferritn-159* TRF-189* [2141-8-1] 02:01PM BLOOD Ret Aut-0.5* [2141-7-31] 05:00AM BLOOD VitB12-617 [2141-7-30] 01:13PM BLOOD %HbA1c-11.6* eAG-286* [2141-7-30] 11:45AM BLOOD Triglyc-62 [2141-7-29] 08:20PM BLOOD Osmolal-369* [2141-7-30] 11:45AM BLOOD TSH-0.18* [2141-7-29] 11:50PM BLOOD TSH-0.21* [2141-7-30] 11:45AM BLOOD T3-68* Free T4-1.2 [2141-7-29] 08:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs on Discharge: [2141-8-2] 07:20AM BLOOD WBC-6.8 RBC-3.91* Hgb-11.6* Hct-35.5* MCV-91 MCH-29.6 MCHC-32.5 RDW-14.7 Plt Ct-97* [2141-8-2] 07:20AM BLOOD Plt Smr-LOW Plt Ct-97* [2141-8-1] 02:01PM BLOOD Ret Aut-0.5* [2141-8-2] 07:20AM BLOOD Glucose-236* UreaN-6 Creat-0.5 Na-148* K-4.1 Cl-115* HCO3-28 AnGap-9 [2141-8-1] 02:01PM BLOOD LD(LDH)-324* [2141-8-1] 02:01PM BLOOD calTIBC-246* Hapto-175 Ferritn-159* TRF-189* [2141-7-30] 01:13PM BLOOD %HbA1c-11.6* eAG-286* Imaging: CT Head ([2141-7-29]): "Slightly limited study due to patient motion demonstrates no acute intracranial process." CT abdomen ([2141-7-29]): "Mild ascending colonic bowel wall thickening likely underdistension and accordingly felt probably due to artifact; however, mild colitis cannot be completely excluded. Emphysematic changes and scarring is noted in the lung apices. Bibasilar atelectasis. Old deformity of T5 vertebral body. Old rib deformities noted bilaterally. No free air or free fluid within the abdomen. No focal fluid collections. Borderline features suggesting fatty liver. Esophagus wall is mildly thickened around the feeding tube." Micro: [2141-7-31] URINE URINE CULTURE-FINAL INPATIENT [2141-7-30] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2141-7-29] URINE URINE CULTURE-FINAL EMERGENCY [Hospital1 ] [2141-7-29] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2141-7-29] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] Brief Hospital Course: 53 year old woman with DM type I on insulin pump at home found unresponsive at home in DKA, extubated and transferred out of the MICU on SQ insulin to the medical floor, with no infectious etiology identified. # Diabetic ketoacidosis: Unclear etiology, however, it appears there was pump dysfunction for 48 hours prior to admission. The patient arrived from OSH, intubated, for management of DKA. She was directly admitted to the MICU, where she received IV insulin until her anion gap closed. At the OSH, she was on vancomycin and cefepime, which was changed to vancomycin and zosyn while here, and subsequently discontinued after 48 hours for lack of clinical signs and symptoms of infection. She was extubated within 24 hours at [Hospital1 18]. After her anion gap closed, she was transferred to the floor, where she was continued on subcutaneous basal-bolus insulin. She was discharged to an immediate [Last Name (un) ] appointment where she will receive insulin pump teaching and increased basal dosing instructions. She was counseled to call her physicians immediately should her glucose be >400 in order to act quickly and prevent recurrence of DKA. # Thrombocytopenia: The patient had a platelet drop from a baseline of mid-200s to 97. HITT was considered, although 4T score is 2 (2 for thrombocytopenia, 0 for timing, 0 for thrombosis, and 0 for other cause). The most likely explanation for her thrombocytopenia is hemodilution, although there may be some effect from vancomycin as well. A platelet factor 4 antibody is pending at the time of discharge, and she was given instructions to follow up with her PCP in two days to have a repeat CBC to evaluate her platelet count. # Hypernatremia: Secondary to free water deficit. Her Na was 148 on the day of discharge. She was encouraged to increase her free water intake and will have her sodium checked in two days at her follow up PCP [Name Initial (PRE) 648]. #Anemia: Increased ferritin with a lowered transferring are consistent with anemia of chronic inflammation in addition to hemodilution. She was guiac negative without any evidence of an acute GI bleed. #GERD: She was transitioned to lansoprazole while in the hospital, but her home omeprazole was restarted at discharge. #Social situation: Concern was raised in the ICU about the behavior of her husband, who was preventing others from seeing Ms. [Known lastname 22571]. She was seen again by social work on [Hospital Ward Name 121] 7 with no identifiation of issues of imminent concern, but these issues should continue to be addressed as an outpatient. All other chronic medical conditions, including hyperlipidema, hypothyroidism, and depression were addressed with continuation of her home medications. The patient was Full Code throughout admission. Transitions of care: - follow up platelet factor 4 antibody (negative) - recheck platelets - recheck sodium - ongoing glucose management and education Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Rosuvastatin Calcium 40 mg PO DAILY 2. Ezetimibe 10 mg PO DAILY 3. LaMOTrigine 75 mg PO QHS 4. Aripiprazole 5 mg PO QHS 5. Duloxetine 120 mg PO DAILY 6. Pregabalin 100 mg PO TID 7. Quetiapine Fumarate 100 mg PO QHS 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Nicotine Patch 14 mg TD DAILY 10. Tiotropium Bromide 1 CAP IH DAILY 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 12. Alendronate Sodium 70 mg PO 1X/WEEK (MO) 13. Estring NF (estradiol) 2 mg Vaginal q3months 14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 15. Aspirin 81 mg PO DAILY 16. Calcium 600 with Vitamin D3 NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral [Hospital1 ] 17. Omeprazole 40 mg PO DAILY 18. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal rate minimum: 1.3 units/hr Basal rate maximum: 1.3 units/hr Target glucose: 80-180 Fingersticks: QAC and HS Discharge Medications: 1. Aripiprazole 5 mg PO QHS 2. Duloxetine 120 mg PO DAILY 3. Ezetimibe 10 mg PO DAILY 4. LaMOTrigine 75 mg PO QHS 5. Levothyroxine Sodium 125 mcg PO DAILY 6. Nicotine Patch 14 mg TD DAILY 7. Pregabalin 100 mg PO TID 8. Quetiapine Fumarate 100 mg PO QHS 9. Rosuvastatin Calcium 40 mg PO DAILY 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 11. Alendronate Sodium 70 mg PO 1X/WEEK (MO) 12. Aspirin 81 mg PO DAILY 13. Calcium 600 with Vitamin D3 NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral [Hospital1 ] 14. Estring NF (estradiol) 2 mg Vaginal q3months 15. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 16. Tiotropium Bromide 1 CAP IH DAILY 17. Glargine 20 Units Breakfast Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 18. Omeprazole 40 mg PO DAILY Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic Ketoacidosis Secondary: Type I Diabetes GERD Depression Hypothyroidism Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 22571], You were recently admitted to [Hospital1 18] for severe diabetic ketoacidosis. This crisis occurs when your glucose is very high and several organs are effected. You received continuous insulin and once your glucose improved, you were transitioned to subcutaneous insulin. You will see the [Last Name (un) ] doctors today who [Name5 (PTitle) ] complete teaching and restart your pump at a higher insulin basal dose. In order to prevent a similar episode like this from happening again in the future, please call your doctor immediately if your fingerstick glucose check is critically high or greater than 500. It is important to act quickly when your glucose is this high. Your platelets were low which may have been due to all the intravenous fluids you received, or perhaps one of your medications. Additionally, your sodium is high. Please drink increasing amounts of water over the next week (8 glasses/day). You have a follow up appointment with your PCP this [Name9 (PRE) 2974] [2141-8-4] where your labs will be checked including your platelets and sodium. We have perscribed you a subcutaneous insulin sliding scale, but this will be changed later today at your appointment at the [Last Name (un) ] when you restart your pump. It was our pleasure to take care of you while you were in the hospital. Please do not hesitate to contact us with any questions, comments or concerns. With Warm Regards, Your Inpatient Medicine Team Followup Instructions: TODAY 4:30PM [Last Name (un) ] DR: [First Name9 (NamePattern2) 22625] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] will restart your insulin pump at this appointment. Department: [Hospital3 249] When: FRIDAY [2141-8-4] at 10:30 AM With: [Company 191] POST [Hospital 894] CLINIC with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[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. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up. Completed by:[2141-8-2]	[ "401.9", "V45.85", "E878.1", "272.4", "244.9", "V49.87", "518.81", "530.81", "300.00", "250.13", "V15.51", "729.1", "287.5", "584.9", "V58.67", "276.0", "285.9", "296.50", "996.57", "733.00", "V15.82" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	12279, 12285	7325, 10136	307, 337	12434, 12434	3909, 3914	14117, 14953	2968, 3087		11363, 12256		12306, 12413		10314, 11340			12585, 14094									3102, 3890																			2155, 2603		255, 269			5795, 7302				365, 2135										3929, 5775		12449, 12561	10157, 10288				2625, 2806	2822, 2952
69,696	154,172	35430	Discharge summary	report	Admission Date: [2113-9-19] Discharge Date: [2113-9-20] Date of Birth: [2032-1-20] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2297] Chief Complaint: syncope and dizziness . Reason for MICU transfer: s/p PEA arrest Major Surgical or Invasive Procedure: TEE History of Present Illness: 81 y/o F w/ HTN, DM2, and h/o AAA graft repair in [2108] c/b leaks requiring multiple endovascular repairs (most recently [Month (only) 116] [2112]), presented today after a likely syncopal event. She reportedly passed out and upon awakening, alerted the emergency call bell and EMS found her on the bathroom floor. Upon arrival to the ED she denied chest pain, shortness of breath, fever or cough. She endorsed feeling dizzy, weak and had abdominal discomfort. . Initial ED vitals were 95.4F, HR 65, 103/49 RR 16 100% 3L. Shortly after arrival her BP dropped to 80/50s, lactate was 6.5, and she was started on fluids and received vancomycin/zosyn for empiric coverage for septic shock. Due to the abdominal discomfort and hypotension in setting of prior AAA, CT abd/pelvis was completed which showed stable AAA in size, leak present but unchanged, and also revealed RA dilitation and hepatic congestion. This led to suspicion for acute right heart failure secondary to a large pulmonary embolism. Bedside ultrasound showed a dilated IVC. Vascular was contact[Name (NI) ] regarding risk of lysis with AAA leak and decision was made to pursue tPA. The patient then went into PEA arrest (duration ~ 10 minutes), CPR initiated and pulse spontaneously returned after epinephrine and atropine were administered. Approximately 15 minutes later she re-entered PEA arrest (duration ~35 minutes). 100mg tPA was given during the code. She was intubated, not sedated, placed on levophed, phenylephrine and epinephrine for pressor support, and transfered to the MICU. . Upon arrival to the floor, she was intubated, non-responsive, not moving any extremities or withdrawing to pain, and pupils were fixed and dilated bilaterally. Vasopressin was started for additional pressor support. Lactate increased from 6 -> 13 -> 16. Fluids were hung wide open. She received one unit of PRBC with appropriate increase in HCT from 28 -> 31 -> 35. Bicarb was persistently low 16 -> 15 -> 9 -> 7, therefore bolus of 2 amps of bicarb were given and she was started on a bicarb drip. She developed wide-complex ventricular tachycardia (maintained pulse throughout) and was given amiodarone 150mg IV x1 with conversion to sinus rhythm. Glucose was elevated ~ 600s, she was therefore given insulin bolus followed by initiation of an insulin drip. PTT was persistently >150 and INR was elevated, therefore arterial line was postponed. Artic sun was placed with temperature goal 33-34C. Bedside ECHO showed RV strain suggestive of pulmonary embolism. TEE was then completed which showed borderline RV function without clot seen within the main pulmonary artery. Her two grandsons were periodically updated on her critical condition and voiced that wishes were for patient to remain full code with aggressive resuscitative care. . Review of systems: unable to obtain because patient unresponsive Past Medical History: - AAA s/p stent graft repair [2111] c/b leak, s/p embolization of lumbar and translumbar embolization, most recently coiled 5/[2112]. - HTN - Diabetes mellitus type 2 - h/o left leg ulcer repair Social History: She has 1 daughter (currently in [Name (NI) 4565]) and 2 grandson's here in [Location (un) 86]. Family History: n/c Physical Exam: On Admission General: intubated, not sedated, unresponsive, extremities cool, pulses diminished but present throughout HEENT: Sclera anicteric, MMM, oropharynx with small amounts red blood after TEE Neck: supple, unable to appreciate JVP, no LAD CV: RRR, normal S1/S2, no murmurs, rubs, gallops Lungs: occasional rhonchi b/l, no wheezes, rales Abdomen: soft, NT, mild distention, no organomegaly GU: no foley Ext: cool extremities, 1+ pulses, no edema Pertinent Results: [2113-9-19] 09:15AM BLOOD WBC-15.6# RBC-4.10 Hgb-12.3 Hct-35.4* MCV-86 MCH-30.0 MCHC-34.8 RDW-13.4 Plt Ct-168 [2113-9-19] 12:45PM BLOOD WBC-12.3* RBC-3.12* Hgb-9.4* Hct-28.9* MCV-93# MCH-30.2 MCHC-32.6 RDW-13.3 Plt Ct-70# [2113-9-19] 01:45PM BLOOD WBC-15.3 RBC-3.31* Hgb-9.9* Hct-31.3* MCV-95 MCH-29.8 MCHC-31.5 RDW-13.1 Plt Ct-90* [2113-9-19] 06:05PM BLOOD WBC-23.0# RBC-3.74 Hgb-11.0* Hct-35.7* MCV-96 MCH-29.4 MCHC-30.8* RDW-13.9 Plt Ct-129* [2113-9-19] 10:05PM BLOOD WBC-18.8* RBC-3.50* Hgb-10.5* Hct-32.8* MCV-94 MCH-30.1 MCHC-32.1 RDW-13.5 Plt Ct-169 [2113-9-20] 03:52AM BLOOD WBC-15.9* RBC-3.31* Hgb-9.8* Hct-29.9* MCV-90 MCH-29.5 MCHC-32.7 RDW-13.7 Plt Ct-146* [2113-9-20] 09:19AM BLOOD WBC-15.7* RBC-3.04* Hgb-8.9* Hct-27.1* MCV-89 MCH-29.3 MCHC-32.9 RDW-14.5 Plt Ct-122* [2113-9-20] 01:22PM BLOOD WBC-19.5* RBC-2.98* Hgb-8.8* Hct-26.6* MCV-89 MCH-29.5 MCHC-33.0 RDW-14.6 Plt Ct-89* [2113-9-19] 09:15AM BLOOD PT-12.1 PTT-21.6* INR(PT)-1.0 [2113-9-19] 12:45PM BLOOD PT-150 PTT-150* INR(PT)->19.2 [2113-9-19] 03:24PM BLOOD PT->150 PTT->150 INR(PT)->19.2 [2113-9-19] 06:05PM BLOOD PT-89.7* PTT->150* INR(PT)-10.5* [2113-9-19] 07:36PM BLOOD PT->150 PTT->150 INR(PT)->19.2 [2113-9-20] 01:00AM BLOOD PT-44.2* PTT->150* INR(PT)-4.6* [2113-9-20] 03:52AM BLOOD PT-32.2* PTT-129.6* INR(PT)-3.2* [2113-9-20] 09:19AM BLOOD PT-36.7* PTT-105.8* INR(PT)-3.7* [2113-9-20] 01:22PM BLOOD PT-38.4* PTT-95.6* INR(PT)-3.9* [2113-9-19] 01:45PM BLOOD Fibrino-<35 [2113-9-19] 07:36PM BLOOD Fibrino-<35 [2113-9-20] 09:19AM BLOOD Fibrino-<35* [2113-9-19] 09:15AM BLOOD Glucose-355* UreaN-37* Creat-1.5* Na-138 K-3.9 Cl-106 HCO3-16* AnGap-20 [2113-9-19] 12:45PM BLOOD Glucose-602* UreaN-31* Creat-1.4* Na-145 K-3.5 Cl-109* HCO3-15* AnGap-25* [2113-9-19] 01:45PM BLOOD Glucose-711* UreaN-32* Creat-1.5* Na-141 K-3.4 Cl-109* HCO3-9* AnGap-26* [2113-9-19] 06:05PM BLOOD Glucose-798* UreaN-31* Creat-1.8* Na-136 K-3.6 Cl-101 HCO3-7* AnGap-32* [2113-9-19] 07:36PM BLOOD Glucose-1038* UreaN-32* Creat-1.7* Na-136 K-3.2* Cl-96 HCO3-14* AnGap-29* [2113-9-19] 10:05PM BLOOD Glucose-882* UreaN-33* Creat-1.8* Na-138 K-2.6* Cl-96 HCO3-10* AnGap-35* [2113-9-20] 12:22AM BLOOD Glucose-847* Na-144 K-2.4* Cl-98 HCO3-12* AnGap-36* [2113-9-20] 03:52AM BLOOD Glucose-803* UreaN-35* Creat-2.2* Na-144 K-2.1* Cl-97 HCO3-12* AnGap-37* [2113-9-20] 06:41AM BLOOD Glucose-822* Na-146* K-2.3* Cl-98 HCO3-15* AnGap-35* [2113-9-20] 09:19AM BLOOD Glucose-695* UreaN-37* Creat-2.5* Na-147* K-2.7* Cl-98 HCO3-16* AnGap-36* [2113-9-20] 01:22PM BLOOD Glucose-643* UreaN-38* Creat-2.9* Na-147* K-3.4 Cl-95* HCO3-15* AnGap-40* [2113-9-19] 12:45PM BLOOD ALT-259* AST-280* TotBili-0.3 [2113-9-20] 01:22PM BLOOD ALT-3106* AST-3186* AlkPhos-67 TotBili-0.7 [2113-9-19] 12:45PM BLOOD Lipase-41 [2113-9-19] 09:15AM BLOOD cTropnT-<0.01 [2113-9-19] 12:48PM BLOOD pH-6.94* Comment-GREEN TOP [2113-9-19] 01:56PM BLOOD Type-ART pO2-285* pCO2-44 pH-6.88* calTCO2-9* Base XS--26 Intubat-INTUBATED Comment-GREEN TOP [2113-9-19] 03:33PM BLOOD Type-[Last Name (un) ] pH-6.87* [2113-9-19] 06:12PM BLOOD Type-[Last Name (un) ] pH-6.92* [2113-9-19] 07:43PM BLOOD Type-[Last Name (un) ] Temp-32.3 pO2-154* pCO2-33* pH-7.17* calTCO2-13* Base XS--15 Comment-GREEN TOP [2113-9-19] 10:23PM BLOOD Type-[Last Name (un) ] Temp-33.4 Rates-22/ Tidal V-600 PEEP-5 pO2-76* pCO2-36 pH-7.02* calTCO2-10* Base XS--21 -ASSIST/CON Intubat-INTUBATED [2113-9-20] 12:47AM BLOOD Type-[Last Name (un) ] Temp-34.3 Rates-30/ Tidal V-500 PEEP-5 pO2-67* pCO2-43 pH-7.04* calTCO2-12* Base XS--19 -ASSIST/CON Intubat-INTUBATED [2113-9-20] 04:17AM BLOOD Type-[Last Name (un) ] Temp-33.3 Rates-30/ Tidal V-500 PEEP-10 pO2-75* pCO2-42 pH-7.08* calTCO2-13* Base XS--17 -ASSIST/CON Intubat-INTUBATED Comment-GREEN TOP [2113-9-19] 10:27AM BLOOD Lactate-6.4* [2113-9-19] 12:48PM BLOOD Glucose-GREATER TH Lactate-13.4* Na-143 K-3.6 Cl-111* calHCO3-15* [2113-9-19] 01:56PM BLOOD Lactate-13.7* [2113-9-19] 03:33PM BLOOD Glucose-GREATER TH Lactate-14.3* Na-139 K-3.6 Cl-112* calHCO3-10* [2113-9-19] 06:12PM BLOOD Glucose-GREATER TH Lactate-15.4* Na-135 K-3.6 Cl-109* calHCO3-8* [2113-9-19] 07:43PM BLOOD Lactate-16.8* [2113-9-19] 10:23PM BLOOD Lactate-17.5* [2113-9-20] 12:47AM BLOOD Lactate-20.0* [2113-9-20] 04:17AM BLOOD Lactate-20.5* [2113-9-19] 12:48PM BLOOD freeCa-1.19 [2113-9-19] 03:33PM BLOOD freeCa-0.96* [2113-9-19] 06:12PM BLOOD freeCa-1.19 [2113-9-19] 07:43PM BLOOD freeCa-1.00* [2113-9-19] 10:23PM BLOOD freeCa-1.13 [2113-9-20] 12:47AM BLOOD freeCa-1.06* [2113-9-20] 04:17AM BLOOD freeCa-1.12 [2113-9-19] 11:25AM URINE Mucous-FEW [2113-9-19] 11:25AM URINE CastHy-8* [2113-9-19] 11:25AM URINE RBC-3* WBC-3 Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 [2113-9-19] 11:25AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2113-9-19] 11:25AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.050* CT Abdomen [9-19] 1. Stable tiny type 2 endoleak with overall aneurysm sac diameter stable from [2113-6-6]. No signs of rupture or retroperitoneal hematoma. 2. Marked right atrial cardiac chamber enlargement with heterogeneous perfusion of the liver suggestive of passive hepatic congestion, which can be seen in the setting of right-sided heart failure. Please correlate clinically. 3. Right adrenal lesion, stable, compatible with adrenal myolipoma. TEE [9-19] The right atrium is dilated. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated with borderline normal free wall function. There is no mass/thrombus in the right ventricle.The pulmonary trunk and bifurcation are seen ,no evidence of pulmonary artety thrombus. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. IMPRESSION: RV borderline normal free wall function.There is no mass/thrombus in the right ventricle.The pulmonary trunk and bifurcation are seen ,no evidence of pulmonary artety thrombus. TTE [9-19] There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with depressed free wall contractility however there is sparing of the RV apex ([Last Name (un) 13367] sign). There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: RV strain suggestive of acute pulmonary embolism. Brief Hospital Course: Primary Reason for Hospitalization: 81 y/o w/ DM, HTN, and AAA s/p endovascular repair w/ persistent leak, presented after syncopal episode, then developed shock, PEA arrest and hypoxic respiratory failure and passed away in the MICU. . #Severe shock with multi-end organ damage: Suspect intial obstructive shock secondary to massive PE, which was lysed with tPA, but nonetheless she suffered prolonged PEA arrest with significant perfusion injuries. Other forms of shock appeared less likely including septic shock (no signs of PNA on CXR, no UTI or fever), cardiogenic shock (overall normal LVEF >55% on TEE), or hypovolemic shock (was 10L positive and no signs of blood loss). TEE did not show tamponade or aortic dissection. She was placed 4 pressors at max dosing but still was not able to main BP. It was suspected that her profound acidosis contributed to poor response to pressors. She appears to have had a post-arrest distributive shock. Her MVO2 was 75, which means her saturation was >90%. Therefore her macro-circulation was basically intact but she was not able to extract oxygen at the micro-circulatory level. She passed away at 2:10 PM on [2113-9-20] with family at the bedside. . #Neurologic compromise: Pupils were dilated and fixed bilaterally since arrival to the unit. She was intubated without sedation and was non-responsive and did not moved any extremities. It was suspected that she had global ischemia and would meet brain death criteria however she passed away before formal brain death evaluation. . #AAA: stable in size, leak present but HCT was stable and did not appear to be losing large amounts of blood. Did not appear to be related to patient's demise. Medications on Admission: amlodipine 10mg daily atenolol 50mg [Hospital1 ] glipizide 5mg daily HCTZ 25mg daily lisinopril 20mg daily simvastatin 20mg daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "V70.7", "995.92", "250.00", "415.19", "441.4", "427.5", "518.81", "427.1", "584.9", "996.1", "780.2", "038.9", "401.9", "286.9", "276.2", "785.52", "E878.2" ]	icd9cm	[ [ [] ] ]	[ "99.10", "38.93", "96.71", "88.72", "99.60", "96.04" ]	icd9pcs	[ [ [] ] ]	13368, 13377	11453, 13151	370, 375	13429, 13439	4166, 11430	13495, 13506	3673, 3678		13336, 13345		13398, 13408		13177, 13313			13463, 13472									3693, 4147																			3260, 3308		265, 332							403, 3240																	3330, 3535	3551, 3657
9,736	106,592	6126	Discharge summary	report	Admission Date: [2184-6-2] Discharge Date: [2184-6-14] Date of Birth: [2115-6-2] Sex: M CHIEF COMPLAINT: Patient presents with shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male well known to the cardiothoracic service after a had initially presented with aortic insufficiency and aortic root dilation with shortness of breath. The patient had a Bentall procedure performed on [2184-5-19] and underwent [Initials (NamePattern4) ] [Last Name (NamePattern4) 3928] postoperative course including mental status confusion, reintubation for pulmonary secretions, and chest tube for a worsening right sided pleural effusion. After postoperative day seven the patient's mental status cleared and the patient postoperative day 11. Initially at home the patient was doing well without complaints. However, the patient soon developed progressive shortness of breath. The patient presented to the emergency department in the evening of [2184-6-2] where Cardiology performed an echocardiogram which showed a moderately large circumferential pericardial effusion, moderate right ventricular invagination, no overt evidence of cardiac tympanode, and no significant aortic regurgitation. PAST MEDICAL HISTORY: Hypertension, DDD pacemaker placed three years ago for AV block PAST SURGICAL HISTORY: Bentall procedure performed [2184-5-19]. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 q day. 2. Lopressor 35 mg b.i.d. 3. Coumadin 5 mg q day. 4. Colace 100 mg b.i.d. 5. Levofloxacin 400 mg q day. 6. Norvasc 10 mg q day. 7. Combivent inhaler. 8. Lasix 40 mg b.i.d. 9. KCL 20 mg b.i.d. 10. Captopril 25 mg q day. 11. Amiodarone 400 mg q day. 11. P.r.n. Percocet and Ativan. ALLERGIES: None. SOCIAL HISTORY: Remote use of alcohol and tobacco. PHYSICAL EXAMINATION: The patient presents as a well developed elderly male, appearing stated age in mild respiratory distress and mildly tachypneic. Lungs showed a right sided rub at the base with decreased bilateral breath sounds. Heart was regular rate and rhythm with distant heart sounds. JVD was noted upon neck examination. Abdomen was normal, nontender, nondistended and with positive bowel sounds External examination did not show evidence of an obvious click. There was no signs of erythema or tenderness at the sternal wound. Extremities showed no signs of edema and were warm and well perfused. ADMITTING LABORATORIES: White count of 14, hematocrit of 27. Chem 7 showed a glucose of 120, sodium 130, potassium 4.5, chloride 100, bicarb 20, BUN 37 and a creatinine of 1.3. ADMISSION RADIOLOGY: 1. Cardiac echo as described above. 2. Chest x-ray showed a moderate right sided pleural effusion, increased cardiac size and a displaced sternal wire in the mid to lower sternal pole. HOSPITAL COURSE: The patient was admitted to the Cardiothoracic surgery service for follow-up of presenting signs and radiologic findings. Over night the patient had large amounts of serous drainage from his right chest tube site without symptomatic change. The patient was afebrile with stable vital signs. The patient was transfused a total of six units of FFP as well as .5 mg of Vitamin K in order to correct a coagulopathy of an INR of 3.6 so that a right sided chest tube could be placed to drain the right side of the pleural effusion. On [2184-6-4] it was noted that the patient developed an area of induration and erythema at the inferior pole of the sternal incision. This area had not been identified on the initial emergency room evaluation. It was felt this was of significant concern for infection of the sternal wound, although there was no expressible puffs from the wound site. Upon re-examination of the sternal wound there was an audible click indicating probable sternal instability. An echocardiogram of [2184-6-4] which showed an enlarged pericardial effusion. A CAT scan with contrast was obtained at this time which helped to distinguish between pleural effusion and pericardial effusion for this patient. It became obvious after the CAT scan that most of the fluid visualized on initial chest x-ray was essentially representative of pericardial fluid. It was also noted that the sternal edges did not align properly, though there was no free fluid or signs of infection present along the sternal incision. Plans were made to perform pericardial window the following day given the size of the pericardial tympanode, the symptomatic state of the patient, and the recorded EF of 20 to 30% on the most recent echocardiogram. On [2184-6-6] the patient underwent pericardial window requiring a sternal Robeicek weave. The patient tolerated the procedure well and was transferred in stable condition to the cardiothoracic care unit. The patient was extubated on postoperative day one and did so without any difficulties. Operative wounds appeared to be clean, dry and intact and the patient sternum was no longer unstable. The patient's cardio and respiratory status were both fine. The patient continued to improve the following days and worked well with physical therapy. He was noted to be afebrile with stable vital signs. The patient walked with physical therapy, regular diet and was able to void on his own. The patient remained having a small O2 requirement of two liters nasal cannula which maintained his O2 saturations in the mid 90's. The patient was continued on antibiotics (Vancomycin) for a total of one week. Operative cultures as well as other cultures taken at the time of admission all turned out to be negative. Therefore, the patient did not require any further antibiotic therapy. The patient was noted to develop atrial flutter as early as [6-6] and was seen by the electrophysiology staff on [2184-6-11]. The patient was started on Amiodarone 400 mg p.o. q day for the treatment of this arrhythmia. The patient was also begun back on his anti-coagulation and was said to be followed by the EP staff. The EP staff would follow the patient and possibly cardiovert the patient in four weeks if the arrhythmias still persisted at that point. On [2184-6-6] the patient was afebrile with stable vital signs. The patient completed full work out with physical therapy without any oxygen requirement. The patient s wounds were clean, dry and intact and there was no sternal click. The patient had no complaints, said he was breathing well and appeared to be doing quite well. The patient was therefore, felt to be stable from medical standpoint to be discharged home. The patient's INR at the time of discharge was 1.4. The patient had been taking 5 mg of Coumadin per night. The patient was started on Lovenox 30 mg subq b.i.d. in replacement of his Heparin drip which he had been on during the hospital stay. The patient would be taking this Lovenox subcutaneously until his Coumadin became therapeutic. DISCHARGE DISPOSITION: Home. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. In addition to preoperative - Zantac 150 mg p.o. b.i.d., 2. Aspirin 81 mg p.o. q day. 3. Norvasc 10 mg p.o. q day. 4. Captopril 25 mg p.o. t.i.d. 5. Lopressor 75 mg p.o. b.i.d. 6. Lasix 40 mg p.o. b.i.d. 7. Potassium 40 mEq p.o. b.i.d. 8. Colace 100 mg p.o. b.i.d. 9. Coumadin 5 mg p.o. q day. 10. Amiodarone 400 mg p.o. q day. 11. Albuterol inhaler two puffs q 4 hours p.r.n. 12. Atrovent inhaler two puffs q 4 hours 13. Percocet one p.o. q 4 to 6 hours p.r.n. 14. Lovenox 30 mg subq b.i.d. until INR is between 2.5 to 3. DISCHARGE INSTRUCTIONS: The patient is to take Lovenox injections b.i.d. through the [Hospital6 407] until his INR is between the therapeutic range of 2.5 and 3. The patient is to have blood drawn on [2184-6-16] for an INR level and then as needed afterwards. The patient is then to have his INRs monitored through his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 11139], [0-0-], who will adjust his Coumadin appropriate to maintain an INR of 2.5 to 3. The patient is to take all his other medications as outlined above. The patient is to follow-up with Dr. [Last Name (STitle) 1537] in one week in order to get wound check and a white blood cell count. The patient was instructed upon the precise types of symptoms and signs which would necessitate the patient coming in to see a cardiothoracic surgeon. [Last Name (LF) ],[First Name3 (LF) ] E. M.D.02-248 Dictated By:[Dictator Info ] MEDQUIST36 D: [2184-6-14] T: [2184-6-14] 19:58 JOB#: [Job Number 21642] 1 1 1 R	[ "511.9", "423.9", "427.32", "998.3", "V43.3", "997.1", "401.9", "V45.01" ]	icd9cm	[ [ [] ] ]	[ "77.61", "34.79", "37.0", "37.12" ]	icd9pcs	[ [ [] ] ]	6964, 6971			6993, 7002					7025, 7565			1445, 1775		2857, 6940		7590, 8685								1373, 1419													1850, 2839									138, 182							211, 1261																	1284, 1349	1792, 1827
24,477	127,433	17708	Discharge summary	report	Admission Date: [2195-10-16] Discharge Date: [2195-10-25] Date of Birth: [2141-6-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (un) 2888] Chief Complaint: shortness of breath, admitted from Cardiology clinic for CHF exacerbation Major Surgical or Invasive Procedure: [2195-10-19] right heart catheterization [2195-10-23] PICC placement History of Present Illness: Mr. [Known lastname 49249] is a 54y/o gentleman with HTN, HLD, DM2, CKD (baseline Cr 2.0-2.2), CAD s/p CABG [2186] (LIMA-LAD, SVG-PDA, and radial-OM1-OM2) with systolic and diastolic heart failure (EF has been as low as 20% in the past) who is admitted from clinic due to concern for CHF exacerbation. In [4-/2195] he had a B&WH admission for heart failure in the setting of a 30 lb weight gain. There he reportedly had an EF of 20% on admission (in acute decompensated CHF), improved to 40% on discharge. He was diuresed down to 220 lbs. After his hospitalization, he was compliant with medications and feels that he has been good about adhering to a low-salt diet. He has been on Lasix 80mg [Hospital1 ] since then. Due to recent dietary changes, he may have a lower baseline dry weight (or, alternatively decreased muscle mass at baseline). He came to Cardiology clinic today because of 2 weeks of progressive shortness of breath on exertion. ~1 month ago, he could walk 4 blocks before getting very tired but over the past 2 weeks he has progressed to the point that he is short of breath after taking a few steps. He has orthopnea and has not been able to sleep comfortably; he gets a few hours of rest when seated in a chair. He feels exhausted. Denies chest pain or palpitations. Prior to CABG, his anginal pain was exertional back pain, but he has had none of this recently. He feels that he has been urinating less after taking his usual dose of Lasix. No missed doses of Lasix. Has been adhering to his low salt diet. His weight is up 5 lbs over the past week and is now 228.17 lbs. Pedal edema is mildly worse than usual. He notes that he has worsening painless ulcers on his anterior calves. Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: Hypertension Dyslipidemia Diabetes mellitus -retinopathy s/p laser surgery -peripheral neuropathy with ulcers Chronic kidney disease (baseline Cr 2.0-2.2) Coronary artery disease -s/p CABG in [2186] (LIMA-LAD, SVG-PDA, and radial-OM1-OM2) Congestive heart failure -[4-/2195]: B&WH admission with EF of 20% in CHF, improved to 40% on discharge Deep vein thrombosis x1 (s/p Warfarin in the past) s/p Right knee arthroscopy Iron deficiency anemia Gout Social History: -Home: Lives in [Location ] with his wife. Married 20 years. -Occupation: Works as a financial planner, lawyer, runs a property company. -Tobacco: used to smoke one cigar daily since high school until stopping after CABG. No cigaretters. -EtOH: None -Illicits: None Family History: Mom had CABG in 60s. 3 brothers all without heart disease or diabetes. Father with ?lymph cancer. Physical Exam: ADMISSION EXAM: T=98.6 HR=104 BP=144/82 RR=26 O2SAT=90%4L NC, 86%RA Weight: 103.5 kgs (228.17 lbs) GENERAL: Alert, oriented x3. Cannot complete long sentences without pausing to catch breath. Not in acute distress, however. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with elevated JVP to earlobe at 45 degrees. CARDIAC: PMI closer to midline w/ RV lift. RR, S1, S2 w/ paradoxical splitting, S3. No murmur or rub. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles [Hospital1 ]-basilar lung fields, worse on the right. ABDOMEN: Softly distended. Abd aorta not enlarged by palpation. No abdominal bruits. BS present. EXTREMITIES/SKIN: Cooler. Severe stasis dermatitis with anterior weeping ulcers on lower extremities. Also with healing ulcer on R side of thigh. [2-9]+ edema to thighs bilaterally. PULSES: dopplerable throughout, left DP is 1+. DISCHARGE EXAM: T=97.4, BP 129/74 (123/155/63-81), HR 71 (67-80), RR 18, POx 99%RA weight: 96kg (211 lbs) GENERAL: Alert, oriented x3. Very comfortable. Ambulating around room with no complaints. HEENT: MMM NECK: Supple with JVP 6-7cm CARDIAC: PMI closer to midline w/ RV lift. RR, S1, S2 w/ paradoxical splitting, S3. No murmur or rub. LUNGS: Clear to auscultation bilaterally ABDOMEN: Softly distended. Abd aorta not enlarged by palpation. No abdominal bruits. BS present. EXTREMITIES/SKIN: Cooler. severe stasis dermatitis with anterior weeping ulcers on lower extremities. also with healing ulcer on R side of thigh. Trace LE edema. Pertinent Results: ================================================== ADMISSION LABS [2195-10-16] 01:30PM GLUCOSE-87 UREA N-61* CREAT-2.5* SODIUM-136 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16 [2195-10-16] 01:30PM CK-MB-6 cTropnT-0.05* proBNP-4874* [2195-10-16] 01:30PM WBC-7.8 RBC-4.13* HGB-9.9* HCT-32.9* MCV-80* MCH-23.9# MCHC-30.0# RDW-18.9* [2195-10-16] 01:30PM PLT COUNT-318# DISCHARGE LABS [2195-10-23] 07:10AM BLOOD WBC-4.9 RBC-3.88* Hgb-8.9* Hct-30.6* MCV-79* MCH-23.0* MCHC-29.1* RDW-18.4* Plt Ct-222 [2195-10-25] 06:57AM BLOOD Glucose-220* UreaN-89* Creat-3.4* Na-137 K-3.8 Cl-91* HCO3-35* AnGap-15 [2195-10-25] 06:57AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.9* ================================================== CREATININE TREND [2195-10-16] Creat-2.5 [2195-10-20] Creat-3.0 [2195-10-21] Creat-3.1 [2195-10-23] Creat-3.1 [2195-10-23] Creat-3.0 [2195-10-24] Creat-3.2 [2195-10-25] Creat-3.4 WBC TREND [2195-10-16] WBC-7.8 [2195-10-19] WBC-13.3 [2195-10-23] WBC-4.9 OTHER PERTINENT LABS [2195-10-16] 01:30PM BLOOD CK-MB-6 cTropnT-0.05* proBNP-4874* [2195-10-17] 07:43AM BLOOD cTropnT-0.04* ================================================== MICROBIOLOGY DATA [2195-10-19] 7:56 pm BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2195-10-22] Blood Culture, Routine (Final [2195-10-22]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final [2195-10-20]): GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [2195-10-20]): GRAM POSITIVE COCCI IN CLUSTERS. [2195-10-22] BLOOD CULTURE Blood Culture, Routine-PENDING [2195-10-21] BLOOD CULTURE Blood Culture, Routine-PENDING [2195-10-20] BLOOD CULTURE Blood Culture, Routine-PENDING [2195-10-19] URINE URINE CULTURE-FINAL [2195-10-19] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL [2195-10-19] 7:56 pm BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2195-10-22] Blood Culture, Routine (Final [2195-10-22]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S ================================================== 2D-ECHOCARDIOGRAM [2195-10-16]: This study was performed with Optison echocardiographic contrast [Doctor Last Name 360] for endocardial border detection. The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall LV systolic function appears moderately-to-severely depressed (ejection fraction 30 percent), with regional variation. The inferior septum, inferior free wall, and posterior wall appear severely hypokinetic, whereas the rest of the left ventricular walls appear mildy-to-moderately hypokinetic. In addition, significant mechanical dyssynchrony with a typical left bundle branch block activation sequence is present. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a marked restrictive filling abnormality, with elevated left atrial pressure. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . The right ventricle was poorly visualized. The right ventricular free wall was seen only in limited subcostal window imaging. On the basis of this single imaging window, the right ventricle appears hypokinetic, possibly severely so. The tricuspid annular dimension of 4.2 cm in the apical four chamber window suggests that the right ventricle is dilated, but the actual right ventricular cavity dimension could not be determined with certainty due to the technically suboptimal nature of this study. . The right ventricular outflow tract pulsed Doppler velocity spectrum is bifid, which suggests that pulmonary arterial hypertension due to precapillary (pulmonary arteriolar) constriction is present. . Compared with the findings of the prior study (images reviewed) of [2192-8-23], significant left ventricular and right ventricular contractile dysfunction is now present. Mechanical dyssynchrony is now present, with a markedly restrictive filling pattern. Suboptimal study, performed with contrast [Doctor Last Name 360]. ================================================== 2D-ECHOCARDIOGRAM 11:22:25 AM Compared with the prior study (images reviewed) of [2195-10-16], regional variation in left ventricular function is more difficult to determine due to absence of intravenous contrast administration. There is no obvious evidence of endocarditis. Estimated pulmonary artery pressure is lower. ================================================== ECG [2195-10-16] 11:32:30 AM Sinus rhythm. Complete left bundle branch block. Compared to the previous tracing of [2191-11-10] complete left bundle-branch block is now present. ECG [2195-10-19] 7:45:50 PM Sinus tachycardia. Left bundle-branch block. Compared to the previous tracing of [2195-10-17] the heart rate has increased. Non-conducted premature atrial contractions are no longer seen. ================================================== RIGHT HEART CATHETERIZATION [2195-10-19] 1. Resting hemodynamics revealed elevated right- and left-sided filling pressures, with a RVEDP of 20 mmHg and PCWP of 35 mmHg. There was severe pulmonary arterial hypertension, with PASP of 83 mmHg. The cardiac output was reduced, with a cardiac index of 2.1 L/min/m2 (using an assumed oxygen consumption). FINAL DIAGNOSIS: 1. Elevated right- and left-sided filling pressures. 2. Severe pulmonary arterial hypertension. 3. Reduced cardiac output. ================================================== BILAT LOWER EXT ULTRASOUND [2195-10-20] 9:01 AM No evidence of deep vein thrombosis in either leg. No superficial thrombophlebitis or edema identified. ================================================== CHEST PORT. LINE PLACEMENT [2195-10-23] 1:27 PM Satisfactory placement of right PICC line with tip in the low SVC. ================================================== Brief Hospital Course: Mr. [Known lastname 49249] is a 54 year old gentleman with HTN, DM2, CKD (baseline Cr 2.0-2.2), CAD s/p CABG [2186], as well as systolic and diastolic heart failure (EF had been as low as 20% but last known to be 40%), who was admitted to the Cardiology service from clinic on [2195-10-16] for worsening dyspnea over 2 weeks. CHF exacerbation was in the setting of new inferior HK and he was diuresed with hopes of pursuing RHC/LHC. Due to [Last Name (un) ] with Cr >3.0, only RHC was done, and showed very elevated filling pressures so he was transferred to the CCU for Milrinone to assist with Lasix gtt. His course has been complicated by PIV-associated MSSA bacteremia for which he is on 4 weeks of Nafcillin. He continued to be diuresed and was transferred back on the Cardiology floor. He was discharged home on oral diuretics with PCP, [Name10 (NameIs) ], and ID follow-up. ACTIVE ISSUES #. CHF exacerbation: volume status much improved, weight 103.5 --> 96kg. Improved JVP, improved pedal edema, no crackles on lung exam. Off supplemental oxygen, ambulating with no complaints. He will follow up at Cardiology Heart Failure clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP two days after discharge, and then will see his primary Cardiologist Dr. [Last Name (STitle) ] in 1 month. (a) diuresis He was treated with a Lasix gtt (mostly @30/hr). In the CCU was on Milrinone for a few hours. Did receive 2 doses of Metolazone. Diuresed well and was discharged on Torsemide instead of Furosemide. Given his Cr elevation, he will hold Torsemide on day of discharge and the subsequent day, but will restart Torsemide 60mg [Hospital1 ] on [2195-10-27]. (b) preload/afterload reduction Given his [Last Name (un) ] he could not be started on an ACEi but he was started on Isosorbide and Hydralazine, which were uptitrated. In addition, his Metoprolol was changed to Carvedilol for better afterload control. Hopefully in the future he can be put on an ACEi if his renal function allows. (c) improve contractile function He is s/p Milrinone in the CCU for a few hours. Also, in case his pump dysfunction is due to ischemic heart disease, he should undergo left heart catheterization when stable from a volume and [Last Name (un) ] standpoint, in order to see if there are any grafts/native vessels that would benefit from revascularization. Finally, he had significant dyssynchrony and he is a candidate for CRT and should get BiV-ICD once his infection is treated (can happen as outpatient within ~6weeks). (d) prevent remodeling He is on a beta blocker (Metoprolol changed to Carvedilol this admission). ACEi was not started because of [Last Name (un) ]. #. Peripheral IV-associated MSSA bacteremia: on Nafcillin x4 weeks. He rigored and spiked to 102.7 on arrival to the CCU from the RHC. Had HR up to 120 and RR 25. Never dropped BP however. WBC 8-->13, 91.5% PMNs. Received Vanc/Zosyn initially. Source was initially unclear. Infectious disease was consulted; the likely source is a right forearm PIV site which was infiltrated and erythematous. Grew MSSA from blood cultures 9/10 but subsequently cleared. Changed from Vanc to Nafcillin [2195-10-21] because it speciated as MSSA. Antibiotics were switched to Nafcillin. He declined TEE but underwent TTE on [10-21] that showed no obvious vegetation. Since cannot rule out endocarditis, will treat for 4 week course with Nafcillin via PICC [four week course [Date range (1) 49250]]. WBC trended down and he remained afebrile since [10-21]. He will follow up with Infectious Disease [Hospital 4898] clinic after discharge, with weekly surveillance labs sent to [Hospital 4898] clinic. #. Hypertension: BP now better controlled. He had SBP 140-160 so his medications were uptitrated. He was started on Isosorbide and Hydralazine, which were uptitrated. In addition, his Metoprolol was changed to Carvedilol for better afterload control. He should follow up with his PCP and Cardiologist to ensure adequate BP control. #. [Last Name (un) ] on CKD: Baseline Cr 2.1, presented at 2.5, now ~3.4. Elevated Cr likely secondary to decreased cardiac output and less perfusion than usual recently. His Allopurinol has been stopped. Medications were renally dosed. Avoided left heart cath due to risk of receiving dye. Creatinine initially improved somewhat with diuresis but then increased again toward the end of this admission. Cr on discharge is 3.4 - his Torsemide was held on day of discharge and the next day, but will be restarted on [10-27]. He should have Cr recheck at his upcoming Cardiology visit. Could benefit from Lisinopril in the future if renal function improves. He should establish care with a Nephrologist if he does not already have one. #. CAD s/p CABG Last cath in [2191] noted severe native 3VD with patent LIMA-LAD, SVG-PDA, and Radial-OM1-OM2. Admission TTE showed new inferior HK. He was continued on ASA, Pravastatin, and beta blocker (Metoprolol changed to Carvedilol). When he is stable from a volume and [Last Name (un) ] standpoint, he would benefit from left heart catheterization in order to assess grafts/native vessels. he will follow up with his Cardiologist. #. Neuropathic & venous statis ulcers. Weeping but not infected. Pulses palpable. He was seen by Wound care. If wounds do not heal with next several weeks, he should be referred for ABIs or a Vascular surgery consult to rule out an arterial component. He should get prescription compression stockings after his ulcers have healed and arterial insufficiency has been ruled out. INACTIVE ISSUES #. Diabetes mellitus: not optimally controlled. HbA1c has been >12% in the past but most recently was 7.1% in 5/[2195]. In house, he was on Lantus with SSI Humalog coverage, and AM glucose was 150-200. He is being discharged on his home Lantus and mealtime Aspart, and should follow up with his PCP for ongoing diabetes management. #. Dyslipidemia: stable. Cholesterol panel in [6-/2195]: TChol 132, TG 99, HDL 42, LDL 77. He continues on Pravastatin. #. h/o Deep vein thrombosis: LENIs negative here. He received Heparin DC TID for DVT prophylaxis. # Iron deficiency anemia: Hct stable at 30-33 this admission. He continues on his home iron supplements. TRANSITIONAL ISSUES -Code status: Full code -Emergency contact: [Name (NI) ] (wife) [Telephone/Fax (1) 49251] -Labs/studies pending at discharge: none -Cardiology follow-up: at [Hospital 1902] clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [MD Number(3) 49252] days, and then with primary Cardiologist Dr. [Last Name (STitle) ] in 1 month -dry weight: 96kg -diuretics: Given his Cr elevation, he will hold Torsemide on day of discharge and the subsequent day, but will restart Torsemide 60mg [Hospital1 ] on [2195-10-27]. -ACEi: Consider Lisinopril once renal function improves. -CRT: Should get BiV-ICD once his infection is treated. -cardiac cath: he should undergo LHC once stable from a volume and [Last Name (un) ] standpoint. -*PICC should be removed after completion of IV antibiotics.* -should be referred for ABIs or a Vascular surgery consult -should get prescription compression stockings after his ulcers have healed and arterial insufficiency has been ruled out -Neprology: He should establish care with a Nephrologist if he does not already have one. -Outpatient labs: He should have Cr/electrolyte recheck at his upcoming Cardiology visit. Also, will have weekly OPAT labs. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientPharmacy. 1. Furosemide 80 mg PO BID 2. Glargine 44 Units Bedtime aspart 22 Units Breakfast aspart 22 Units Lunch aspart 22 Units Dinner 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Pravastatin 80 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Allopurinol 100 mg PO DAILY Discharge Medications: 1. Nafcillin 2 g IV Q4H [four week course [Date range (1) 49250]] RX nafcillin in D2.4W 2 gram/100 mL 2 grams IV every 4 hours Disp #288 Gram Refills:0 2. Aspirin 81 mg PO DAILY 3. Glargine 44 Units Bedtime aspart 22 Units Breakfast aspart 22 Units Lunch aspart 22 Units Dinner 4. Pravastatin 80 mg PO DAILY 5. Carvedilol 25 mg PO BID RX carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 6. HydrALAzine 50 mg PO Q8H RX hydralazine 50 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY RX isosorbide mononitrate 120 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Outpatient Lab Work TUESDAY [2195-10-27]: Please check CHEM10. To be followed up by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [MD Number(3) 49253] ([Telephone/Fax (1) 49254] and also Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 49255]. 9. Torsemide 60 mg PO BID hold your Torsemide today and tomorrow, and restart on Tuesday [10-27] RX torsemide [Demadex] 20 mg 3 tablet(s) by mouth twice a day Disp #180 Tablet Refills:0 Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: PRIMARY: Congestive heart failure (Acute on Chronic) MSSA bacteremia SECONDARY: coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 49249], It was a pleasure taking care of you at [Hospital1 827]! You were admitted here because you were having worsening shortness of breath. You were found to have an exacerbation of your congestive heart failure. You underwent right heart catheterization which found that the filling pressures in your heart were very high so you went to the cardiac ICU for more aggressive fluid removal. Then you were transferred back to the floor and were changed back to oral diuretics. You have lost many pounds of fluid weight and are much more comfortable. Today's weight is 96kg (211 lbs). Please weigh yourself every morning, and call your doctor if weight goes up more than 3 lbs. Due to poor blood flow to the kidneys, your creatinine is elevated. On the day of discharge, your creatinine is 3.4. Please hold your Torsemide today and tomorrow, and restart on Tuesday [10-27]. You shuld have labs checked at your upcoming appointment (lab slip has been included). When your infection has been treated and kidney function is better, you will likely be referred for left heart catheterization to make sure there are no new blockages in your bypass grafts or heart arteries. In addition, you will be evaluated for a possible pacemaker/defibrillator that can help improve the pump function of your heart. Your hospital stay was comlpicated by a peripheral line-associated Staph bloodstream infection. You declined transesophageal echo to make sure there was no heart valve infection, so you will receive a full 4 weeks. You will follow up with the Infectious Disease team in Outpatient Antibiotic Therapy (OPAT) clinic. We made the following changes to your home medication list: -STOP Metoprolol -STOP Furosemide (Lasix) -STOP Allopurinol (because your kidney function is worsened; ask your Primary Care doctor when you can restart this) -START Carvedilol -START Torsemide (hold your Torsemide today and tomorrow, and restart on Tuesday [10-27]) -START Isosorbide mononitrite -START Hydralazine -START Nafcillin (Four week course [Date range (1) 49250].) Followup Instructions: CARDIOLOGY - HEART FAILURE CLINIC When: TUESDAY [2195-10-27] at 1:30 PM With: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please have labs checked at this visit. A lab slip had been included.* PRIMARY CARE Department: Primary Care - Dr. [Last Name (STitle) 49256] [Name (STitle) 49257] office [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724], NP Tue. [2195-11-3]; 4:00 pm [Location (un) 6138] Physicians 100 [Last Name (un) 49258] Way [Location (un) ], [Numeric Identifier 49259] Phone: [Telephone/Fax (1) 49260] CARDIOLOGY Department: CARDIAC SERVICES When: WEDNESDAY [2195-11-18] at 10:40 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage INFECTIOUS DISEASE - [Hospital 4898] CLINIC You will be contact[Name (NI) ] at home with an appointment. If you do not hear back within [4-13] business days, please call ([Telephone/Fax (1) 21403] to schedule a follow-up visit.	[ "250.50", "280.9", "V58.67", "999.39", "041.11", "707.19", "357.2", "459.81", "584.9", "E879.8", "V45.81", "790.7", "362.01", "274.9", "414.00", "403.90", "416.8", "585.9", "428.0", "428.43", "414.8", "272.4", "250.40", "276.2", "250.60", "V12.51" ]	icd9cm	[ [ [] ] ]	[ "37.21", "38.93", "89.64" ]	icd9pcs	[ [ [] ] ]	21406, 21451	12131, 18644	378, 457	21600, 21600	4902, 11537	23882, 25215	3126, 3225		20173, 21383		21472, 21579		19788, 20150		11554, 12108	21751, 23859									3240, 4243						4259, 4883								18658, 19762							265, 340							485, 2321												21615, 21727					2365, 2823	2839, 3110
11,626	151,820	21369	Discharge summary	report	Admission Date: [2149-7-10] Discharge Date: [2149-7-29] Date of Birth: [2083-2-22] Sex: Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old female transferred from [Hospital3 ] [Location (un) 620] for question of lymphoma. The patient recently presented to the [Last Name (un) 4068] on [2149-6-24], with a history of weakness, 50-pound weight loss over the past 3 months, and mouth sores. Her mouth sores were not responding to topical nystatin or p.o. Diflucan. At the [Last Name (un) 4068], she was found to have an urinary tract infection, hyponatremia to 127, an elevated alkaline phosphatase of 238, leukocytosis with an overall lymphopenia (white blood cell count 13.7, with a differential of 75 polys, 15 bands, 3 lymphocytes). A CAT scan of her thorax was performed at the outside hospital on [2149-6-25], showing bilateral axillary nodes as well as mediastinal, hilar, and pretracheal nodes that were enlarged. She also had enlarged inguinal nodes that were biopsied and preliminary pathology reports showed distorted architecture with eosonophilic predominance. During that hospitalization at the [Last Name (un) 4068], she also had a rash that was biopsied and that was consistent with a lichenoid keratosis or lichen planus. While at the [Last Name (un) 4068], she received a course of antibiotics, including levofloxacin for UTI and a course of Augmentin for a question of pneumonia by CT. She also received a short taper of prednisone from [2149-7-4] to [2149-7-10] for the possibility of pemphigus as a cause of her oral lesions. She received a short course of acyclovir for a small lesion on her left lower eyelid, which was potentially herpetic. She had negative HIV test and negative [Doctor First Name ] at the outside hospital. She had intermittent fevers while an inpatient and continued to complain of mouth pain, chronically poor vision, and a generalized rash. She also complained of increasing diarrhea. PAST MEDICAL HISTORY: Type 2 diabetes. Hyperlipidemia. Peptic ulcer disease/gastritis. Macular degeneration. Hypertension. SIADH. PAST SURGICAL HISTORY: Status post cholecystectomy. Status post appendectomy. Status post total abdominal hysterectomy. ALLERGIES: NSAIDS. HOME MEDICATIONS: 1. Lopressor. 2. Hydrochlorothiazide. 3. Cozaar. 4. Neurontin. 5. ________. 6. Calcium and vitamin D. 7. Lescol. 8. Insulin, dosage is not noted on the chart. SOCIAL HISTORY: The patient has no history of tobacco use or ethanol ingestion. She has 3 children and a sister who lives in the area. PHYSICAL EXAMINATION: On initial presentation, the patient's vital signs were as follows; temperature of 98.6, blood pressure of 128/51, heart rate of 76, respiratory rate of 18, saturation of 94 on room air. She was a woman in her mid 60s in no apparent distress. She had bilateral surgical pupils that were equally reactive and had full extraocular motions. She had no cervical lymphadenopathy, but large nontender axillary nodes were noted on exam. She had a regular rate with normal S1 and S2. There were no murmurs, rubs, or gallops. She had bibasilar rales noted. Her abdomen was nontender. There were two well-healed old surgical scars, one in the right upper quadrant from old a cholecystectomy and one below the umbilicus in the midline from her TAH. She had no hepatosplenomegaly noted on exam. She had no extremity clubbing, cyanosis, or edema. Her skin exam was notable for a diffuse macular rash on the legs and arms with signs of excoriation. She was alert and oriented times 3. Cranial nerves were intact. She had a normal strength and 1 plus symmetric DTRs. LABORATORY DATA: Her initial CBC showed a white count of 11.1, hematocrit of 32.6, platelet count of 375. Her chemistry showed a sodium of 128, potassium of 5.1, chloride of 93, CO2 of 26, BUN of 13, creatinine of 0.7, and glucose of 225. Her LFTs were as follows; ALT of 37, AST of 27, total bilirubin of 0.3, alkaline phosphatase of 199, LDH of 183, albumin of 2.2. HIV and [Doctor First Name ] tests were negative per the outside hospital. HOSPITAL COURSE: This 66-year-old female with history of mouth ulcerations, diffuse skin rash, lymphadenopathy, diarrhea, lymphopenia, hyponatremia, and anemia, was transferred in from the [Hospital3 ] [Location (un) 620] for workup of symptoms of unclear etiology. Multiple consult services were involved in order to determine the etiology of this lady's symptoms. Dermatology was consulted on [2149-7-11] in order to investigate her rash and oral ulcerations. They noted a diffuse maculopapular rash with a wide differential noted on their note. They requested several additional labs including HCV antibodies and performed a DFA of one of the lesions from the inside of her mouth. They followed upon the biopsy results from the outside hospital of the rash, which was most consistent with lichen planus. They recommended Aquaphor to her lips for symptomatic treatment. The gastrointestinal service was consulted on [2149-7-12], due to her diarrhea and oral ulcerations. The GI service wound up performing both the colonoscopy as well as an EGD on this patient. The colonoscopy was performed on Tuesday, [2149-7-15], for the history of diarrhea and weight loss. They found multiple non-bleeding aphthous ulcers ranging from 5 to 10 mm seen throughout the entire colon as well as terminal ileum. The differential at that time for the ulceration included Crohn's disease as well as Behcet disease or some form of vasculitis. Biopsies were performed at multiple sites. The EGD was also performed on [2149-7-15]. They found diffuse erythema and friability of the mucosa with no bleeding in the stomach, body, and antrum. Findings were compatible with gastritis. Biopsies were also performed here. The duodenum was noted to be normal. Surgery was also consulted on [2149-7-12] to determine if there is a surgical cause for her symptom. They recommended adding some additional studies to follow up on the elevated alkaline phosphatase. Optimizing nutrition, and offered to repeat open biopsy despite the fact that it has had been done previously at the outside hospital. She initially had been admitted to the BMT service because of the question of lymphoma, but was transferred over to the Acove Service on [2149-7-15]. The patient was started on tube feeds and was given TPN supplementation in order to optimize her nutritional status. The pulmonary service was consulted on [2149-7-16], given the diffuse pulmonary infiltrates that were seen as well as the chest CT patchy infiltrates and lymphadenopathy, they recommended adding some additional rheumatological investigations such as pANCA, cANCA, sedimentation rate, and requested a high-resolution chest CT to better evaluate the lung changes. Differential for her pulmonary complaints included eosinophilic pneumonitis versus some form of vasculitis. MRSA had been noted on the sputum [Last Name (LF) ], [First Name3 (LF) ] she was started on vancomycin. The ophthalmology service was consulted on [2149-7-17] because of her complaints of gradually decreasing vision bilaterally over the past month. She had a past eye history significant for bilateral cataract surgeries as well as panretinal photocoagulation for diabetic retinopathy done by Dr. [First Name (STitle) ]. She also has a history of iritis of unclear etiology in the past. The ophthalmology service recommended intensive course of topical lubrication as well as erythromycin ointment. They also recommended that they continue the Travatan drops that she has been receiving while in the hospital. Thus it was obvious from the above dictation, multiple services were involved with this patient in order to determine the cause of her diffuse multisystem disease. The overall clinical picture was puzzling. The small bowel-follow-through initially requested by GI had been performed which showed a stricture in the terminal ileum that the radiologist felt could be consistent with Crohn 's disease. However, the biopsies done from the diffuse colonic ulcerations were not consistent with Crohn's. The cutaneous biopsies were also not consistent with Crohn's disease. Vasculitis was still in everyone's differential, but there was no firm diagnosis at this time. Rheumatology was consulted on the [2149-7-17] in order to see if an unifying diagnosis could be discovered for her symptoms. The initial impression of the rheumatologist was that the most likely diagnosis at this point was Crohn's disease covering oral ulceration, chronic ulceration, ileal stricture, diarrhea, and weight loss, with possible associated complication of the sclerosing cholangitis leading to the biliary ductal dilatation and elevation of alkaline phosphatase and GTT. However, this could not explain the wide spread lymphadenopathy that has been noted. The thoracic service was consulted on [2149-7-19] to investigate the possibility of lung biopsy to further characterize her infiltrates and lymphadenopathy. On [2149-7-21] the patient had right upper lobe biopsies via VATS. She tolerated the procedure well. In the PACU, however, they were unable to wean the Neo-Synephrine drip for pressure. She also had a perioperative decreased urinary output under 10 cc an hour that was not responsive to multiple fluid boluses. She had an arterial line that was placed in the OR for monitoring of her blood pressure. She also had increasing hypoxia over her baseline 4 L requirement. The gas taken around that time was 7.31, 50, 90 on a 70 percent facemask and then 7.39, 46, 178, on a 100 percent nonrebreather. Status post VATS she had a chest tube kept to suction followed by CT surgery. The issue of whether or not to institute steroids was a longstanding conversation between the multiple services following this patient. She was on ocular steroids per ophthalmology and topical steroids for her rash, but systemic steroids were initially withheld secondary to concern for systemic infection. The patient had periodic fevers as well as the history of MRSA-positive sputum which was previously mentioned. There was also a question of whether or not she had pneumonia that was being treated. The ultimate perspective was that if there was no source of infection found following the VATS procedure that they would likely start systemic steroids. On [2149-7-22] at 2350 hours, the code was called stat for respiratory arrest possibly secondary to a postictal period. The patient was obtunded. She was intubated with etomidate and succinylcholine and 7-0 ETT tube was easily passed. Per notes from the overnight attending, the patient prior to that intubation was found semiconscious with her eyes rolled back, thrashing her arms, and unresponsive. At that time her vitals were 89/60 for blood pressure and heart rate of 130. An EGD was repeated on Wednesday [2149-7-23] secondary to an episode of hematemesis. They found grade 4 esophagitis with spontaneous bleeding seen in the middle third of the esophagus and lower third as well. The entire gastric mucosa was noted to be oozing, friable, and edematous. There was no discrete site of bleeding. The findings were consistent with a severe hemorrhagic gastritis. The duodenal mucosa was normal in that study. The recommendations of upper GI service were to continue the pantoprazole that she had been on and to begin Carafate slurry q.i.d. and follow her hematocrit. She was extubated on [2149-7-24], but had to be re-intubated several hours later for respiratory distress. This was done by anesthesia using the etomidate and succinylcholine with a 7.5 ETT tube. There were no complications from the reintubation. Additional complications aroused during her MICU stay including MRSA positive blood cultures. The patient was put on linezolid therapy. She was also found to be hep positive, therefore all heparin products were stopped. There was a consideration of argatroban to be started, however, the patient's hematocrit was stable; even still they were concerned about the history of severe gastritis and GI bleeding that occurred several days prior. The patient was started on Solu-Medrol for question of IBD. She was seen by Dr. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 9916] who saw the patient and was not convinced that Crohn's was the ultimate diagnosis to unite her symptoms. The patient continued to do poorly on the [2149-7-29]. A repeat head CT was done to look for evidence of CNS pathology which found new small infarcts including wedge shaped low attenuation sections in the right occipitoparietal junction and left anterior frontal area. A right basal ganglia lacunar infarct was also seen. These mini-strokes were possibly embolic and MRI was considered, but held pending a family meeting to discuss wishes regarding how aggressive they wanted to be in her treatment in the phase of this information. A family meeting was held later that day including the daughter. This patient was initially full code, but later that day was changed to CMO. The patient was put on the morphine drip and was pronounced dead later that evening. DISPOSITION: The patient deceased. DR.[First Name (STitle) ],[First Name3 (LF) ] 12-981 Dictated By:[Last Name (NamePattern1) 56466] MEDQUIST36 D: [2149-10-6] 14:45:49 T: [2149-10-7] 13:39:47 Job#: [Job Number 56467]	[ "434.91", "038.11", "783.7", "518.5", "535.01", "263.9", "428.0", "482.41", "276.1" ]	icd9cm	[ [ [] ] ]	[ "45.16", "41.31", "45.25", "45.13", "32.29", "00.14", "33.24", "88.72", "86.11", "38.7", "99.04", "38.93", "99.15", "99.07" ]	icd9pcs	[ [ [] ] ]														4194, 13635										2198, 2319				2337, 2498									2659, 4176																163, 2037																	2060, 2174	2515, 2636
17,966	194,273	2566	Discharge summary	report	Admission Date: [2160-4-29] Discharge Date: [2160-5-12] Date of Birth: [2132-7-11] Sex: F Service: CARDIOTHORACIC CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old female with a history of diabetes mellitus type I x18 years and hypercholesterolemia who presented with chest pain. The patient reported that one week ago she started experiencing epigastric pain after eating which she thought might be indigestion. A few days prior to her admission, the patient reports pain changed in quality from burning to pressure or tightness in the chest. She had this at rest and was worse with inspiration and exertion. She is experiencing shortness of breath, but denies any nausea, vomiting or diaphoresis. She also denied any recent fevers or upper respiratory tract symptoms. She went to [Hospital ] Clinic for her routine diabetes follow up and she was then sent to the Emergency Room for further evaluation. In the Emergency Room, electrocardiogram showed ST depressions and T-wave inversions in 1, 2, F, V4 through V6. She received aspirin, Lopressor and intravenous nitroglycerin GGT. A transthoracic echocardiogram showed ejection fraction of 25% with global hypokinesis, troponin of 3.2, CK of 275 and an MB of 5. She was admitted to the cardiac service for work up of her cardiac event. PAST MEDICAL HISTORY: 1. Diabetes mellitus type I x18 years 2. Hypercholesterolemia PAST SURGICAL HISTORY: None ADMISSION MEDICATIONS: 1. Insulin U-500 20 units q a.m., 26 q p.m. 2. Sliding scale with U-100 3. Glucophage 500 mg po bid 4. Lipitor 20 mg po qd 5. Zestril 40 mg po qd ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies any tobacco, alcohol, or drug use. FAMILY HISTORY: The patient's grandmother died at age 64 from coronary artery disease. PHYSICAL EXAM: VITAL SIGNS: The patient's temperature is 98.9??????, heart rate 87, blood pressure 112/54, respiratory rate 12, O2 saturation 95% on 2 liters. The patient weighs 93 kg. GENERAL: The patient is in no acute distress. HEAD, EARS, EYES, NOSE AND THROAT: No jugular venous distention. LUNGS: Clear bilaterally. HEART: Regular rate and rhythm with no murmur. ABDOMEN: Obese, soft and nontender with no masses. RECTUM: Heme negative. There is 1+ edema at the ankles. LABORATORY EXAMINATION: White count of 7.4, hematocrit 40.2, platelets 297. PT 12.7, PTT 22.4, INR 1.1. Sodium 142, potassium 3.9, chloride 104, bicarbonate 28, BUN 14, creatinine 0.8, glucose of 118. CK 275, MB 5, troponin I 3.2. She was beta HCG negative. IMAGING: Electrocardiogram showed sinus tachycardia at a rate of 110 with inferior lateral ST changes suggestive of myocardial injury. Chest x-ray showed heart size upper limits of normal, otherwise normal. Echocardiogram on [2160-4-29] significant for severe global hypokinesis, mild mitral regurgitation with ejection fraction of 25%. HOSPITAL COURSE: The patient was admitted to the cardiology service. The patient underwent cardiac catheterization on hospital day #1. This was significant for RCA stenosis of 70% and LAD stenosis of 90% and OM1 stenosis of 80% and OM2 stenosis of 60%. The patient tolerated this procedure well, was stabilized on aspirin, nitroglycerin drip, Zestril and a heparin drip. Hospital day #2, the patient was seen by [Last Name (un) ] for elevated blood glucose level resistant to insulin sliding scale. The patient was started on insulin drip for better glucose control. The patient was then seen by cardiothoracic surgery and evaluated for coronary artery bypass grafting. On hospital day #3, the patient was taken to the Operating Room where she underwent coronary artery bypass graft x4 with Dr. [Last Name (STitle) 70] and the cardiothoracic team. The grafts were left internal mammary artery to LAD, left radial to OM, supraventricular tachycardia to AM and supraventricular tachycardia to diagonal. The patient tolerated this procedure well. She underwent an EVH on the right thigh with hybrid skip of the right calf. She was transferred to the cardiothoracic surgery Intensive Care Unit stable on propofol and nitroglycerin drip. The patient postoperatively has remained stable. The patient was extubated without incident. The patient remained hemodynamically stable although the first postoperative night remained tachycardic. The patient was managed with intervascular expansion with Hespan and heart rate responded appropriately. The patient was weaned of all drips. Hematocrit was stable at 22. The patient had episode of chest tightness on postoperative day #1. Echocardiogram was performed which was significant for improvement in inferior wall motion compared to the previous study on [2160-4-29]. The patient continued to remain hemodynamically stable. Electrocardiogram showed no significant changes. On postoperative day #3, the patient continued to remain afebrile and hemodynamically stable and was transferred to the floor for the remainder of her recovery. The patient was seen by physical therapy and this is currently a level 5 activity. Hematocrits remained stable with the last hematocrit being 24. The chest tube, wires and Foley were discontinued without incident. Her blood glucose levels have been followed by the [Hospital ] Clinic, has remained in the 100s to 200s. The patient has been restarted on her fixed U-500 insulin dose in a sliding scale [First Name8 (NamePattern2) ] [Last Name (un) ]. The patient is tolerating a cardiac diet. Wounds remain clean, dry and intact. The patient stable, now ready for discharge home with follow up with Dr. [Last Name (STitle) 70] in six weeks and follow up with Dr. [Last Name (STitle) ] in one week. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft x4 2. Diabetes mellitus type I 3. Hypercholesterolemia DISCHARGE MEDICATIONS: 1. U-500 insulin 12 units subcutaneous q a.m., 10 units subcutaneous q p.m. 2. Lopressor 75 mg po bid 3. Colace 100 mg po bid 4. Zantac 150 mg po bid 5. Enteric coated aspirin 375 mg po qd 6. Imdur 30 mg po qd x3 months 7. Lasix 20 mg po bid x7 days 8. Lipitor 10 mg po qd 9. Percocet 5/325 po q 1 to 2 q4h prn 10. Insulin sliding scale [First Name8 (NamePattern2) ] [Last Name (un) ] DISCHARGE CONDITION: Stable FOLLOW UP: The patient will follow up with Dr. [Last Name (STitle) ] in one week, Dr. [Last Name (STitle) 70] in six weeks and Dr. [Last Name (STitle) ] in cardiology in one month, [Telephone/Fax (1) ]. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 3835] MEDQUIST36 D: [2160-5-12] 12:20 T: [2160-5-12] 12:28 JOB#: [Job Number 12973]	[ "424.0", "425.4", "410.71", "429.9", "362.01", "250.53", "272.0", "414.01" ]	icd9cm	[ [ [] ] ]	[ "36.13", "88.56", "37.23", "36.15", "39.61", "36.19" ]	icd9pcs	[ [ [] ] ]				6388, 6396			1792, 1864	5812, 5940	5963, 6366					2977, 5791			1513, 1703							1484, 1490	1879, 2959								6408, 6921													165, 177							206, 1373																	1395, 1460	1720, 1775
43,602	163,467	45465	Discharge summary	report	Admission Date: [2134-10-3] Discharge Date: [2134-10-7] Date of Birth: [2074-12-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 943] Chief Complaint: hematemesis, melena Major Surgical or Invasive Procedure: Endoscopy [2134-10-3] TIPS [2134-10-5] History of Present Illness: This is a 59 yo male h/o Hep C cirrhosis, h/o variceal bleed [6-28] and status post banding and MSSA R 1st MTP joint chronic osteomyelitis s/p resection R MTP joint who presents with hematemesis and 5 days of dark tarry stools. Patient reports about 3 episodes of hematemesis this am. Stool has been dark black x 5 days but not grossly bloody. In the ED, initial vs were: T98 P114 BP147/75 R20 O2 sat: 99RA. NG lavage positive for coffee ground emesis. Patient started on octreotide and protonix drips. He also received 3L NS. Two large bore IVs placed. Pt admitted to MICU for urgent EGD. Vitals prior to transfer were BP:135/72 HR:101 RR:19 O2Sat:97% RA. . In the ICU, patient denied any discomfort and is awaiting EGD. . Review of systems: (+) 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. No abd pain. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Hepatitis C cirrhosis, s/p failed interferon and ribavirin and s/p interferon only treatment in co-pilot study [2133] s/p esophageal variceal bleed [6-28] and s/p banding MSSA bacteremia, R 1st MTP joint MSSA septic arthritis, s/p resection of R MTP joint and plmt antibiotic spacer -Diabetes A1C 7.6 [4-19]. HTN Hyperlipidemia GERD OA Colonic Polyps Right olecranon bursitis-- followed in rheum clinic; cultured twice in [11/2133] with negative cultures BPH Chronic back pain Social History: Remote h/o IVDU. No ETOH or illicit drug use at this time. Smokes about [3-2] cigarettes per day. Lives with his wife and two sons. [Name (NI) 1403] as a Sales Engineer. Family History: non-contributory Physical Exam: General: Well appearing, 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, mildly distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact, 5/5 strength in all 4 ext Pertinent Results: Labs on admission: [2134-10-3] 10:20AM GLUCOSE-276* UREA N-25* CREAT-1.1 SODIUM-140 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15 [2134-10-3] 10:20AM ALT(SGPT)-54* AST(SGOT)-119* ALK PHOS-134* TOT BILI-3.4* [2134-10-3] 10:20AM WBC-6.4# RBC-3.44* HGB-9.8* HCT-31.6* MCV-92 MCH-28.5 MCHC-31.1 RDW-19.0* [2134-10-3] 10:20AM NEUTS-75.5* LYMPHS-13.6* MONOS-8.1 EOS-1.8 BASOS-1.0 [2134-10-3] 10:20AM PLT COUNT-133* [2134-10-3] 10:20AM PT-16.0* PTT-32.9 INR(PT)-1.4* [2134-10-3] 04:29PM HCT-25.2* [2134-10-3] 09:46PM HCT-26.7* [2134-10-3] 11:32PM HCT-27.0* [2134-10-3] 10:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Micro: [2134-10-3] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [2134-10-3] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2134-10-3] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT EGD: Esophagus: Protruding Lesions 3 cords of grade II varices were seen in the middle third of the esophagus and lower third of the esophagus. A red [Last Name (un) 23199] spot was seen on a varix at the GEJ. No active bleeding noted. Stomach: Blood was seen in the stomach and obscured visualization of the greater curvature. Protruding Lesions Non bleeding varices were seen in the fundus of the stomach, along the lesser curvature. They appeared to be non-contiguous with the esophageal varices. Fresh blood coated a gastric varix, though no oozing or active bleeding was noted. Duodenum: Normal duodenum. Impression: Varices at the middle third of the esophagus and lower third of the esophagus. Blood in the stomach. Varices at the fundus. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Assessment and Plan: This is a 59 yo male with history of hep c cirrhosis, h/o variceal bleed [6-28] who presents with hematemesis since this am and 5 days of tarry stools. . Upper GI Bleed: On EGD, patient was found to have three cords of grade II varices in the middle and lower [1-23] of the esophagus with fundal varices. While in the MICU he was maintained initially on octreotide and pantoprazole drips and transfused one unit of pRBCs for a HCT drop of 31-->25. Patient subsequently recieved TIPS [10-5]. The following day he had a drop in his hct 24.8 to 19.5, but repeat hct was 24. Patient was transfused 1 u pRBC, and hct remained stable. The octreotide drip was stopped and his ppi was converted from iv to po. Ceftriaxone was started for ppx for a 5 day course. A follow up US showed patent TIPS but with slow flow velocities, but with reversed flow within the left portal vein and the anterior right portal vein. Patient was discharged with instructions to have a repeat US with dopplers within 2 weeks. . Melena: Likely related to UGIB given hematemesis and significant coffee ground emesis from NG lavage. EGD was sone as above to assess for upper source. No colonoscopy was done in the MICU, though he may need one as an outpatient. . DM II: Patient was maintained on an ISS. . BPH: Initially terazosin was held given GI bleeding and possible development of hypotension. After TIPs home terazosin was restarted. . Hep C cirrhosis: Nadolol was held during active bleed, and discontinued after TIPs. Medications on Admission: Levemir 60 units QPM, 30 units QAM Novalog SS Terazosin 5mg qHS ASA 81 mg daily Prilosec 20mg daily Nadolol 20mg daily Discharge Disposition: Home Discharge Diagnosis: Esophageal variceal bleeding Discharge Condition: Stable Discharge Instructions: You were admitted with another bleed from your esophageal varices. We decided together to go forward with the TIPS procedure to help prevent further bleeding. You tolerated this well without any complications. . The following changes were made to your medications: 1. We increased your omeprazole from 20mg daily to 40mg twice daily 2. We stopped your nadolol 3. We added lactulose, please take enough to have three bowel movements per day 4. We would like you to complete a seven day course of cipro, you have two more days left . IT IS VERY IMPORTANT THAT YOU FOLLOW UP WITH AN ULTRASOUND OF THE ABDOMEN WITHIN THE NEXT TWO WEEKS TO MAKE SURE YOUR TIPS IS WORKING. Please follow up as indicated below. . If you experience vomiting with blood, black or bloody stools, or any other concerning symptoms, please return to the emergency department to be evaluated. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 250] Date/Time:[2134-11-16] 3:30 . You will need an ultrasound of your abdomen within 2 weeks to make sure your TIPS is still working. We have placed an order in the computer, just call [Telephone/Fax (1) 327] to make an appointment within the next 2 weeks. . Please make an appointment to see Dr. [Last Name (STitle) 10924] within 4 weeks, his number is ([Telephone/Fax (1) 1582] Completed by:[2134-10-7]	[ "456.20", "572.3", "724.5", "600.00", "338.29", "571.5", "715.90", "530.81", "272.4", "401.9", "250.00", "285.1", "070.54" ]	icd9cm	[ [ [] ] ]	[ "39.1", "45.13" ]	icd9pcs	[ [ [] ] ]	6261, 6267	4556, 6091	335, 384	6340, 6349	2805, 2810	7262, 7829	2238, 2256				6288, 6319		6117, 6238			6373, 7239									2271, 2786																			1160, 1477		276, 297							412, 1141										2825, 4533							1499, 2027	2043, 2222
15,875	107,604	14034	Discharge summary	report	Admission Date: [2182-6-5] Discharge Date: [2182-7-11] Date of Birth: [2143-12-21] Sex: M Service: MEDICINE Allergies: Penicillins / Levaquin / Biaxin Attending:[First Name3 (LF) 2297] Chief Complaint: Tracheal Obstruction Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: 38 y/o male with PMHx significant for type 1 diabetes, history of jail time, who initially presented at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with 10 days of chest tightness, mylagias, couging, fever, and wheezing, as well as shortness of breath. At OSH patient was being treated for CAP and started on azithromycin and ceftriaxone. Patient had CXR done at OSH which showed diffuse reticular nodular opacities involving bilateral lungs. CT chest at OSH was reported to show diffuse ground glass opacification and diffuse adenopathy. There was also adenopathy that was compressing the trachea, given this concern for airway obstruction patient was intubated and transferred to [Hospital1 18] for further management. He was ruled out for MI with negative CEx3 and negative EKG Past Medical History: Type 1 diabetes Asthma Diabetic nephropathy fractures fibula [3-/2181] H/O MRSA PNA Social History: Smokes 1ppd for many years, no drug or etoh history, history of jail time Family History: NC Physical Exam: PE: T 97.8 BP 110/48 HR 102 RR 16 O2SAt 97% AC 450x14 PEEP 5 FiO2 60 7.21/70/80 Gen: Patient intubated, sitting up in bed, gagging on tube Heent: PERRL, EOMI, ETT tube in place Neck: no LAD appreciated Lungs: diffuse ronchi throughout Cardiac: tachy, RR S1/S3 Abdomen: soft NT +BS Ext: no edema Neuro: awake Pertinent Results: [2182-6-5] 03:55PM NEUTS-55 BANDS-14* LYMPHS-19 MONOS-8 EOS-4 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2182-6-5] 04:15PM TYPE-ART RATES-14/ TIDAL VOL-450 PEEP-5 O2-60 PO2-80* PCO2-70* PH-7.21* TOTAL CO2-30 BASE XS--1 INTUBATED-INTUBATED VENT-CONTROLLED . CT chest [6-6]: FINDINGS: Endotracheal tube is in place, with tip terminating just above the level of the aortic arch. The trachea is abnormal in size and contour. The trachea is enlarged with coronal diameter of 2.8 cm. Additionally, it has a lunate configuration with elevated coronal to sagittal ratio. During expiration, there is excessive collapsibility of the tracheal lumen, resulting in reduction of cross-sectional area from 149 mm2 to 53 mm2. This likely underestimates the degree of collapsibility because it was not performed as a dynamic expiratory scan. Dense consolidation is present throughout both lower lobes with homogeneous increased density with prominent air bronchograms. More heterogeneous lung opacities are present within the anterior, nondependent portions of the lungs, including the upper lobes, middle lobe and lingula. These areas demonstrate peribronchiolar ground-glass opacities, areas of consolidation, and centrilobular/tree-in-[Male First Name (un) 239] opacities. Enlarged lymph nodes are present within the mediastinum, measuring up to 13 mm within the right paratracheal and precarinal regions. Additionally, there is diffuse stranding throughout the mediastinal fat, likely due to edema. The heart size is normal. There is no pericardial effusion. Small bilateral pleural effusions are present. Within the imaged portion of the upper abdomen, there is a trace amount of ascites. The remaining imaged portion of the upper abdomen is unremarkable on this unenhanced CT which was not specifically tailored to evaluate the abdominal organs. Diffuse anasarca is present throughout the chest and abdominal wall soft tissues. IMPRESSION: 1. Enlarged, lunate trachea configuration with associated tracheomalacia. Severity of tracheomalacia is likely underestimated on this end-expiratory scanning sequence. 2. Diffuse bilateral lung parenchymal abnormalities, including peribronchiolar opacities in the upper and mid lungs and extensive confluent consolidation in the lower lobes. The findings are most consistent with diffuse infection complicated by ARDS. A component of hydrostatic edema is also possible, particularly given the presence of diffuse anasarca and bilateral pleural effusions. . echo [6-6]: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%). The right ventricular cavity is dilated. Right ventricular systolic function is borderline normal; there are echolucent areas in the basal and midventricular segments of the right ventricular free wall; the apical segment of the right ventricular free wall appears thin. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Impression: status post cardiac arrest; dilated hypocontractile right ventricle; consider arrhythmogenic right ventricular cardiomyopathy . CTA [6-15]: IMPRESSION: 1. No evidence of pulmonary embolus. 2. Redemonstration of multifocal parenchymal opacities. Some of the right lung opacities appear to have progressed, while others in the left upper lobe, appear slightly better than on [2182-6-6]. 3. Bilateral lower lobe consolidation, unchanged. Unchanged bilateral pleural effusions. 4. Severe tracheobronchomalacia. Suggestion of bronchiectasis in multiple areas, difficult to assess given the presence of intubation/positive-pressure ventilation. . TTE [6-18]: No evidence for intracardiac (right-to-left) shunt identified. . PORTABLE ABDOMEN [2182-7-1] 11:11 AM Bowel gas pattern is unremarkable and there is no evidence of free air on this portable film. Possible nlargement of the liver silhouette may represent hepatomegaly or a prominent Riedel's lobe. Surrounding osseous structures are unremarkable. IMPRESSION: No evidence of ileus or obstruction. . CHEST (PORTABLE AP) [2182-7-2] 12:45 AM IMPRESSION: AP chest compared to [6-26] through 9. Small bilateral pleural effusion has increased, with new fissural components. Atelectasis or consolidation at the left base has improved since [6-29] and atelectasis at the right lung base, which has been difficult to assess all along appears to have improved, restricted to the posterior basal segment. Heart size is normal. No pneumothorax. Tracheostomy tube and right subclavian line in standard placements. No pneumothorax. . CT CHEST W/O CONTRAST [2182-7-6] 2:35 PM There is dense collapse and consolidation of the dependent aspects of both lung bases, right greater than left. There is minimal improvement in the aeration of the left lower lobe. Patchy nodular airspace opacification is again noted involving the right upper lobe, left upper lobe and the aerated portions of the left lower lobe. This has not significantly changed from the prior examination. Small bilateral pleural effusions are again noted which have slightly improved from the prior examination. As previously described there is evidence of tracheomalacia. A tracheostomy tube appears in the mid trachea. No pericardial effusion is present. Limited unenhanced images through the upper abdomen are unchanged. IMPRESSION: Dense collapse and consolidation of lung bases eith minimal improvement in the aeration of the left lower lobe. Patchy nodular airspace disease throughouth the lungs relatively unchanged consistentwith multilobar pneumonia and ARDS. . [2182-7-10] 9:47 AM CHEST, UPRIGHT AP PORTABLE: Comparison is made to five days earlier and to a more recent CT from [2182-7-6]. Patient is status post tracheostomy. A PICC line terminates at the cavoatrial junction. Cardiac and mediastinal contours are unremarkable. There are no effusions or pneumothorax. Patchy bilateral alveolar opacities are somewhat more extensive than before. IMPRESSION: Worsening patchy bilateral, predominantly basilar, parenchymal opacities. Brief Hospital Course: 38 y/o M with DM type 1, history of jail time who presented to OSH with what was thought to be CAP, found to have ground glass opacification and diffuse adenopathy on chest CT s/p intubation for airway obstruction, development of ARDS. . ## Respiratory Failure/ARDS - The patient was admitted with respiratory failure due to ARDS from PNA. Of note, pt HIV and TB negative. He could not be consented in house given intubation and current sedation. The patient was treated per ARDS NET protocol. He was started on broad spectrum antibiotics, which initially included vancomycin and ceftazidime. Pt was proned to aid in ventilation. He required paralytics as he was quite agitated and needed them to tolerate proning. He underwent BAL which grew MRSA. (Pt initially treated w/ vanco, and later linezolid as pt had positive screen for VRE). Patient seemed to improve over a week or so, no longer needing ARDS protocol/proning. He then subsequently decompensated and became more hypoxic, possibly from volume overload. This persisted despite attempts at aggressive diuresis. Thus, he underwent CTA which was negative for PE but showed some progression of prior opacities (along w/ stable b/l effusions). Based on his vent settings it appeared as if his ARDS might be worsening. Because of this, he was restarted on paralytics, placed on ARDS protocol again with proning. Pt was aggresively diuresed (as he was over 20lb up since admission). With diuresis & abx, pt slowly improved. Proning was discontinued during the second week of [Month (only) ]. He was gradually weaned off the vent. Pt went for tracheostomy w/ surgery. Eventually transitioned to trach mask alone. (Of note, on admission and on CT scan there was question of possible tracheomalacia/obstruction. This was not seen on pt's bronchoscopy.) ABG's demonstrate no marked hypercarbia. Tolerating trach mask well on 0/35 FiO2. Off abx for pneumonia, stable on trach mask. Treated with abx. . ## PNA: Pt had been treated with CTX & azithro at OSH. His coverage was broadened to ceftazidime & vanco following admission to [Hospital1 18]. Pt's BAL grew MRSA (?colonization vs pathogen). ID was consulted. They felt that pt did not have typical MRSA PNA picture as cx had low MRSA colony count and imaging showed lymphadenopathy and ARDS/multifocal pneumonia. ID recommended extensive workup for other causes, including legionella, erhlichia, tuleremia, chlamydia, mycoplasma, and babesia, all of which were negative. Pt received 16 days of ceftazidime and 14 days of linezolid and doxycycline, the latter of which was added for empiric tularemia tx. Pt defervesced and white count decreased with above treatment. Off antibiotics for pneumonia at the time of discharge to rehab. With slight worsening appearance of opacities on chest x-ray, still concern for tularemia or other pathology not covered/ -Follow up on Tularemia abx, blood cx -Follow up appointment with ID . ## Pulm Edema: likely ARDS plus component of fluid overload following aggressive fluid resuscitation. Pt was aggressively diuresed w/ lasix lasix gtt--this was stopped on [6-25]. Pt was given lasix bolus PRN. CXR shows resolving effusions/edema. Lasix was given PRN, and as [7-10] CXR demonstrated possible fluid overload 40 IV lasix given. Patient net + 5 liters at time of discharge. Lasix to be given as needed if signs of overload, clinical and imaging studies demonstrate need. . ## Sedation: Pt required enormous doses of sedatives to keep him calm and prevent him from removing lines/self-extubating. He required paralytics on top of sedatives for this and to tolerate the proning. Weaning sedation proved very difficult. Methadone was started to help wean off IV fentanyl and other sedatives. Then, fentanyl patch initiated, in attempt attempt to wean methadone and prevent opiate withdrawal. Fentanyl patch decreased, use methadone PRN and then DC'd; used haldol PRN agitation. Final regimen at time of discharge included Fentanyl patch at 150 mcg to be decreased as tolerated: Clonipine 3 mg TID, to be weaned as tolerated slowly, Morphine 1-2 mg q 2 for agitation pain, ativan as needed, and standing Haldol to be decreased to PRN as needed. . ## PEA arrest: On the night of admission the patient had pea arrest, with cpr for 2-5 minutes. The patient responded to epi and atropine. The cause was likely respiratory as prior to the event the patient had oxygen sats in the 70's. The patient required fluids and pressors and eventually was weaned off pressors. . ## Hypotension: Thought to be primarily from sepsis, although high PEEP and large doses of propofol likely also contributed. His [Last Name (un) 104] stim was negative. As his infection was treated and propofol weaned, he was able to be weaned off Levophed. Once of sedatives, and ventilator, BP increased and pt was hypertensive during weaning off narcotics and sedation. . ## Anemia: The patient had a slow drop in his hematocrit. Required occasional transfusions. Thought to be due to infection, renal failure and dilutional effect. Guaiac negative. EPO was started per renal recommendation. Discontinued several days prior to DC as felt anemia related to renal failure which was resolving in addition to acute illness. Stable at time of discharge, guiac negative. . ## ARF: ATN from hypotension/contrast nephropathy. Muddy brown casts on UA. FEUrea 65%. This slowly resolved. However, renal function again worsened in setting of aggressive diuresis. Renal followed patient while in house. Once diuresis slowed and pressors discontinued, pt's renal function improved. Not worsened with diuresis and close to baseline at the time of discharge. . ## HSV: Facial vesicular rash, swab-no virus isolated. Day 13/14 on day of discharge. . ## Hyponatremia/Hypernatremia: likely hypervolemic hyper-Na+, diurese & volume restrict. Resolved. Hypernatremia ensued later in the course, treated with free water flushes, which resolved after several days as well. . ## Hypothermia- axillary, possibly related to propofol, infection, narcotics. Resolved at the time of discharge. . ## Diffuse adenopathy - Noted on admission. this could be reactive secondary to infection as mentioned above. Given history of jail time patient with risk factor for TB. PPD placed at OSH which was negative. Other differential could be HIV, though this was also negative at OSH. Other concern would be malignant such as lymphoma. [Month (only) 116] still require LN biopsy if this does not resolve w/ tx of PNA. At time of discharge no inguinal lymphadenopathy palpated, likely reactive secondary to infection. . ## DM type 1 - The patient's sugars were closely followed and was treated intermittently with insulin drip and when off the drip glargine and SSI according to his finger sticks. Stable on glargine and sliding scale at the time of discharge. . ## PPx: Heparin SC, PPI, bowel regimen ## Code: full ## FEN: on TPN then transitioned tubefeed TF. PEG placed by surgery. Patient receiving tube feeds at goal via the PEG tube with minimal residual. Diuresed as needed, but not grossly fluid overloaded at the time of discharge to the rehab facility. ## Access: PICC line ##Comm: Mother [Name2 (NI) 41890] [Telephone/Fax (1) 41891] Medications on Admission: Lantus 20U qhs Humalog sliding scale Combivent Advair 250/50 [Hospital1 ] . Meds on transfer: Lantus 12 units Duonebs q4 via neb Mucinex 2 tabs [Hospital1 ] Azithromycin 500mg q24 Ceftriaxone 1g q24 Advair 250/50 [Hospital1 ] Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: Four (4) Puff Inhalation Q6H (every 6 hours). 2. Ipratropium Bromide 17 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation QID (4 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 4. Acetaminophen 160 mg/5 mL Solution [Hospital1 ]: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 5. Polyvinyl Alcohol 1.4 % Drops [Hospital1 ]: 1-2 Drops Ophthalmic PRN (as needed). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 7. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day as needed for constipation. 9. Bisacodyl 10 mg Suppository [Last Name (STitle) ]: One (1) Suppository Rectal DAILY (Daily) as needed. 10. Clonazepam 1 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO TID (3 times a day). 11. Lactulose 10 g/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO Q8H (every 8 hours) as needed. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Fentanyl 100 mcg/hr Patch 72 hr [Last Name (STitle) ]: One (1) Transdermal Q72H (every 72 hours): 125 MCG patch. 14. Acyclovir 400 mg IV Q8H d# 1 [6-29] 15. Lorazepam 0.5-1 mg IV Q4H:PRN agitation 16. Haloperidol 5 mg IV TID 17. Morphine Sulfate 1-2 mg IV Q2H:PRN hold for sedation and rr<10 18. Insulin Glargine 100 unit/mL Cartridge [Month/Day (4) ]: Twelve (12) units Subcutaneous at bedtime: in addition to ISS, see attached table. Discharge Disposition: Extended Care Facility: Radius Discharge Diagnosis: Primary: ARDS pneumonia Acute renal failure Narcotic withdrawal/agitation DM I Anemia HSV Hypotension Hypernatremia Hyponatremia . Secondary: Asthma diabetic nephropathy h/o MRSA pneumonia Fibula fracture Discharge Condition: stable Discharge Instructions: You were admitted with ARDS, and had a long hospital stay -Continue all medications, neb treatments. -Wean narcotics as tolerated -Acyclovir x 2 days, to complete 14 day course -Follow up with infectious disease -Follow up on pending tularemia antibody and blood culture data -CXR, abx and diuresis as needed -Trach and PEG tube placement Followup Instructions: Please follow up with PCP from rehab facility . Please follow up with infectious disease, discussion of Tularemia and review of cx and Antibiotic data.	[ "583.81", "250.41", "V58.67", "038.9", "782.1", "518.81", "584.5", "305.1", "995.92", "482.41", "785.6", "V09.0", "528.9", "493.90", "293.0", "427.5", "285.21", "707.07" ]	icd9cm	[ [ [] ] ]	[ "33.24", "99.04", "43.11", "38.91", "96.72", "99.60", "31.1", "00.14", "00.17", "96.6", "38.93", "99.15" ]	icd9pcs	[ [ [] ] ]	17675, 17708	8283, 15567	313, 327	17958, 17967	1730, 8260	18354, 18509	1382, 1386		15856, 17652		17729, 17937		15593, 15673			17991, 18331									1401, 1711																					253, 275							355, 1163																	1185, 1275	1291, 1366		15691, 15833
25,367	189,965	52527	Discharge summary	report	Admission Date: [2153-7-28] Discharge Date: [2153-8-2] Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 17683] Chief Complaint: Fever, abdominal pain Major Surgical or Invasive Procedure: [2153-7-29] PTC tube placement [2153-7-30] ERCP History of Present Illness: This is an 82 year old male with 5 days of diarrhea as well as dysuria treated with bactrim and now with new-onset abdominal pain and distension. He denies nauseas or vomiting. He has chills and today had a fever to 101. He has no constipation . His prior abdominal history os notable for a hernia repair 20 years ago Past Medical History: Lumpar stenosis s/p repair COPD Peripheral [Month/Day/Year 1106] disease Prostatectomy Hernia repair Hypertension Social History: Lives with wife. Retired president of insurance company. The patient is a 100-pack year smoker. He drinks alcohol socially. Family History: non-contirbutory Physical Exam: ON admission: Temp 103, 85/48, pulse 120, 22, 95% on 2 liters Gen: alert, awake Pulm: CTAB CV: RRR, no murmur Abd: soft, no tendreness, no rebound, negative [Doctor Last Name ] sign Extr: warm, well-perfused, palpable distal pulses Pertinent Results: [2153-7-28] 04:00PM BLOOD WBC-22.7# RBC-3.60 Hgb-9.5* Hct-29.2* MCV-81* MCH-26.4* MCHC-32.6 RDW-14.1 Plt Ct-402 [2153-7-29] 02:46AM BLOOD WBC-23.4* RBC-3.07* Hgb-8.4* Hct-25.4* MCV-83 MCH-27.3 MCHC-33.1 RDW-14.4 Plt Ct-257 [2153-7-29] 11:23AM BLOOD WBC-19.0* RBC-3.40* Hgb-9.3* Hct-27.2* MCV-80* MCH-27.3 MCHC-34.0 RDW-14.5 Plt Ct-283 [2153-7-30] 03:13AM BLOOD WBC-11.7* RBC-3.28* Hgb-8.8* Hct-26.8* MCV-82 MCH-26.8* MCHC-32.8 RDW-14.8 Plt Ct-267 [2153-7-31] 05:03AM BLOOD WBC-11.0 RBC-3.72* Hgb-9.9* Hct-30.9* MCV-83 MCH-26.6* MCHC-32.1 RDW-14.6 Plt Ct-263 [2153-7-28] 04:00PM BLOOD Neuts-96.9* Bands-0 Lymphs-2.3* Monos-0.7* Eos-0.1 Baso-0.1 [2153-7-28] 12:40PM BLOOD PT-15.9* PTT-30.1 INR(PT)-1.7 [2153-7-28] 09:19PM BLOOD PT-17.2* PTT-32.5 INR(PT)-2.0 [2153-7-30] 03:13AM BLOOD PT-15.3* PTT-29.2 INR(PT)-1.6 [2153-7-28] 09:19PM BLOOD Glucose-119* UreaN-26* Creat-2.0* Na-132* K-4.1 Cl-100 HCO3-21* AnGap-15 [2153-7-29] 02:46AM BLOOD Glucose-116* UreaN-26* Creat-2.0* Na-135 K-4.1 Cl-98 HCO3-24 AnGap-17 [2153-7-29] 11:23AM BLOOD Na-136 K-3.6 [2153-7-30] 03:13AM BLOOD Glucose-93 UreaN-41* Creat-2.0* Na-138 K-3.9 Cl-101 HCO3-25 AnGap-16 [2153-7-31] 05:03AM BLOOD Glucose-108* UreaN-37* Creat-1.7* Na-139 K-3.5 Cl-100 HCO3-25 AnGap-18 [2153-7-28] 04:00PM BLOOD ALT-1076* AST-1591* AlkPhos-749* Amylase-49 TotBili-3.7* [2153-7-28] 09:19PM BLOOD ALT-759* AST-922* LD(LDH)-333* AlkPhos-569* Amylase-44 TotBili-3.2* DirBili-2.8* IndBili-0.4 [2153-7-29] 02:46AM BLOOD ALT-587* AST-623* LD(LDH)-233 AlkPhos-478* Amylase-49 TotBili-2.4* DirBili-1.9* IndBili-0.5 [2153-7-30] 03:13AM BLOOD ALT-363* AST-187* LD(LDH)-164 AlkPhos-382* Amylase-54 TotBili-1.6* [2153-7-31] 05:03AM BLOOD ALT-254* AST-71* LD(LDH)-176 AlkPhos-395* Amylase-108* TotBili-1.4 [2153-7-28] 04:00PM BLOOD Lipase-26 [2153-7-28] 09:19PM BLOOD Lipase-22 [2153-7-29] 02:46AM BLOOD Lipase-17 [2153-7-30] 03:13AM BLOOD Lipase-25 [2153-7-31] 05:03AM BLOOD Lipase-55 [2153-7-31] 05:03AM BLOOD Albumin-3.1* Calcium-9.0 Phos-2.8 Mg-2.0 [2153-7-28] 04:12PM BLOOD Lactate-9.4* [2153-7-28] 06:22PM BLOOD Lactate-2.8* [2153-7-28] 08:08PM BLOOD Lactate-2.5* [2153-7-28] 09:29PM BLOOD Lactate-2.2* [2153-7-29] 03:26AM BLOOD Glucose-121* Lactate-1.4 [2153-7-30] 03:26AM BLOOD Glucose-98 Lactate-1.1 RADIOLOGY: [2153-7-28] RUQ ultrasound: 1. Distended gallbladder containing sludge and nonshadowing stones without correlative ultrasonographic findings to suggest acute cholecystitis. This could be further evaluated with HIDA scan if clinically indicated. 2. Right lobe hepatic cyst versus gallbladder diverticulum. ERCP [2153-7-30]: 1. Periampullary diverticulum. 2. Mild dilation of the common bile duct and intrahepatic ducts. 3. No stones in the common bile duct. 4. 9 cm 10 French Cotton [Doctor Last Name ] biliary stent successfully placed, with drainage of bile into the duodenum. Brief Hospital Course: This is an 82 year old gentleman who was admitted on [2153-7-28] with the fevers, abdominal pain, and significantly elevated LFTs. The admitting diagnosis was cholangitis with cholecystitis. On presentation in the ER he was found to be hemodynamically unstable and the sepsis protocol was initiated with central line placement, fluid resuscitation, and broad spectrum antibiotics. He was admitted to the ICU. He underwent emergent cholecystostomy tube placement shortly after admission. His condition improved on hospital day two with an improvement in his white blood cell count and LFTs and normalization of his hemodynamics. ON hospital day 3 he underwent ERCP with stent placement( 9 cm 10 french); no stones were appreciated and there was minimal ductal dilitation. A periampullary diverticulum was seen. His LFTs continued to trend downward and he was transferred out of the ICU on hospital day 3. He was advanced to a regular diet by hospital day 6 which he tolerated well. He was discharged to home on hospital day 6 with continuation of a 2 week course of Levofloxacin and a home visiting nurse [First Name (Titles) ] [Last Name (Titles) 108497]e with his PTC drainage tube. All questions were answered to his satisfaction upon discharge. Medications on Admission: Lipitor Toprol XL Prilosec Colace Rhinocort Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days. Disp:12 Tablet(s) Refills:0 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 3. Lipitor Oral 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Prilosec Colace Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Cholangitis Discharge Condition: Stable. Tolerating POs. Good pain control. AMbulating. Discharge Instructions: Take all medications as prescribed. Do not drive while taking narcotics. You should call the office with any worsening abdominal pain or nausea/vomitting or fever to 101. You may continue with a regular diet. A visiting nurse [First Name (Titles) ] [Last Name (Titles) ] you with your drain care Followup Instructions: Please follow-up with Dr. [First Name (STitle) ] [Name (STitle) ] in 2 weeks (call for an appointment-- [Telephone/Fax (1) 10533]) Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3627] [Name12 (NameIs) 3628] [Name12 (NameIs) ] [Name12 (NameIs) 3628] (NHB) Where: [Name12 (NameIs) ] [Name12 (NameIs) 3628] (NHB) Date/Time:[2154-7-8] 9:30 Provider: [Name10 (NameIs) 1111],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Where: [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2154-7-8] 10:00 [Name6 (MD) 843] [Name8 (MD) 844] MD [MD Number(1) 845] Completed by:[2153-8-2]	[ "443.9", "428.0", "496", "995.91", "576.1", "401.9", "038.9", "V10.46" ]	icd9cm	[ [ [] ] ]	[ "51.02", "99.04", "38.93", "99.07", "51.87" ]	icd9pcs	[ [ [] ] ]	5966, 6024	4235, 5497	240, 298	6080, 6136	1234, 4212	6488, 7230	944, 962		5591, 5943		6045, 6059		5523, 5568			6160, 6465									977, 977																					179, 202							326, 645										992, 1215							667, 787	803, 928
65,692	119,016	19898	Discharge summary	report	Admission Date: [2188-4-7] Discharge Date: [2188-4-11] Date of Birth: [2105-10-16] Sex: F Service: MEDICINE Allergies: Aspirin / Azithromycin / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 8104] Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 82 y/o F with a history of HTN, COPD, and dementia who was brought from NH with an O2 sat 48% on RA. Patient denies any shortness of breath, CP, ab pain. In the ER, patient's oxygen saturation improved with with 2L NC. Patient's initial vitals were 100.6, 134, 133/54, 24, 99% 2L NC. Patient's exam was notable for LLL rales, abdominal tenderness. CTA PE was performed which was negative for PE. Patient was given Ondansetron, Levofloxacin 750mg, ceftriaXONE 1g, MetRONIDAZOLE (FLagyl) 500mg, Vancomycin 1g, and 4L NS. On transfer, patient's VS were 83/32 106 95% on 2L. . Upon discussion with patient's family, patient's wishes are to be DNR/DNI, and has declined placement of central venous catheter. Past Medical History: - Alzheimer's Dementia - Hypertension - Hypercholesterolemia - Hypothyroidism - Bilateral hearing loss - Basilar artery stenosis, noted on MRI/A of brain [2184-8-31] - Paroxysmal atrial fibrillation, not on anticoagulation due to fall risk - Peripheral vascular disease Social History: Positive tobacco 50 pack years, quit ~10 years ago. No history of alcohol use. The patient lives in a nursing home, [Hospital1 599] house. DNR/DNI per form sent with NH records Family History: Father with CVA in his 60s. Mother with history of [Name (NI) 2481] dementia Physical Exam: GENERAL - comfortable, appropriate HEENT - PERRLA, EOMI, sclerae anicteric, dry MM NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - L lung - rhonch [12-22] way up lung field, R lung CTA. HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - on c/c/e. Bilateral heel decubitus lesions noted. RLE lesion is healing, LLE is unstagable. SKIN - Unstagable sacral decubitus ulcer with 4cm surrounding erythema. NEURO - awake, A&Ox1, Unable to assess muscle strength. Pertinent Results: [2188-4-7] 11:00AM WBC-32.4# RBC-2.38# HGB-7.0# HCT-23.0# MCV-90 MCH-29.6 MCHC-32.9 RDW-22.6* [2188-4-7] 11:00AM NEUTS-78* BANDS-0 LYMPHS-11* MONOS-2 EOS-0 BASOS-5* ATYPS-1* METAS-3* MYELOS-0 [2188-4-7] 11:00AM PLT SMR-VERY HIGH PLT COUNT-641# [2188-4-7] 11:00AM PT-15.8 PTT-29.2 INR(PT)-1.4* [2188-4-7] 11:00AM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-4.5 MAGNESIUM-3.0* [2188-4-7] 11:00AM CK-MB-5 [2188-4-7] 11:00AM cTropnT-0.04* [2188-4-7] 11:00AM LIPASE-25 [2188-4-7] 11:00AM ALT(SGPT)-14 AST(SGOT)-23 CK(CPK)-396* ALK PHOS-74 TOT BILI-0.5 [2188-4-7] 11:00AM GLUCOSE-143* UREA N-46* CREAT-1.4* SODIUM-146* POTASSIUM-5.1 CHLORIDE-108 TOTAL CO2-20* ANION GAP-23* [2188-4-7] 05:08PM WBC-25.4* RBC-1.70# HGB-5.0# HCT-16.2# MCV-95 MCH-29.6 MCHC-31.2 RDW-22.6 [2188-4-7] 05:08PM calTIBC-160* VIT B12-1463* FOLATE-13.7 HAPTOGLOB-212* FERRITIN-1389* TRF-123* [2188-4-7] 05:08PM PLT COUNT-465* LPLT-2+ [2188-4-7] 05:08PM CALCIUM-6.7* PHOSPHATE-4.3 MAGNESIUM-2.3 IRON-108 [2188-4-7] 05:08PM LD(LDH)-299* COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2188-4-9] 05:20AM 17.2* 2.88* 8.7* 25.4* 88 30.3 34.3 19.4* 357 [2188-4-7] CTA CHEST W&W/O C&RECON IMPRESSION: 1. No evidence of PE. 2. Interlobular septal thickening with small left pleural effusion, suggestive of CHF. 3. Mediastinal and hilar adenopathy, may be reactive secondary to CHF. However, follow-up CT in 6 months is recommended to assess for resolution. 4. Diverticulosis without diverticulitis. 5. Stool-filled rectal vault, with suggestion of rectal prolapse. Correlate clinically. [2188-4-7] Cardiology ECG [2188-4-9] Sinus tachycardia with PAC(s) Possible inferior infarct - age undetermined Lateral ST-T changes suggest myocardial injury/ischemia Since previous tracing of [2186-4-7], ST-T wave abnormalities more marked [2188-4-8] Radiology CHEST (PORTABLE AP) Since yesterday, lung volumes are lower. Left lower lobe opacity increased, could be due to worsening pneumonia. Small left pleural effusion is likely unchanged. Mild interstitial edema is new. The cardiomediastinal silhouette and hilar contours are otherwise unchanged. Scoliosis is stable. Brief Hospital Course: 82 y/o F with a history of COPD who presents with LLL Pneumonia and anemia. #. LLL Pneumonia: Currently stable. Patient has possible LLL infiltrate on CXR, not seen on Chest CT the day before and is unclear if this is related to her high WBC count. Patient has been saturating comfortably on 2L NC and transtitioned to room air. Patient has not had any recent antibiotic exposures to be concerned for MRSA or ESBL bacteria. Vancomycin/Ceftriaxone were discontinued and the patient remained stable. She was continued on levofloxacin. #. Anemia, unclear etiology: Patient has low retic count, concern for possible MDS. Patient was transfused 2 units PRBCs overnight and HCT responded. Patient likely has low baseline HCT, unclear etiology. Patient??????s NG lavage was negative, no blood in stool. Hemolysis markers were unremarkable. Hematocrit remained stable. Patient's family declined further work-up. Decision made not to provide additional blood transfusions. - continue home iron supplementation/bowel regimen #. Sacral and left heal Decubitus Ulcers: Present on admission. Albumin wnl. - wound care consulted (see discharge paperwork for recommendations) - continue with adequate nutritional support - reposition Q2hours, keep heal off bed #. Dementia - continued risperdal and effexor #. hypothyroidism: continued levothyroxine #. Hypercholesterolemia: continued simvastatin . # Leg pain: Patient with several month history of leg pain. Appeared to have hyperesthesia with diminished sensation. Low dose neurontin started with apparent good results, though unclear if complaints of leg pain [1-21] cognitive status as was at times distractible. Although, per daughter leg symptoms have been an ongoing complaint. # Goals of care: The palliative care service was consulted to assist with goals of care discussion with the daughter who is the health care proxy, and the family declined further work-up or aggressive treatment of medical issues. Plan was made to continue level of care and will consult hospice service at nursing home. The . Medications on Admission: Docusate Sodium 200 mg PO DAILY Iron Polysaccharides Complex 150 mg PO DAILY Levothyroxine Sodium 62.5 mcg PO DAILY Omeprazole 20 mg PO DAILY Risperidone 0.75 mg PO BID Senna 1 TAB PO DAILY Simvastatin 20 mg PO DAILY Sodium Chloride Nasal [12-21] SPRY NU QID:PRN Venlafaxine XR 112.5 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare Discharge Diagnosis: 1)Leukocytosis NOS-?infection vs. primary blood disorder 2)Possible Pneumonia 3)Dementia Discharge Condition: Stable Discharge Instructions: You were admitted with low oxygen, which resolved. Followup Instructions: You should follow-up with your regular doctor as needed	[ "331.0", "584.9", "433.00", "038.9", "244.9", "995.92", "427.31", "486", "272.0", "707.25", "238.75", "707.07", "707.03", "294.10", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6942, 7006	4521, 6591	327, 334	7139, 7148	2232, 4498	7247, 7306	1594, 1677				7027, 7118		6617, 6919			7172, 7224									1692, 2213																					278, 289							362, 1081																	1103, 1379	1395, 1578
70,871	122,321	18978	Discharge summary	report	Admission Date: [2114-12-25] Discharge Date: [2114-12-28] Date of Birth: [2068-5-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4327] Chief Complaint: pericardial effusion Major Surgical or Invasive Procedure: right heart catheterization and pericardiocentesis History of Present Illness: 46 y/o M with no significant PMHx who was transferred to [Hospital1 18] for urgent pericardiocentesis for pericardial effusion with tamponade physiology. Patient was in his usual state of health until early [Month (only) 1096] when he developed persistent low-grade fevers (99.5 to 100.5). He then developed right-sided arm pain, which prompted him to present to an OSH ED, where CXR showed cardiomegaly. Lyme serologies and a Monospot were negative. On exam, he had evidence of left-sided otitis media and was treated with 10-days of Amoxicillin therapy. He then presented to his PCP, [Name10 (NameIs) 1023] repeated CXR and found persistent cardiomegaly. Patient was then referred to BIDN for echo today. This revealed pericardial effusion with tamponade physiology; pulsus paradoxus was 10. Pt was then transferred here for urgent pericardiocentesis. . In the cath lab, the patient underwent pericardial drain placement, with subsequent drainage of 500 cc from pericardium. BP was stable the entire time; however, patient has remained persistently tachycardic to the 120's. He received 3L IVF's prior to pericardiocentesis. RHC was performed before and after pericardiocentesis and reportedly did not show significant change in pressures, raising concern for potential constrictive physiology. . On arrival to the ICU, the patient denied any complaints. He reports that, aside from his persistent fevers and right-sided arm pain, he has not experienced any other symptoms. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or pre-syncope. . ROS: The patient denies a history of prior stroke/TIA, deep venous thrombosis or pulmonary embolus. He denies bleeding at the time of prior procedures or surgeries. Denies headaches or vision changes. No cough or upper respiratory symptoms. Denies chest pain, dizziness or lightheadedness; no palpitations. Denies shortness of breath. No nausea or vomiting, denies abdominal pain. No dysuria or hematuria. No change in bowel movements or bloody stools. Denies muscle weakness, myalgias or neurologic complaints. No exertional buttock or calf pain. . Past Medical History: * CABG: None * PERCUTANEOUS CORONARY INTERVENTIONS: None * PACING/ICD: None . PAST MEDICAL & SURGICAL HISTORY: 1. s/p ORIF right lateral malleolar fracture (right ankle fracture, [2106-7-25]) 2. s/p Removal of syndesmotic screws from right ankle ([2106-10-28]) Social History: Patient lives at home with his wife, works as a [Name (NI) 51873] of a software company. Two children, son and daughter. [Name (NI) 4084] smoking history. Rare alcohol use; no recreational substance use. Exercises 2-4 times weekly. Family History: Denies family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; grandmother with diabetes (died at age 81), uncle with diabetes. Physical Exam: ADMISSION EXAM VITALS: Temp 99.9 BP 155/86 HR 101 RR 22 SaO2 96% on 2LNC GENERAL: Appears in no acute distress. Alert and interactive. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Mucous membranes moist. No xanthalesma. NECK: Supple without lymphadenopathy. LVP difficult to assess. CVS: PMI located in the 5th intercostal space, mid-clavicular line. Regular rhythm, without murmurs or gallops. S1 and S2 normal. No S3 or S4. Tachycardic. Audible friction rub. Hyperdynamic precordium. RESP: Respirations unlabored, no accessory muscle use. Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. Abdominal aorta not enlarged to palpation, no bruit. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses DERM: No stasis dermatitis, ulcers, scars, or xanthomas. PULSE EXAM: Right: DP 2+ Left: DP 2+ Pertinent Results: ADMISSION RESULTS [2114-12-24] 09:50AM BLOOD WBC-9.6 RBC-4.16* Hgb-12.3* Hct-36.8* MCV-88 MCH-29.5 MCHC-33.4 RDW-12.7 Plt Ct-394 [2114-12-25] 09:34PM BLOOD Neuts-73.9* Lymphs-18.0 Monos-6.9 Eos-0.9 Baso-0.2 [2114-12-25] 09:34PM BLOOD PT-14.9* PTT-29.8 INR(PT)-1.4* [2114-12-25] 09:34PM BLOOD Glucose-108* UreaN-8 Creat-0.9 Na-139 K-4.4 Cl-106 HCO3-28 AnGap-9 [2114-12-25] 09:34PM BLOOD ALT-33 AST-19 LD(LDH)-137 AlkPhos-152* TotBili-1.2 [2114-12-25] 09:34PM BLOOD Albumin-3.4* Calcium-8.4 Phos-3.4 Mg-2.0 [2114-12-24] 09:50AM BLOOD TSH-0.85 [2114-12-25] 04:54PM BLOOD Lactate-0.8 PERTINENT LABS AND STUDIES [2114-12-25] 06:00PM PERICARDIAL FLUID WBC-763* Hct,Fl-5* Polys-57* Lymphs-33* Monos-0 Macro-10* [2114-12-25] 06:00PM PERICARDIAL FLUID TotProt-5.4 Glucose-91 LD(LDH)-530 Amylase-24 Albumin-3.3 [2114-12-25] PERICARDIAL FLUID negative for malignant cells [2114-12-25] ECHOCARDIOGRAM Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a large pericardial effusion, most prominent outside of the lateral and posterior walls. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. IMPRESSION: Large pericardial effusion, most suitable for pericardiocentesis via the lateral intercostal approach. [2114-12-25] CXR Comparison is made with prior study performed 4 hours earlier. There has been decrease in size in cardiac silhouette, now mildly enlarged. There is mild pneumopericardium. If any, there are small bilateral pleural effusions. Aside from left lower lobe atelectasis, the lungs are clear. There is no pneumothorax. [2114-12-25] CXR There are low lung volumes. Moderate-to-severe enlargement of the cardiac silhouette appears unchanged compared to the prior study. The mediastinal and hilar contours are within normal limits. Pulmonary vascularity is not engorged. No focal consolidation, pleural effusion, or pneumothorax is present. There are no acute osseous abnormalities. IMPRESSION: Unchanged enlargement of the cardiac silhouette without evidence of pulmonary vascular congestion. [2114-12-26] ECHOCARDIOGRAM 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized pericardial effusion mostly located adjacent to the lateral and inferior walls. There is a trivial amount of pericardial fluid anterior to the right ventricle. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2114-12-25], the effusion is smaller and there is no echocardiographic evidence of tamponade. PENDING STUDIES:** [2114-12-25] blood cultures x3 [2114-12-25] PERICARDIAL FLUID [2114-12-25] URINE CULTURE [2114-12-25] 06:00PM PERICARDIAL FLUID ADENOSINE DEAMINASE, FLUID-PND [2114-12-26] 06:46PM PERICARDIAL FLUID MYCOPLASMA PNEUMONIAE DNA, PCR-PND Brief Hospital Course: IMPRESSION/PLAN: 46 y/o M with no significant PMHx who was transferred to [Hospital1 18] for urgent pericardiocentesis for pericardial effusion with tamponade physiology in the setting of persistent fevers. # Pericardial Effusion - Mr. [Name14 (STitle) 51874] was transferred to [Hospital1 18] from an OSH to have the pericardial fluid drained. 500cc of fluid was drained during the initial tap and subsequently drained an additional 120cc prior to removal. A RHC was also performed at the time of pericardiocentesis which showed elevated right and left filling pressures with equilization of diastolic pressures. Repeat echo after the drain was placed showed a smaller effusion with no evidence of tamponade physiology. Another echo was obtained after the drain was removed showed smaller effusion with no echocardiographic evidence of tamponade. He was started on ibuprofen during this admission to reduce pericardial inflammation, which he will continue for 3 weeks. The etiology of the effusion remains unclear at the time of discharge. Given that he has been having persistent fevers of unknown origin as well as the new pericardial effusion, an infectious etiology was thought to be most likely, however we also considered thyroid disease (had a normal TSH), malignancy and rheumatologic disease. ID was consulted, as discussed below. His HIV test was negative, PPD was placed and was also negative, [Doctor First Name ] was negative. ESR and CRP were elevated at 87 and 203, respectively. The pericardial fluid had no growth and showed 1+ PMNs with no organisms on gram stain, there were no AFB. The rest of his infectious work-up was unrevealing, as described below. # Fever of unknown origin - He has had persistent fevers of unknown origin for several weeks now. CXR did not show clear evidence of an infectious process. He reportedly had tests for Lyme and Monospot which were negative at OSH. The fevers were thought to be related to his pericardial effusion. Infection was thought to be the primary cause, with viral etiologies being the most likely cause (echovirus, adenovirus, coxsackievirus, parvovorus). Numerous serologies were ordered to evaluate for these infections, which were still pending at the time of discharge, Lyme was tested again and was negative. As mentioned above, HIV and PPD were negative. It is also possible that his fevers are caused by malignancy or rheumatologic disease, although he has no additional signs/symptoms to suggest either of these diagnoses. # Tachycardia - Patient had sinus tachycardia during the first 2 days of admission, which was noted to be somewhat correlated with when he had low grade fevers. He remained asymptomatic during these episodes. He appeared euvoluemic. The tachycardia had resolved at the time of discharge, he was also afebrile for 36 hours prior to discharge. # Code status this admission - FULL CODE #Transitional issues: -Follow-up parvovirus, mycoplasma serologies and mcyoplasma PCR -Follow-up pericardial fluid viral culture -Will see ID after discharge regarding his ongoing fevers and recent pericardial effusion Medications on Admission: none Discharge Medications: 1. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 3 weeks: After 3 weeks, take as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Pericardial effusion with pericardiocentesis Fevers of unknown origin 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 during your admission to [Hospital1 18]. You were admitted to the Cardiac Intensive Care Unit because you had fluid around your heart, called a pericardial effusion, which was drained. As you know, you had been having fevers of unclear origin for a number of weeks which we think is from the same process that caused your pericardial effusion. Numerous tests are still pending and we don't have a clear cause for the fevers and effusion, although the most likely cause would be a virus. At the time of discharge, your effusion was smaller and there was no evidence that it wasi nterfering with your heart function. You will follow-up with the infectious disease clinic after discharge. Please note the following changes to your medications: START ibuprofen 400mg by mouth every 8 hours for 3 weeks, then as needed for pain Followup Instructions: Department: BIDHC [Location (un) ] When: THURSDAY [2115-1-3] at 9:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10604], MD [Telephone/Fax (1) 3329] Building: [Location (un) 3966] ([Location (un) 55], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: INFECTIOUS DISEASE When: THURSDAY [2115-1-10] at 11:30 AM With: [First Name8 (NamePattern2) 1955] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name **] Garage	[ "423.3", "427.89", "420.91", "780.60" ]	icd9cm	[ [ [] ] ]	[ "37.0", "37.21" ]	icd9pcs	[ [ [] ] ]	11040, 11046	7694, 10616	327, 379	11179, 11179	4368, 7671	12256, 12903	3195, 3351		10890, 11017		11067, 11067		10861, 10867			11330, 12120									3366, 4349																10637, 10835		12149, 12233			267, 289							407, 2629									11086, 11158			11194, 11306					2651, 2921	2937, 3179
83,301	170,258	53509	Discharge summary	report	Admission Date: [2167-9-15] Discharge Date: [2167-9-22] Date of Birth: [2113-11-30] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 9824] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: Upper GI endoscopy with variceal banding 1 unit blood transfusion 1 unit platelet transfusion History of Present Illness: 53M h/o polycystic kidney disease s/p cadaveric renal transplant in [2147], esophageal and gastric varices s/p banding procedures (last 3 wks ago), and hypertension presented to [Hospital ] Hospital with fevers and hypotension, transferred to [Hospital1 18] [2167-9-15]. Of note, the patient was recently admitted to [Hospital1 18] MICU for hypotension in the setting of UGIB from [Date range (3) 110000] bleeding varicies for emergent endoscopy. . At OSH reported diarrhea, feeling unwell x3 days, and occasional subjective fevers. Denied any pulmonary or upper respiratory symptoms including no cough. Noted to be febrile to 104 with intake BP 73/57 that responded to SBP 88 with IVF resuscitation. Labs notable for worsening renal failure. He was started on vancomycin, CTX, and flagyl for presumed sepsis. Also given stress dose steroids. Sent to [Hospital1 18] ED. . In our ED he was afebrile 66 89/55 13 96% on 2L. Continued to be asymptomatic. Blood cultures were sent and lactate was 1.4. Rectal was guaiac negative. A CVL was placed and he was consented, typed and crossed. CXR with possible PNA although continued to deny respiratory symptoms. Admitted to MICU. . On exam here, he reports fevers to 103-104 since 3 days PTA with worsening chronic diarrhea, 6-7BMs per day loose brown stool. No melena/hematochezia or abd. pain. No N/V. Reports lightheadedness/dizziness upon standing with falls x [1-4] on day of admission but no LOC or head trauma. Also reports decreased PO intake and UOP with occasional dry cough. Denies congestion, chest pain, shortness of breath, dysuria, hematuria, leg pain, swelling, numbness or weakness. All other review of systems negative in detail. Past Medical History: Polycystic Kidney Disease s/p cadaveric renal transplant in [2147] Chronic stage III kidney disease Portal Vein Thrombosis Esophageal and Gastric Varices Hepatic Cysts Recurrent Skin Cancers (basal cell) Osteopenia Tertiary Hyperparathyroidism Chronic Diarrhea Vitamin D deficiency Depression Hypertension Lower Extremity Edema Hyperlipidemia Hyperglycemia Neuropathy with Charcot Foot Gout Social History: Originally from [Location (un) 58443], [State ]. Moved to Mass 20 years ago to work as an editor of various car company technical brochures. He does not smoke. Occassional alchohol. No drug use. Family History: Mother had polycystic kidney disease, died of complications of transplant. Father had MI at 77. He has two sisters, one with polycystic kidney disease. Physical Exam: Vitals: T 97 HR 50 BP 102/60 RR 18 SaO2 98% General: Alert, oriented, pleasant, NAD HEENT: Sclera anicteric, scab on R outer orbit, MMM, oropharynx clear, good dentition Neck: JVP flat, no LAD CV: RRR, s1 + s2, no murmurs, rubs, gallops Resp: Clear to auscultation bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, mildly distended, +BS. RLQ scar. No tenderness over R pelvic kidney. + splenomegaly Ext: 2+ pulses, no clubbing, cyanosis. Trace edema BL, L>R Neuro: CN II-XII intact Strength: symmetric BL UE and LE, absent pronator drift Sensation: symmetric BL Pertinent Results: Admission Labs [2167-9-15] 09:30PM BLOOD WBC-3.0# RBC-2.86 Hgb-8.2# Hct-26.0# MCV-91 MCH-28.7 MCHC-31.5 RDW-15.6* Plt Ct-23# [2167-9-15] 09:30PM BLOOD Neuts-92 Bands-4 Lymphs-1* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2167-9-15] 09:30PM BLOOD PT-19.0* PTT-56.6* INR(PT)-1.8* [2167-9-16] 09:44AM BLOOD Fibrino-318# [2167-9-15] 09:30PM BLOOD Glucose-120* UreaN-54* Creat-3.6# Na-138 K-3.8 Cl-109 HCO3-19* AnGap-14 [2167-9-15] 09:30PM BLOOD CK(CPK)-61 [2167-9-15] 09:30PM BLOOD CK-MB-NotDone cTropnT-0.02* [2167-9-16] 02:45AM BLOOD Albumin-2.6* Calcium-7.7* Phos-4.7# Mg-1.6 [2167-9-16] 09:44AM BLOOD Hapto-76 . Interval Labs: [2167-9-16] 09:44AM BLOOD WBC-2.9 RBC-2.89* Hgb-8.7* Hct-26.3* MCV-91 MCH-30.1 MCHC-33.1 RDW-15.6* Plt Ct-30# [2167-9-16] 05:29PM BLOOD Hct-26.7 [2167-9-16] 09:44AM BLOOD PT-19.0* PTT-50.7* INR(PT)-1.8* [2167-9-19] 05:45AM BLOOD Glucose-113* UreaN-73* Creat-2.5* Na-142 K-3.6 Cl-117* HCO3-17* AnGap-12 [2167-9-18] 05:00AM BLOOD Cyclspr-151 [2167-9-19] 05:45AM BLOOD Cyclspr-214 [2167-9-20] 05:50AM BLOOD Cyclspr-167 Microbiology: CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2167-9-20]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [2167-9-15] 9:25 pm BLOOD CULTURE FINAL REPORT [2167-9-21] Blood Culture, Routine (Final [2167-9-21]): NO GROWTH. [2167-9-16] 4:01 am URINE Source: Catheter. FINAL REPORT [2167-9-17] URINE CULTURE (Final [2167-9-17]): STAPHYLOCOCCUS SPECIES. ~1000/ML. [2167-9-17] 10:45 am CATHETER TIP-IV Source: central. FINAL REPORT [2167-9-19] WOUND CULTURE (Final [2167-9-19]): No significant growth. [2167-9-16] 2:03 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2167-9-18] FECAL CULTURE (Final [2167-9-18]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2167-9-18]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2167-9-17]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). FECAL CULTURE - R/O E.COLI 0157:H7 (Final [2167-9-17]): NO E.COLI 0157:H7 FOUND. FECAL CULTURE - R/O VIBRIO (Final [2167-9-18]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [2167-9-18]): NO YERSINIA FOUND. . Discharge Labs: . [2167-9-22] 04:45AM BLOOD WBC-4.5 RBC-3.39* Hgb-10.4* Hct-30.7* MCV-91 MCH-30.7 MCHC-33.9 RDW-16.8* Plt Ct-65* [2167-9-22] 04:45AM BLOOD PT-17.0* PTT-33.7 INR(PT)-1.5* [2167-9-18] 05:00AM BLOOD ALT-24 AST-18 AlkPhos-61 TotBili-0.7 [2167-9-22] 04:45AM BLOOD Cyclspr-159 . Studies: CHEST PORT. LINE PLACEMENT Study Date of [2167-9-15] 10:21 PM IMPRESSION: Satisfactory placement of left central venous line with tip at the SVC. No pneumothorax. . RENAL TRANSPLANT U.S. RIGHT Study Date of [2167-9-16] 10:17 AM RENAL TRANSPLANT ULTRASOUND: The transplant kidney in the right lower quadrant measures 11.3 cm. There is no evidence of hydronephrosis or nephrolithiasis. Apparent mild increase of echogenicity of the cortex may be technical in nature. An 18-mm cyst medially in the upper pole is unchanged. Doppler ultrasound was performed. The resistive indices in the lower pole and interpolar region of 0.7 are normal. There is only slight elevation of the resistive index in the upper pole measuring 0.84. The waveforms appear normal. IMPRESSION: 1. Slight elevation of the resistive index in the upper pole of the transplant kidney. 2. No change in cyst in the upper pole medially. 3. Otherwise unremarkable renal transplant ultrasound. . ECG Study Date of [2167-9-18] 10:10:04 AM Sinus bradycardia with first degree atrio-ventricular conduction delay. Left atrial abnormality. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [2167-8-25] no definite change. . DUPLEX DOP ABD/PEL LIMITED Study Date of [2167-9-18] 5:57 PM 1. Innumerable hepatic and left renal cysts. Hepatopetal flow within the main portal vein. 2. Gallbladder wall edema without evidence for acute cholecystitis. 3. Moderate ascites. 4. Splenomegaly. . TTE (Complete) Done [2167-9-22] at 1:45:46 PM The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The chordae tendineae appear echogenic and redundant without obvious vegetation attached (clip [Clip Number (Radiology) ]). There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: No valvular vegetations identified. Prominent and thickened chordae tendinae in the left ventricle without apparent vegetation. Normal global and regional biventricular systolic function. Mild aortic regurgitation. . . Brief Hospital Course: Mr. [Known lastname ] is a 53 year old man with a history of polycystic kidney disease with cadaveric renal transplant in [2147], esophageal and gastric varices s/p banding procedures (last 3wks prior to admission) who was transferred from an outside hospital to [Hospital1 18] MICU for hypotension and fever. . # Fever: The patient initially presented to [Hospital ] Hospital with a clinical picture resembling sepsis (hypotension, fever, rigors). He received stress dose steroids and Vancomycin, Ceftriaxone at the outside hospital and was transferred to the [Hospital1 18] MICU where the patient was afebrile with blood pressures ranging in the 90-100's/60-70's and patient's blood pressure then improved with intravenous fluids. The patient had blood cultures with no growth and a urine culture that showed ~1000/ML staph species. Ultrasound of the transplanted kidney was normal. The likely source of the patient's infectious presentation was infectious diarrhea. Since the patient had received antibiotics during a recent admission for bleeding varices, C. diff was considered most likely the cause of the patient's brief septic episode. Assay for C. diff was negative on three separate samples, and fecal culture and CMV viral load were negative. The patient's diarrhea improved with empiric metronidazole therapy and with discontinuation of Mycophenolate Mofetil. After the patient had been afebrile and culture-negative for 48 hours vancomycin and cefepime were discontinued, which the patient tolerated well. The patient was discharged with a course of metronidazole. . # Acute on chronic renal failure: The patient has known chronic kidney disease as well as a renal transplant. The patient's increase in creatinine was likely due to a prerenal etiology in the setting of septic physiology and hypotension. The patient's renal function improved to near the baseline creatinine of 2 with intravenous fluids. The nephrology consult service followed the patient and recommended holding mycophenolate mofetil as it is a known cause of chronic diarrhea, and increasing the patient's prednisone. Cyclosporine was continued and daily cyclosporine levels were monitored. . # Portal hypertension: The patient has known esophageal and gastric varices and had a recent admission for emergent banding of varices. During this admission the patient was followed by the liver consult service and the patient had a repeat EGD and had banding of varices again. Interventional radiology was asked to comment on whether a TIPS procedure would be feasible in this patient given the multple hepatic cysts seen on ultrasound and IR stated that they would consider TIPS but would require a CT with contrast of the abdomen, which, in the setting of this patient's poor renal function, would present another potential kidney injury. The patient was discharged with a plan to follow up with his primary care doctor as well as have a repeat EGD approximately three weeks post-discharge. . # Pancytopenia: The patient is on chronic immunsuppression for his renal transplant, but had worse anemia and thrombocytopenia on this admission. The patient was guaiac negative and hemolysis labs were normal. Through his ICU course the patient received 1 unit of packed Red Blood Cells for a hematocrit of 23 with an appropriate bump in his hct to 26. He also received one platelet transfusion, but had some additional worsened thrombocytopenia while on the floor that was attributed to increased splenic sequestration in the setting of sepsis. The patient's platelets improved over the course of admission and he did not require additional transfusions. . # Ectopy on Cardiac Telemetry: During his hospitalization the patient was noted to have episodes of frequent PVC's and trigeminy on telemetry. This was thought to be due to having been taken off his home beta-blocker while septic in the MICU and nadolol was re-started on the floor. The patient had a trans-thoracic echocardiogram while admitted to evaluate for possibility of vegetations. The echo did not reveal any vegetations and the patient was discharged on his home dose of nadolol. Medications on Admission: Calcitriol 0.25 mcg PO EVERY OTHER DAY Citalopram 40 mg PO DAILY Cyclosporine 75 mg PO QAM Cyclosporine 50 mg PO QPM Atorvastatin 5 mg PO DAILY Gabapentin 300 mg PO Q12H Allopurinol 100 mg PO DAILY Mycophenolate Mofetil 500 mg PO BID Prednisone 10 mg PO every other day Sucralfate 1 gram PO QID Nadolol 20 mg PO DAILY Pantoprazole 40 mg PO Q12H Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. Disp:6 Tablet(s) Refills:0 2. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO once a day. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fosamax 35 mg Tablet Sig: One (1) Tablet PO once a week: Take with a full glass of water and stay upright for half an hour. 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 10. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO QAM (once a day (in the morning)). 11. Cyclosporine 25 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 12. Soriatane CK 25 mg Kit Sig: One (1) Miscellaneous once a day. 13. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 14 days. Disp:56 Tablet(s) Refills:0 14. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Outpatient Lab Work On [2167-9-29] please obtain the following blood tests: Chem 7, Calcium, Magnesium, Phosphate, cyclosporine level, CBC. Results should be forwarded to Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968] and Dr [Last Name (STitle) 1366]. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Sepsis, Diarrhea . Secondary diagnosis: Portal hypertension, esophageal varices Discharge Condition: Fair. Discharge Instructions: You were admitted with diarrhea and fevers to [Hospital ] Hospital and then transferred to [Hospital1 18] to the MICU. In the MICU you did well, and you were transferred to the floor. You were given antibiotics and your diarrhea improved. You also did not experience any additional fevers once you were transferred to the floor. . We have discontinued your Cellcept because this can lead to chronic diarrhea. Your calcitriol was also held, and you will have labs next week to determine whether you should stay on it. We have continued all of your other home medications. You will take an antibiotic called metronidazole for two days to finish the 7 day course for diarrhea. . During this admission you had an endoscopy with a banding procedure. You will need to have a follow up endoscopy in 3 weeks. . If you develop sudden chest pain, shortness of breath, nausea or vomiting, bloody vomiting, please call your primary care doctor or go to the nearest emergency room. Followup Instructions: Primary Care Follow-up: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 250] Date/Time:[2167-10-1] 12:10 You should have your labs (Chem 10) checked at this appointment. You should discuss arranging a follow up endoscopy (in 3 weeks) for further banding at this appointment. . Gastroenterology follow up: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2167-11-4] 9:00 . Renal follow up: Provider: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2167-11-5] 2:00	[ "285.9", "038.9", "995.92", "585.3", "284.1", "403.90", "287.5", "787.91", "584.9", "572.3", "V42.0", "456.21" ]	icd9cm	[ [ [] ] ]	[ "38.93", "42.33" ]	icd9pcs	[ [ [] ] ]	15587, 15593	9515, 13657	282, 378	15736, 15744	3551, 6180	16769, 17159	2787, 2942		14053, 15564		15614, 15614		13683, 14030			15768, 16746			6196, 9492						2957, 3532								17341, 17501													234, 244							406, 2130					15673, 15715				15633, 15652								2152, 2548	2564, 2771
45,847	184,460	5155	Discharge summary	report	Admission Date: [2105-10-21] Discharge Date: [2105-10-26] Date of Birth: [2034-4-17] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Keflex / Ciprofloxacin / Sulfa (Sulfonamide Antibiotics) / Bactrim Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2105-10-21] 1. Coronary artery bypass graft x2, left internal mammary artery to left anterior ascending artery and saphenous vein graft to obtuse marginal artery. 2. Endoscopic harvesting of the long saphenous vein. 3. Aortic valve replacement with a size 21 [Last Name (un) 3843]- [Doctor Last Name ] Magna tissue pericardial valve. History of Present Illness: This is a 71 year old female who presented with atypical chest pain and abnormal EKG changes at her [Last Name (un) ] appointment. She underwent stress testing which showed inducible ischemia. Subsequent cardiac cathterization revealed multivessel coronary artery disease and surgical revascularization was recommended (when seen in [2105-7-30]). Currently, she still occasionally develops chest pain and now presents again for surgical evaluation. Past Medical History: Coronary Artery Disease Mild Aortic Stenosis Hypertension Diabetes mellitus type II Carotid Disease Peripheral neuropathy Social History: Never smoked. No alcohol use. Denies all current or past drug use. Lives in an apartment with her demented husband of who she is the primary caretaker. She has 3 biological sons and 1 son + 1 daughter from her remarriage. Family History: Dad: HTN, [Name (NI) 3495] attack at age 70 Mom: Liver CA Physical Exam: Pulse: 66 Resp: 16 O2 sat: 100% RA B/P Right: 129/57 Left: 127/54 Height: 5'4" Weight: 84.4kg General: NAD, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 2/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] no edema, minimal spider veins Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: NP Left: NP PT [Name (NI) 167]: NP Left: NP Radial Right: 1+ Left: 1+ Carotid Bruit Right/Left: no bruits appreciated Pertinent Results: [2105-10-24] 04:41AM BLOOD WBC-12.2* RBC-3.27* Hgb-10.3* Hct-29.5* MCV-90 MCH-31.5 MCHC-34.9 RDW-14.1 Plt Ct-189 [2105-10-23] 05:13AM BLOOD WBC-14.1* RBC-3.37* Hgb-10.5* Hct-30.5* MCV-91 MCH-31.1 MCHC-34.4 RDW-14.5 Plt Ct-204 [2105-10-24] 04:41AM BLOOD Glucose-162* UreaN-24* Creat-0.8 Na-139 K-3.4 Cl-103 HCO3-25 AnGap-14 [2105-10-23] 05:13AM BLOOD Glucose-133* UreaN-21* Creat-0.8 Na-137 K-4.3 Cl-106 HCO3-23 AnGap-12 Intra-Op TEE [2105-10-21] Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. 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 moderately thickened. There is severe aortic valve stenosis (valve area 0.9 by 2 observers; peak gradient 34, mean 22). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: The patient was brought to the operating room on [2105-10-21] where the patient underwent AVR, CABG x 2. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis, given the patient's preoperative stay of greater than 24 hours. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was hemodynamically stable, weaned from inotropic and vasopressor support. She did exhibit some immediate post-op confusion which resolved on discontinuation of narcotics. 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. She did develop rapid atrial fibrillation and converted to sinus rhythm with IV amiodarone bolus and drip. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged in good condition with appropriate follow up instructions and all appointments advised. Medications on Admission: Amlodpine 10mg daily Carvedilol 25mg [Hospital1 ] Lisinopril 40mg daily Simvastatin 40mg daily Hydrochlorothiazide 12.5 mg daily Aspirin 325mg daily NPH Insulin 18 units in the morning and 16 units in the evening. HISS Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: please take 400mg once a day until [11-3] than decrease to 200 mg daily until follow up with cardiologist . 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). 11. Outpatient Lab Work please check electrolytes twice a week bun/cr potassium magnesium 12. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Eighteen (18) units Subcutaneous qbreakfast. 13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) unit unit Subcutaneous qdinner . 14. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day. 15. insulin sliding scale Insulin SC Sliding Scale - Lispro Breakfast Lunch Dinner Bedtime Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2 Units 2 Units 2 Units 0 Units 160-199 mg/dL 4 Units 4 Units 4 Units 2 Units 200-239 mg/dL 6 Units 6 Units 6 Units 4 Units 240-279 mg/dL 8 Units 8 Units 8 Units 6 Units Discharge Disposition: Extended Care Facility: [Hospital1 15331] TCC Discharge Diagnosis: Aortic Stenosis and Coronary Artery Disease PMH: Coronary Artery Disease Mild Aortic Stenosis Hypertension Diabetes mellitus type II Carotid Disease Peripheral neuropathy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage 1+ edema bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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 Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [First Name (STitle) ] [11-16] at 1:45pm [Telephone/Fax (1) 170] Cardiologist Dr. [Last Name (STitle) 911] [2105-12-9] at 1500 Please call to schedule the following: Primary Care Dr.[First Name (STitle) ] [0-0-] in [5-4] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2105-10-26]	[ "997.1", "250.80", "414.01", "250.60", "E937.9", "424.1", "788.38", "518.0", "401.9", "511.9", "356.9", "357.2", "427.31", "285.1" ]	icd9cm	[ [ [] ] ]	[ "36.11", "36.15", "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	7102, 7154	3489, 4849	360, 721	7369, 7548	2378, 3466	8420, 9028	1610, 1673		5123, 7079		7175, 7348		4875, 5100			7572, 8397									1688, 2359																					309, 322							749, 1208																	1230, 1354	1370, 1594
49,106	126,638	35651	Discharge summary	report	Admission Date: [2185-12-7] Discharge Date: [2185-12-21] Date of Birth: [2164-9-1] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: seizure Major Surgical or Invasive Procedure: none History of Present Illness: Ms [Known lastname 81114] is a 21F w SLE with multisystem involvment including nephritis, myo-pericarditis, pancytopenia, recently admitted for 1-month at OSH for treatment of above. She presented here after focal seizures with visual auras and with secondary generalization and found to have new cerebral arterial ischemic strokes. . The patient was discharged [12-6] from OSH ([Hospital 81115] Hospital, [State 5887]) after 31-day long complicated stay for lupus flare notable for pericardial effusion with tamponade physiology requiring pericardial window, acute on chronic [State ] failure (BUN/Cr 136/5.5), with [State ] biopsy showing grade [2-19] membranoproliferative and membanous nephropathy, Citrobacter Freundii and bacteroides bacteremia, thrombocytopenia and anemia (required 4 units pRBC and 4 units platelets during stay), pleural effusion requiring thoracentesis and chest tube, peritonitis with ascites, and urinary tract infection discharged on ciprofloxacin and metronidazole. She was treated with high dose steroids and cellcept. The patient was found to develop worsening thrombocytopenia and bradycardia while on the cellcept, and it was discontinued 1 week ago. She returned to MA last night in the care of her mother. . After arriving home at approximately 2200, she complained of headache, floaters and seeing '[Holiday 944] trees'. Her eyes then deviated to the left and neck stiffened with rhythmic extension of arms and legs. There was lip biting and urinary incontinence. The episode lasted a few minutes. EMS was activated and she was taken to [Hospital3 417] Hospital for evaluation and had another witnessed seizure en route. . At OSH, a third seizure occurred similar to the others that terminated with 2mg lorazepam. FSGB at that time was 111. She was not dilantin loaded. Head CT at OSH showed ill defined hypodensity of left cerebellum, in addition to old infarcts in right occipital and parietal lobes. Labs notable for WBC 3.1, Hb 10.9, Plt 76, Na 142, K 2.9, Cre 2.1, Glu 121, Ca 7.4, CK 67, Trop 1.08, INR 1.1, negative urine toxicology screen. Transferred to [Hospital1 18] ED for neurology evaluation, where vitals were T-98.6 BP-127/96 HR-105 RR-16 O2Sat 96%. Concern for lupus cerebritis or sinus thrombosis. The patient refused lab draws and requested a PICC line. The neuro team recommended keppra load 750mg, changing antibiotics to zosyn from cipro/flagyl which may lower the seizure threshold, MRI/MRA/MRV brain, EEG, and formal echocardiogram (bedside ED echo showed effusion but no evidence of tamponade physiology). Potassium was repleted. Due to medical complexity, MICU admission was requested by the Neurology service. . Rheumatology was also consulted and they reccommended high dose solumedrol 1000mg daily times three days once infectious or vascular process has been ruled out. They also recommended evaluation for TTP. . On [2185-12-7] echo showed LVEF 20% with akinesis of the distal [12-20] of the LV, in addition to RV apical hypokinesis and a moderate pericardial effusion. These findings were thought secondary to lupus induced myopericarditis. Given the extent of her myopericarditis, she was transferred to the CCU service. . Currently she complains of feeling tired and back pain from lying flat all night. Review of systems is otherwise negative in detail including no SOB, chest pain, headache, nausea, vomiting, abominal pain, photophobia, visual hallucinations or other visual changes, numbness, weakness, rash. Reports chronic LE edema bilaterally but no calf pain. . Past Medical History: SLE complicated by nephritis, serositis (currently on prednisone, but previously on Cytoxan, Cellcept [6-23], and then transitioned to Paquinil; followed by Dr. [Last Name (STitle) 19849] in [Doctor Last Name 40074]and Dr [Last Name (STitle) 81116]/[Location (un) 27598] at [Hospital 81115] Hospital) Pericardial effusion ([10-24]) with tamponade physiology Pleural effusion, left Chronic [Month (only) ] failure (not on HD but concern for HD needs at most recent hospitalization; [Month (only) ] biopsy with mixed membranous glomerulonephritis stage 5; followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital 81115] Hospital) Multiple ICU admissions Social History: Lives with her mother (cell: [Telephone/Fax (1) 81117]) in [Hospital1 1474], MA. No tobacco, EtOH, illicit drug use. Pharmacy student in [State 5887]. Family History: Father with sarcoid, no family history of miscarriages/coagulation disorders/sickle cell trait Physical Exam: T-97.4 BP-112/85 HR-78 RR-15 O2Sat100% Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit. Right neck wound from IJ line which is removed. CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally ABd: distended, +BS soft, nontender, no organomegaly ext: Severe pedal edema, no calf swelling/edema Neurologic examination: MS: General: alert, awake, flat affect Orientation: oriented to person, place, date, situation Attention: +MOYbw. Follows simple/complex commands. Speech/[Doctor Last Name ]: fluent w/o paraphasic errors; comprehension, repetition, naming and [Location (un) 1131] intact Memory: Registers [1-17] and Recalls [1-17] at 5 min L/R: Touches left thumb to right ear Praxis: Able to brush teeth CN: I: not tested II,III: VFF to confrontation, PERRL 3mm to 2mm III,IV,V: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [Doctor First Name 81]: SCM/trapezeii [3-21] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk and tone; no tremor, asterixis or myoclonus. No pronator drift. Delt [Hospital1 ] Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 4 4 4 4 4 4 4 R 4 4 4 4 4 4 4 IP Quad Hamst DF [Last Name (un) 938] PF L2 L3 L4-S1 L4 L5 S1/S2 L 4 4 5- 5 4+ 5- R 4 4 4- 5- 5- 5- Reflex: No clonus [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 2 + Extensor R - 2 2 2 + Equivical Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS. Coordination: finger-nose-finger normal RAMs normal. Gait: N/A Romberg: N/A Pertinent Results: LABS: *** . * ADMISSION LABS: ** . HEMATOLOGY: [2185-12-7*] 07:00AM BLOOD WBC-3.1 RBC-3.40* Hgb-10.1* Hct-28.7* MCV-85 MCH-29.8 MCHC-35.2* RDW-19.6* Plt Ct-70* [2185-12-7] 07:00AM BLOOD Neuts-83* Bands-0 Lymphs-10* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2185-12-7] 07:00AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Stipple-1+ [2185-12-7] 07:00AM BLOOD PT-14.7* PTT-35.6* INR(PT)-1.3* [2185-12-7] 07:00AM BLOOD Ret Aut-8.6* . CHEMISTRY: [2185-12-7] 07:00AM BLOOD Glucose-122* UreaN-47* Creat-2.0* Na-143 K-3.2* Cl-117* HCO3-17* AnGap-12 [2185-12-7] 07:00AM BLOOD Calcium-6.9* Mg-1.6 Phos-3.6 [2185-12-7] 07:00AM BLOOD ALT-9 AST-22 LD(LDH)-282* AlkPhos-39 TotBili-0.5 Albumin-2.0* . [2185-12-7] 09:19PM BLOOD cTropnT-0.20* CK(CPK)-47 CK-MB-NotDone . [2185-12-7] 07:00AM BLOOD TSH-1.7 [2185-12-9] 08:00AM BLOOD HCG-<5 . URINE: [2185-12-7] 06:45AM URINE RBC->50 WBC-[10-6]* Bacteri-RARE Yeast-NONE Epi-0-2 [2185-12-7] 06:45AM URINE Blood-LGE Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR [2185-12-7] 06:45AM URINE Hours-RANDOM Creat-24 TotProt-290 Prot/Cr-12.1* [2185-12-7] 06:45AM URINE UCG-NEGATIVE . . *** HOSPITAL COURSE: ** ANEMIA WORKUP: [2185-12-7*] 07:00AM BLOOD Iron-10 calTIBC-98* Ferritn-808* TRF-75* [2185-12-9] G6PD - negative [2185-12-8] 05:09AM BLOOD Hapto-109 (nl) [2185-12-9] 12:05PM BLOOD Hapto-120 (nl) . HYPERCOAGULABILITY WORKUP: [2185-12-9] Antithrombin III - 83 (normal) [2185-12-9] Protein C - 106 (normal) [2185-12-9] Protein S - 182 (HIGH) [2185-12-9] FACTOR V LEIDEN - negative [2185-12-8] FACTOR V LEIDEN - negative . [2185-12-8] Anticardiolipin AB IgG - 4.6 [2185-12-8] Anticardiolipin AB IgM - 7.2 [2185-12-8] Lupus Anticoagulant - NEGATIVE . IMMUNOLOGICAL WORKUP: [2185-12-7] ESR-14 [2185-12-7] CRP-9.1* (hi) [2185-12-9] Serum IgA-124 [2185-12-8] dsDNA-NEGATIVE [2185-12-7] C3-LESS THAN ASSAY, C4-6.0* (LOW) [2185-12-15] C3-15, C4-10 . . [2185-12-7] SERUM TOX: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . NEURO: [2185-12-9] 11:04AM BLOOD LEVETIRACETAM (KEPPRA)- 16.8 . . MICROBIOLOGY: [2185-12-9] 08:00AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG - 4.8 (POSITIVE) [2185-12-9] 08:00AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM - 1050 (POSITIVE) . [2185-12-9] Serum Cryptococcal Antigen - negative Blood Cultures ([12-7], [12-8], [12-9]) - negative Mycolytic cx - pending Urine Cultures ([12-7], [12-9]) - negative . CARDIOLOGY: TTE ([2185-12-7]): The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with near akinesis of the distal 2/3rds of the left ventricle. The apex is mildly aneurysmal. Basal systolic function is relatively preserved (LVEF 20%). No thrombus is seen in the left or right ventricular cavity. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. 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 regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized circumferential pericardial effusion most prominent lateral to the left ventricle and anterior to the right atrium (1.5cm) and 0.5-1cm elsewhere. There are no echocardiographic signs of tamponade. IMPRESSION: Normal left ventricular cavity size with marked regional systolic dysfunction c/w multivessel CAD or other diffuse process. Right ventricular free wall hypokinesis. Moderate circumferential pericardial effusion without evidence for tamponade physiology. Mild mitral regurgitation. . TTE ([2185-12-8]): Compared with the prior study (images reviewed) of [2185-12-7], the left ventricular function maybe slightly better (LVEF 25-30%). The size of the pericardial effusion is similar, and there are signs of early tamponade with impaired ventricular filling. . TTE ([2185-12-9]): AM study IMPRESSION: Large pericardial effusion with tamponade physiology. Severe regional left ventricular systolic dysfunction. Compared with the prior study (images reviewed) of [2185-12-8], pericardial effusion appears slightly larger and there is echocardiographic evidence of further increase in intrapericardial pressure. . TTE ([2185-12-9]): PM study after fluid bolus (>1L NS) Compared with the prior study (images reviewed) of [2185-12-9], there is essentially no change. . TTE ([2185-12-12]): Compared with the prior study (images reviewed) of [2185-12-9], the pericardial effusion is slightly larger and the estimated pulmonary artery systolic pressure is higher. Tamponade physiology is not suggested, but can be masked by PA hypertension. The aortic valve leaflets now appear mildly thickened (?significance). Left and right ventricular systolic function are similar. . TTE ([2185-12-14]): Compared with the prior study (images reviewed) of [2185-12-12], the findings are similar. . . RADIOLOGY: . CXR (AP/Lat): [2185-12-7] IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Right lung is clear. Cardiac silhouette is substantially enlarged. A region of opacification at the base of the left lung is substantially pleural effusion but some consolidation is present as well. Short of a CT scan, a left decubitus view might be helpful in determining whether the left pleural effusion is mobile, how big it is, and whether the left lower lobe abnormality clears, suggesting that it is atelectasis and not pneumonia. The likely region affected by aspiration would be the right lower lobe which is normal. A small vascular catheter projects over the right lower neck, but does not enter a central vein. No pneumothorax. . CXR (PICC placement): [2185-12-7] IMPRESSION: 1. Interval placement of right PICC with tip terminating in right atrium that can be withdrawn by approximately 5.5 cm. 2. Globular appearance of the heart compatible with known pericardial effusion, however differential includes dilated cardiomyopathies. These findings were discussed with IV nurse, [Doctor First Name 8513] at 4:20 p.m. on [2185-12-7]. . MRI Brain: [2185-12-8] 1. Abnormal diffusion consistent with infarct involving the right parietal, occipital, and temporal lobes. Additionally, smaller foci of abnormal diffusion consistent with infarcts are identified in the left cerebellum and vermis. Corresponding T2 abnormality suggests that these infarcts may be several days old. Given the unusual distribution of these infarcts and patient's history of lupus, vasculitis and possible thromboembolic events, or possibly cortical venous infarct should be considered. 2. Relative mild vascular narrowing of the MCAs bilaterally, right greater than left. 3. Left vertebral artery appears larger than the right, possibly representing a left dominant system. 4. No evidence of dural sinus venous thrombosis. . Abd U/S ([2185-12-9]): IMPRESSION: 1. Very large fluid collection containing organized material throughout the abdomen and extending into the pelvis. The son[Name (NI) 493] appearance is consistent with hemorrhagic collection (with features suggesting chronicity including the evidence of a peripheral rim); echogenic contents could also relate to highly proteinaceous fluid or, possibly, infection. Evaluation of beta hCG is recommended to exclude the possibility of pregnancy as ruptured ectopic pregnancy would be considered in the differential diagnosis. Further evaluation with CT suggested. 2. Large bilateral pleural effusions. 3. Moderate right-sided hydronephrosis and bilateral echogenic kidneys consistent with a provided history of lupus nephritis. Cause of right sided hydronephrosis is not determined on this examination. . CT A/P ([2185-12-9]): IMPRESSION: 1. Moderate to large amount of intermediate density fluid within the abdomen and pelvis, consistent with hemorrhage. No definite cause is identified. 2. Large pericardial effusion. 3. Bilateral pleural effusions. 4. Bilateral moderate hydronephrosis, right worse than left. No cause for the hydronephrosis can be identified. 5. Probable left ovarian cyst. 6. Asymmetry in the caliber of the femoral veins, right larger than left, which could raise the possibility of a right-sided DVT. . PELVIC U/S ([2185-12-9]) - limited IMPRESSION: Limited views of the pelvis demonstrate no uterine pathology. Large complex fluid collection as seen on the prior CT scan. An endovaginal exam was declined. The left adnexal structure seen on the prior CT was not assessed. . RLE U/S w Doppler ([2185-12-9]): -limited IMPRESSION: Limited examination (color Doppler only) with no DVT identified in bilateral common femoral veins, bilateral superficial femoral veins, and bilateral proximal deep femoral veins. Remainder of the examination was declined by the patient. . [Year (4 digits) 2793] U/S ([2185-12-12]): IMPRESSION: 1. Decreased right hydronephrosis, now mild-to-moderate and no hydronephrosis on the left. 2. Persistent bilateral echogenic kidneys consistent with provided history of lupus nephritis. 3. Persistent bilateral pleural effusions. 4. Large abdominal fluid collection with low-level echoes consistent with hemorrhage. . Right groin U/S ([12-16]): IMPRESSION: No evidence of right groin arteriovenous fistula or pseudoaneurysm. Small hematoma. . . NEUROLOGY: EEG ([12-8]): MPRESSION: Mildly abnormal portable EEG due to the periods of generalized slowing. Most of the background was dominated by faster beta activity, usually in a situation of benzodiazepine medications. The slowing suggest prominant drowsiness or early sleep or possibly a more widespread encephalopathy. Nevertheless, there were no areas of prominant focal slowing, and there were no epileptiform features. Brief Hospital Course: Ms [Known lastname 81114] is a 21-y/o F w h/o SLE c/b nephritis, pleural and pericardial effusions, s/p recent 1-month-long admission at OSH for lupus flare, who now presented with new-onset generalized tonic-clonic seizures x3 at home and was found to have multiterritorial strokes, pericardial effusion w tamponade physiology as well as intraabdominal bleed. . [Hospital 81118] HOSPITAL COURSE: Discharged on [2185-12-6] from OSH ([Hospital ] Hospital, PA) after 31-day long complicated stay for SLE flare notable for pericardial effusion with tamponade, acute on chronic [Hospital ] failure (BUN/Cr 136/5.5), with [Hospital ] biopsy showing grade [2-19] membranoproliferative and membranous nephropathy, Citrobacter freundii and Prevotella loescheii bacteremia ([2185-11-10]), thrombocytopenia and anemia, pleural effusion requiring thoracentesis and chest tube, peritonitis with ascites, and UTI discharged on ciprofloxacin and metronidazole. She was treated with high dose steroids and cellcept. Cellcept has been d/c due to thrombocytopenia, but high dose steroids continue. Discharged [12-6] and driven home to [Hospital1 1474] by Mom. Once home had a tonic clonic seizure proceeded by visual hallucinations1/21 had 2 more at OSH. . [Hospital 18] HOSPITAL COURSE: . # Systemic lupus erythematosis: The unifying cause of the patient's acute medical issues was likely a lupus flair. The rheumatology team was involved in all stages of her care. On admission she was on prednisone 50 mg daily. She was given 3 days of solumedrol 1 g daily followed by resumption of prednisone 50 mg daily. Cyclophosphamide vs mycophenilate mofetil was considered for steroid-refractory disease treatment, decision was made to start mycophenolate mofetil given that pt has been succesfully treated w this drug before and that cyclophosphamide could increase the risk of infertility. Mycophenolate was started at 500mg [Hospital1 ], increased to 1000mg [Hospital1 ]. In addition, hydroxychloroquine 200mg [Hospital1 ] was added. C3/4 were checked to follow response and they were uptrending. . # Seizure: The neurology team was involved. In considering the etiology, visual hallucinations suggested a parietal/occipital focus. There was concern for lupus cerebritis or an epileptic focus secondary to CVA. MRI showed abnormal diffusion consistent with infarct involving the right parietal, occipital, and temporal lobes. Infection was less likely, and after a single attempt at an LP was unsuccessful the decision was made not to pursue this further given low suspicion for infection and thrombocytopenia. Ciprofloxacin was stopped out of concern for lowering the seizure threshold. She received keppra. On keppra she did not have any further seizures. . # Pericardial effusion: The most likely etiology was myopericarditis secondary to lupus. Takasubo myocarditis in the context of recent sepsis was also considered. TTE showed stable signs of early tamponade, not responsive to IV fluids. Lisinopril was started for afterload reduction. Serial TTEs showed stable moderate pericardial effusion, therfore no invasive intervention was done. . # Abdominal Bleeding: On ultrasound done to evaluate biliary system, intra-peritoneal blood was seen, a finding confirmed by CT. It appeared to be old(organized debris with peripheral rim on U/S). Hct dropped from 27 to 23, however, while on argatroban, which was subsequently stopped. The most likely cause of bleeding was hemorrhagic mucositis secondary to lupus. . # Thrombocytopenia: The most likely cause was immune thrombocytopenia secondary to SLE. She had been on argatroban out of a questionable history of HIT. This was continued until intra-peritoneal bleeding was found. PF4 antibody was negative shortly thereafter. She was treated with platelet tranfusions and IVIG x 5 days to keep platelets >100k given bleeding. . # Prior cerebrovascular accident: MRI showed abnormal diffusion consistent with infarct involving the right parietal, occipital, and temporal lobes. Additionally, smaller foci of abnormal diffusion consistent with infarcts were identified in the left cerebellum and vermis. Hypercoagulability work-up was negative for factor V leiden, protein C/S deficiency, antithrombin III deficiency, and anticardiolipin antibodies. . # Acute on chronic [Hospital1 ] insufficiency: On admission, [Hospital1 ] function was apparently improving compared to outside hospital trend. Chronic [Hospital1 ] insufficiency was likely secondary to lupus nephritis, as demonstrated on recent outside hospital biopsy (grade [2-19] membranoproliferative and membanous nephropathy). For this she was treated with phosphate binders and immunosuppression for lupus as above. Also, CT abdomen showed bilateral, R>L hydronephrosis of unclear etiology. This may have been contributing to her [Month/Day (1) ] failure. Urology was consulted and recommended conservative management given preserved overall kidney function (stable Cr). Pt refused Foley for decompression. Outpatient followup recommended. . #ID: Outside hospital cultures with Morganella growing from thoracentesis fluid from [11-9], Citrobacter freundii blood culture from blood culture on [11-10], and Prevotella blood culture from [11-19]. She was sent home on [12-6] and instructed to complete a course of cipro and flagyl through [12-11]. Her antibiotics were switched to zosyn on admission out of concern for ciprofloxacin lowering the seizure threshold. On [12-11] her abx were discontinued after the completion of a 16-day course. Mycoplasma IgM, IgG positive, Mycoplasma PCR from any fluid recommended, but were not performed as no invasive procedure was done. Pt remained afebrile with no sxs/ss of infection. As per infectious disease consult, PCP prophylaxis [Name Initial (PRE) ] atovaquone vs bactrim was recommended. Given G6PD-negative status, pt was discharged on bactrim prophylaxis. Medications on Admission: 1. Prednisone 50 mg QDay 2. Zofran 4 mg QDay 3. Ciprofloxacin 500 mg [Hospital1 ] 4. Metronidazole 500 mg Q8h 5. Phoslo 667 mg one tablet tid w meals 6. Sodium bicarb 1300 mf [Hospital1 ] w meals 7. Celexa 10 mg QDay 8. Protonix 40 mg QDay Discharge Medications: 1. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 2. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please take for 4 weeks. Your doctor will help you taper off this medication after that time. Disp:28 Tablet(s) Refills:0 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 11. 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:5 12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: as directed by your [Hospital 197] Clinic. Disp:30 Tablet(s) Refills:5 13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for breakthrough pain. Disp:30 Tablet(s) Refills:0 14. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:5 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: systemic lupus erythematosus complicated by pericardial effusion, pleural effusion, abdominal bleed embolic stroke . Discharge Condition: afebrile, hemodynamically stable Discharge Instructions: You were admitted to the hospital with seizures. You were found to have active lupus with involvement in multiple organs, including your heart, lungs, and kidneys. You will need very close followup and you will need to continue taking multiple medications. . We changed your medications as follows: 1) You were started on aspirin 81 mg PO daily as per neurology 2) You were started on calcium as well as vitamin D becuase you are on chronic steroids 3) You were started on hydrochloroquine for your lupus 4) You were started on Keppra for your seizure 5) You were started on a low dose ACE inhibitor to prevent [Name (NI) ] damage 6) You were started on a beta blocker 7) You were started on Cellcept for your lupus 8) Your dose of Celexa was increased 8) You were continued on your prednisone. You will need to take this for at least 6 more weeks. . You should weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Should you have any concerning symptoms such as chest pain, shortness of breath, or fever, please go to the emergency room. It has been a pleasure taking care of you at [Hospital1 ]. Followup Instructions: [2185-12-27] 09:30a [Last Name (LF) 162],[First Name3 (LF) ] NEUROLOGY [Hospital6 29], [Location (un) ] [Telephone/Fax (1) 44] . [2185-12-27] 11:30a LUPUS,[Doctor Last Name ] RHEUMATOLOGY LM [Hospital Unit Name ], [Location (un) ] [Telephone/Fax (1) 2226] . [2185-12-29] 12:00p [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] [Telephone/Fax (1) 60] . [2186-1-4] 09:00a [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] UROLOGY SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] [Telephone/Fax (1) 164] . [2186-1-6] 03:20p [Doctor Last Name ] CARDIOLOGY SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] CC7 [Telephone/Fax (1) 62] . [2186-1-24] 02:00p [Last Name (LF) ],[First Name3 (LF) 674] PRIMARY CARE SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] [Telephone/Fax (1) 250] Completed by:[2186-1-11]	[ "780.39", "287.4", "429.83", "511.9", "285.9", "V13.02", "428.21", "585.9", "434.11", "710.0", "428.0", "V58.65", "584.9", "041.85", "583.81", "423.9", "599.0", "790.7", "568.81", "591", "569.89", "323.81" ]	icd9cm	[ [ [] ] ]	[ "38.93", "03.31" ]	icd9pcs	[ [ [] ] ]	25125, 25196	17060, 17448	322, 328	25356, 25390	6834, 6854	26593, 27719	4899, 4995		23374, 25102		25217, 25335		23101, 23351	18376, 23075		25414, 26570									5010, 5425																					275, 284							356, 3949							6870, 8112									5449, 6815	3971, 4703	4719, 4883
14,394	142,343	30090	Discharge summary	report	Admission Date: [2198-2-22] Discharge Date: [2198-3-13] Date of Birth: [2130-11-20] Sex: M Service: CARDIOTHORACIC Allergies: Phenytoin / Ancef Attending:[First Name3 (LF) 165] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [3-3] Redo MVR (27 mm [Company 1543] Mosaic Porcine Valve) & CABG x 2 History of Present Illness: 67M with h/o of multiple medical problems including VF arrest now w/ AICD, ischemic cardiomyopathy EF 25-30%, CAD s/p CABG and mechanical MVR, CVA w/ residual L weakness, here w/ probable CHF exacerbation vs. possible PNA. In ED, noted to be tachy to 110s, O2 sat 91-94% RA w/ ambulation. Pt underwent CTA to evaluate for PE ->revealed severe CHF. No large PE, but limited by motion. Given lasix 40mg IV, w/ good response ~ 600cc out w/in the first hour. Then approximately 700cc overnight and became acutely hypotensive (systolic in the 80's). The pt was diaphoretic but mentating and was fluid resuscitated, which brought his pressure back up. Currently, pt denies any symptoms (specifically denies dyspnea or chest pain or cough), however his wife reported that he was weak, febrile, and slightly short of breath w/ non-productive cough over last 2-3 days. Pt himself states that he had no complaints and that his "wife was just nervous," denies f/c/abd pain, DOE, PND, HA, dysuria, dizzyness, LOC, visual changes, weakness. Brought in by ambulance today when wife called 911. Past Medical History: Upper GI bleed VF Arrest in setting of hypokalemia [7-30], now s/p AICD [2197-8-23] CVA w/ left sided weakness tx with oral anticoagulation -> complicated by SDH which required decompression by burr hole - the timing of this event is not clear. DM CAD s/p CABG (SVG-RCA), Mech MVR [2189] - [2193] PCI to LAD, D1 - [2194] PCI to instent restenosis D1 - [2196] post-VF cath - TO SVG-RCA, PCI to LCX Ischemic Cardiomyopathy (EF 25-30%) CVA - residual L sided weakness, failed anticoagulation previously despite ASA, plavix, anticoagulation Seizure Disorder tx'ed with Keppra SDH while on coumadin, s/p burr hole evacuation Upper GI bleed - s/p EGD/vessel clipping in [7-30] Social History: Tobacco: Denies Alcohol: Denies Lives with wife and 45 [Name2 (NI) ] daughter at home Family History: NC Physical Exam: VS 98.5 98/72 100 24 94%2L GENERAL: NAD, sitting up in bed breathing with mild HEENT: PERRL EOMI NECK: JVP 8cm, supple, no LAD CARDIOVASCULAR: RRR, quite S1 (mechanical) and S2 LUNGS: Bibasilar rales ABDOMEN: Soft, NT, ND, no rebound or guarding. Obese. EXTREMITIES: Warm, no CCE, 2+ DP pulses. NEURO: A/OX3. L facial droop, continued LUE and LLE weakness. Discharge Vitals 99.0, 91 SR, 124/71, rr 24, 95% on RA wt 91.9 kg Neuro alert oriented to place, person, year, not season/month RUE [3-29] RLE [2-26] LUE [2-26], LLE [1-29] left facial droop - speech clear in spanish Cardiac RRR no m/r/g Pulm clear to ausculation decreased bilat bases Abd Soft, NT, large ND + BS Ext warm pulses palpable edema +2 Incision Sternal healing no drainage/erythema sternum stable Right thigh inc with steris healing ecchymotic Left groin inc erythema no drainage Left leg EVH healing no erythema/drainage Pertinent Results: [2198-3-12] 05:05AM BLOOD WBC-10.0 RBC-2.94* Hgb-8.8* Hct-26.4* MCV-90 MCH-29.9 MCHC-33.3 RDW-14.7 Plt Ct-418 [2198-2-22] 04:30PM BLOOD WBC-10.9 RBC-4.28* Hgb-13.0* Hct-38.1* MCV-89 MCH-30.3 MCHC-34.0 RDW-14.4 Plt Ct-235 [2198-2-23] 09:05PM BLOOD Neuts-84.6* Bands-0 Lymphs-10.7* Monos-1.6* Eos-2.8 Baso-0.3 [2198-3-12] 05:05AM BLOOD Plt Ct-418 [2198-3-12] 05:05AM BLOOD PT-13.8* PTT-28.7 INR(PT)-1.2* [2198-2-22] 04:30PM BLOOD Plt Smr-NORMAL Plt Ct-235 [2198-2-22] 04:30PM BLOOD PT-12.6 PTT-24.4 INR(PT)-1.1 [2198-3-3] 04:11PM BLOOD Fibrino-186 [2198-2-22] 04:30PM BLOOD D-Dimer-942* [2198-3-1] 03:15PM BLOOD ESR-60* [2198-3-12] 05:05AM BLOOD Glucose-164* UreaN-25* Creat-1.1 Na-136 K-4.0 Cl-99 HCO3-29 AnGap-12 [2198-2-22] 04:30PM BLOOD Glucose-155* UreaN-22* Creat-1.5* Na-136 K-4.7 Cl-102 HCO3-26 AnGap-13 [2198-3-5] 02:19AM BLOOD ALT-18 AST-38 LD(LDH)-630* AlkPhos-30* Amylase-19 TotBili-0.4 [2198-3-5] 02:19AM BLOOD Lipase-9 [2198-3-9] 02:29AM BLOOD Calcium-8.1* Phos-5.2* Mg-2.0 [2198-2-27] 05:45AM BLOOD calTIBC-339 Ferritn-199 TRF-261 [2198-3-5] 02:19AM BLOOD Cortsol-17.9 [2198-3-1] 05:40AM BLOOD CRP-14.6* RADIOLOGY Final Report CHEST (PA & LAT) [2198-3-13] 9:47 AM CHEST (PA & LAT) Reason: evaluate effusion - please do when he comes down for carotid [Hospital 93] MEDICAL CONDITION: 67M ischemic s/p mvr and cabg REASON FOR THIS EXAMINATION: evaluate effusion - please do when he comes down for carotid u/s thank you INDICATION: Evaluate known left-sided pleural effusion. COMPARISON: Prior chest radiograph from [2198-3-12]. TECHNIQUE AND FINDINGS: Portable frontal and lateral chest radiographs were obtained at the bedside with a grid, in upright position. Mild further improvement in basilar atelectasis, especially on the left, is noted as compared to yesterday. There is stable left basilar pleural effusion, unchanged position of the right-sided PICC line with its tip at the cavoatrial junction, and stable position as well of the left-sided, dual chamber pacemaker and its leads. The cardiomediastinal silhouette, mediastinal clips and sternotomy wires are unchanged. Lung volumes remain low. CONCLUSION: Mild ongoing improvement of left basilar atelectasis but stable left pleural effusion as compared to yesterday. DR. [First Name (STitle) 16722] [Name (STitle) ] D' [Doctor Last Name ] Approved: TUE [2198-3-13] 12:16 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2198-3-9] 9:38 AM CT HEAD W/O CONTRAST Reason: r/o new CVA [Hospital 93] MEDICAL CONDITION: 67 year old man with s/p redo MVR/CABG, s/p CVA in past. REASON FOR THIS EXAMINATION: r/o new CVA CONTRAINDICATIONS for IV CONTRAST: None. CT SCAN OF THE BRAIN HISTORY: Status post redo mitral valve replacement and coronary artery bypass procedure, status post prior CVA. Rule out new CVA. TECHNIQUE: Non-contrast head CT scan. COMPARISON STUDY: Non-contrast head CT scan, reported by Drs. [Last Name (STitle) 12919], [Name5 (PTitle) ] and [Name5 (PTitle) ] as revealing "no intracranial pathology or hemorrhage identified. Extensive encephalomalacia from prior ischemic events". FINDINGS: Comparison with the prior CT scans re-demonstrates the large right middle cerebral artery territory infarct, moderately large left posterior cerebral artery territory infarct and a much smaller inferior division left middle cerebral artery infarct, all chronic appearing. Within the limits of CT scanning, there is no new infarct identified. There is also a probable small chronic left cerebellar hemispheric infarct seen on both studies. It should be noted that some of the posterior fossa images are of poor quality due to motion artifacts. There are no other interval changes appreciated at this time. There is re-demonstration of the left-sided calvarial burr holes. There are no other new abnormalities seen aside from a probable mixture of fluid and mucosal thickening within the left sphenoid air cell. This abnormality could indicate an inflammatory process; however, the patient was recently intubated, as determined by reference to the [2198-3-5] chest x- ray. Such a procedure could account for new sinus fluid or mucosal findings. CONCLUSION: No definite signs for new infarct. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9987] Approved: FRI [2198-3-9] 1:39 PM PATIENT/TEST INFORMATION: Indication: Redomitral valve and CABG, post mechanicamitral valve and thrombs Weight (lb): 210 BP (mm Hg): 120/60 HR (bpm): 65 Status: Inpatient Date/Time: [2198-3-3] at 11:21 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW01-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] [Name (STitle) ] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 6.0 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 5.6 cm Left Ventricle - Fractional Shortening: 0.07 (nl >= 0.29) Left Ventricle - Ejection Fraction: 15% to 20% (nl >=55%) Aorta - Valve Level: 2.1 cm (nl <= 3.6 cm) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 8 mm Hg Aortic Valve - Mean Gradient: 5 mm Hg Aortic Valve - Valve Area: 2.1 cm2 (nl >= 3.0 cm2) Mitral Valve - Mean Gradient: 13 mm Hg Mitral Valve - Pressure Half Time: 304 ms Mitral Valve - MVA (P [12-26] T): 0.7 cm2 Mitral Valve - E Wave: 2.0 m/sec Mitral Valve - A Wave: 1.5 m/sec Mitral Valve - E/A Ratio: 1.33 INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. Moderate to severe spontaneous echo contrast in the body of the LA. Moderate to severe spontaneous echo contrast in the LAA. Depressed LAA emptying velocity (<0.2m/s) Cannot exclude LAA thrombus. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast or thrombus in the body of the RA or RAA. A catheter or pacing wire is seen in the RA and extending into the RV. A mass/thrombus associated with a catheter/pacing wire in the RA or RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. No LV aneurysm. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Moderate-severe regional left ventricular systolic dysfunction. Severely depressed LVEF. LV WALL MOTION: Regional LV wall motion abnormalities include: mid inferoseptal - hypo; mid inferior - hypo; mid inferolateral - hypo; mid anterolateral - hypo; inferior apex - hypo; lateral apex - hypo; RIGHT VENTRICLE: Mild global RV free wall hypokinesis. Moderate global RV free wall hypokinesis. Nl interventricular septal motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Abnormal MVR leaflet/disc motion. Increased MVR gradient. Mitral valve mass. Severe MS (MVA <1.0cm2). Mild (1+) MR. Prolonged (>250ms) transmitral E-wave decel time. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient appears to be in sinus the patient. Conclusions: PRE-BYPASS: 1) The left atrium is mildly dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium mainly originating from left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A left atrial appendage thrombus cannot be excluded. 2) No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. A mass/thrombus associated with a catheter/pacing wire is seen in the right atrium and/or right ventricle. No atrial septal defect is seen by 2D or color Doppler. 3) Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. No left ventricular aneurysm is seen. Due to suboptimal technical quality (poor Midesophageal views because of mechanicalmitral valve), a focal wall motion abnormality cannot be fully excluded. 4) There is moderate to severe regional left ventricular systolic dysfunction in the RCA and circumflex territory. Mid anterior and anteroseptal wallmotions are preserved at rest. Overall left ventricular systolic function is severely depressed with EF of 15 to 20%. 5) There is mild to moderate global right ventricular free wall hypokinesis. There is mild TR with normal septal motions. 6) There are simple atheroma in the aortic arch and descending thoracic aorta. 7) The aortic valve leaflets (3) are mildly thickened with no stenosis or regurgitation. 8) There is a bileaflet mechanical mitral valve with the preserved motion of the leaflet close to the aortic valve. The other leaflet is immobile with 8 to 10mm mass (? Thrombus with no independent motion) and pannus sitting on the left atrial aspect. The gradients are higher than expected for this type of prosthesis with a mean of 12mm of Hg. There is severe mitral stenosis (area <1.0cm2). There is a trace to miild MR seen along with the mobile leaflet consistent with its washing jet. 9) There is no pericardial effusion. Post_Bypass: Mild RV global systolic dysfunction. Patient is on epinephrine, milrinone and levophed. His global LVEF is 25% to 30%. The previously hypokinetic inferior and inferoseptal walls are moving a little bit better. There is a bioprosthesis in the mitral position, well seated and functioning well, residual mean gradient of 4mm of HG. There are no regurgitant lesions across the mitral valve. No other new valvular abnormalities. Ascending aortic contour is well preserved. Electronically signed by [Name6 (MD) 3892] [Name8 (MD) 3893], MD on [2198-3-3] 16:06. [Location (un) ] PHYSICIAN: Brief Hospital Course: Pt is a 67M with h/o of multiple medical problems including VF arrest now w/ AICD, ischemic cardiomyopathy EF 25-30%, CAD s/p CABG and mechanical MVR, CVA w/ residual L weakness admitted for shortness of breath and fever due to probable CHF exacerbation vs. infection (UTI vs. endocarditis). In ED, the patient was noted to be tachy to 110s, O2 sat 91-94% RA w/ ambulation. Pt underwent CTA to evaluate for PE ->revealed severe CHF. No large PE, but limited by motion. Given lasix 40mg IV, w/ good response ~ 600cc out w/in the first hour. Then approximately 700cc overnight and became acutely hypotensive (systolic in the 80's). The pt was diaphoretic but mentating and was fluid resuscitated, which brought his pressure back up. On [2198-2-23] the patient underwent a transthoracic echocardiogram which showed an ejection fraction of 15% (which was decreased compared with his study at [Hospital1 112] in [2197-7-25]) and increased gradient to ~16mm across his mechanical mitral valve. On [2198-2-28] he underwent a transesophageal echo which showed partial thrombosis of the mechanical mitral prosthesis with severe inflow obstruction (MS). Severe stasis of the LA/LAA. Possible pacemaker lead infection. At this point in time a multiservice evaluation took place. Cardiology recommended patient's options to be thrombolysis of clot vs. valve replacement as soon as possible given developing thrombis shown on echo. Cardiac surgery evaluated patient for mechanical MV replacement and spoke with family regarding this. At this time the family wishes to proceed with a replacement. The patient underwent angio on [2198-3-2] in preparation for possible replacement surgery. Neurology consultation for anticoagulation recs: neuro feels pt is ok to be tx'ed with heparin and ok for thrombolysis procedure. Hematology felt that the patient was ok for heparin now (goal PTT 80-100), but long terms dosing is high risk. On [2198-3-3] he was taken to the operating room where he underwent a Redo MVR and CABG x 2. He was transferred to the CSRU in critical but stable condition on multiple pressors. An IABP was placed post operatively. On POD #1 he was seen by transplant/general surgery for concern of ischemia gut given high pressor requirement, and increasing lactic acidosis. He continued to be followed by ID for question of endocarditis, there was no evidence of infection intraoperatively or on microbiology and his antibiotics were discontinued. After much volume repletion his vasoactive were able to be weaned over several days. His IABP was removed on POD #2. He was extubated on POD #3. He had initally been started on amiodarone post operatively, but had heart block and the amiodarone was dc'd. He then had SVT which terminated with beta blockade. He was transferred to the floor on POD #6. He was followed for neurology throughout his postoperative course for a re-presentation/exacerbation of his previous CVA. On [3-12] he had a carotid u/s which showed < 40%. He was ready for discharge to rehab on POD # 10. Medications on Admission: ASA 325 PO daily Keppra 1g PO BID Lantus insulin 48 units SC qhs Lasix 20 PO daily Lipitor 80 mg PO daily Lisinopril 5 mg PO daily Lovenox 70 units SC BID MVI Omeprazole 20 PO daily Toprol XL 200 PO daily Trazadone 25 PO daily Tricor 145 PO daily Zetia 10 PO daily Plavix 75 PO daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:0 Tablet Sustained Release 24 hr(s)* Refills:0 10. Lantus 100 unit/mL Cartridge Sig: Twenty Five (25) units Subcutaneous at bedtime. 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Congestive heart failure exacerbation, Mitral stenosis Secondary - urinary tract infection, chronic renal failure, type-II diabetes, coronary artery disease, ischemic cardiomyopathy, seizure disorder, anemia Discharge Condition: Good. Discharge Instructions: [Month (only) 116] shower, 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 Followup Instructions: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 71741] at [Hospital6 ] ([Telephone/Fax (1) 71742]. 2 weeks Dr. [Last Name (STitle) ] (PCP) 2 weeks Dr. [First Name (STitle) ] 4 weeks [Telephone/Fax (1) 170] please call to schedule [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2198-3-13]	[ "996.61", "V45.02", "E878.8", "996.71", "E849.8", "518.0", "584.9", "585.6", "E849.9", "414.8", "403.91", "453.9", "E879.0", "413.9", "394.0", "426.9", "250.92", "780.39", "041.01", "414.01", "599.0", "414.02", "428.0" ]	icd9cm	[ [ [] ] ]	[ "37.78", "38.93", "36.12", "37.61", "99.05", "88.72", "35.23", "97.44", "37.22", "39.61", "88.56", "99.04" ]	icd9pcs	[ [ [] ] ]	18520, 18590	13824, 16886	304, 384	18842, 18850	3298, 4647	19315, 19707	2346, 2350		17221, 18497	5911, 5968	18611, 18821		16912, 17198			18874, 19292					7752, 13764				2365, 3279																					245, 266	5997, 7726						412, 1498				13801, 13801													1520, 2222	2238, 2330
31,260	165,822	2723	Discharge summary	report	Admission Date: [2111-6-23] Discharge Date: [2111-7-1] Date of Birth: [2045-4-2] Sex: F Service: MEDICINE Allergies: Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending:[First Name3 (LF) 2297] Chief Complaint: Lethargy, diffuse body pain, inability to ambulate Major Surgical or Invasive Procedure: Intubation Arthrocentesis of right wrist, left wrist, and right hallux Central line placement CVVH, dialysis catheter placement Arterial Line Placement (Axillary) EGD times 2 Attempted CT-guided Emoblization History of Present Illness: 66F with known RV and LV diastolic dysfunction, CKD with baseline Cr 1.5, AF not on coumadin who presents with lethargy and pain throughout her body, limiting her ability to walk, which started approx. 4 days prior to admission. History is limited as patient is poor historian and somnolent at times. She denies any recent travel, new medications except prednisone which was started approx. 5 days ago for R great toe pain. In the ED, initial VS: 97.9 102 83/59 18 99% RA. Exam notable for bruising over extremities and flank, non focal neuro exam, DRE with guaiac positive brown stool. CXR showed no evidence of PNA. UA showed trace leuks, 2 WBC, no bacteria or nitrites. She was given 3L NS with no change in BP but lactate improved from 2.2 to 1.2. SBP was in the 40s at one point and a R IJ CVL was placed under sterile conditions. She was started on norepinephrine with minimal improvement in BP despite maxing out. Dopamine was added and she was extremely responsive to dopamine, with improvement in MAPs immediately. She was given hydrocortisone 100mg IV x1 for stress dose steroids. She was also given Zosyn and Vancomycin IV empirically given bandemia and overall instability. CT abdomen/pelvis without PO or IV contrast showed no clear cause for leukocytosis. On arrival to the MICU, she complains of pain throughout her body. Review of systems: (+) Per HPI, otherwise negative. Past Medical History: -Dyslipidemia -Hypertension -severe diastolic dysfunction of left ventricle -severe pulmonary hypertension -right ventricular contractile dysfunction and dilatation with recurrent right heart failure, requiring ultrafiltration in past -severe tricuspid regurgitation -atrial fibrillation not on coumadin [1-22] GI bleed -Patent foramen ovale (closed [3-/2109]) -ulcerative colitis -angioectasia of entire colon (last colonoscopy [2108]) -chronic renal insufficiency (baseline 1.5) -history of ETOH abuse with current ETOH use -Chronic massive leg edema with recurrent leg cellulitis -Ventral hernia status post repair -gout -appendicitis, medically managed [3-/2111] Social History: - four children - Tobacco history: denies - ETOH: 1 drinks per week, denies history of withdrawal symptoms. Prior heavy EtOH use. - Illicit drugs: denies Family History: -Father with MI at age 68 -Mother breast cancer at age 52 Physical Exam: Admission physical exam: General: Alert, oriented to person, place, time, anxious at times HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated to earlobe, no LAD CV: Regular rate and 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, diffusely tender GU: foley with clear yellow urine Ext: slightly cool, 1+ pulses, no clubbing, cyanosis or edema Skin: ecchymoses noted over BUE, L posterior and R lateral flank Neuro: moving all extremities, non-focal Discharge physical exam: Expired Pertinent Results: Admission labs: [2111-6-23] 08:35PM BLOOD WBC-33.1# RBC-4.10 Hgb-12.3 Hct-38.6 MCV-94 MCH-30.1 MCHC-32.0 RDW-16.5* Plt Ct-125* [2111-6-23] 08:35PM BLOOD Neuts-89* Bands-4 Lymphs-0 Monos-6 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2111-6-23] 08:35PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-2+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL Burr-2+ [2111-6-23] 08:35PM BLOOD PT-13.5* PTT-26.7 INR(PT)-1.3* [2111-6-23] 08:35PM BLOOD Glucose-123* UreaN-133* Creat-4.3# Na-128 K-4.4 Cl-93* HCO3-21* AnGap-18 [2111-6-23] 08:35PM BLOOD ALT-11 AST-36 AlkPhos-196* TotBili-0.8 [2111-6-23] 08:35PM BLOOD Lipase-11 [2111-6-23] 08:35PM BLOOD cTropnT-<0.01 [2111-6-23] 08:35PM BLOOD Albumin-3.3* Calcium-9.6 Phos-3.3 Mg-1.9 [2111-6-23] 08:35PM BLOOD TSH-4.1 [2111-6-23] 08:38PM BLOOD Lactate-2.2* Imaging: CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There is a persistent rounded right lower lobe opacity with an unchanged moderate right pleural effusion. Minimal left dependent atelectasis is identified, and there is also a trace left pleural effusion. There is unchanged cardiomegaly and a PFO occlusion device partially visualized. Complete evaluation of the abdominal and pelvic viscera is limited secondary to the non-contrast technique. The liver appears homogeneous without focal lesion. No intra- or extra-hepatic biliary ductal dilatation is identified. Redemonstrated is are multiple large gallstones measuring up to 1.9 cm. The spleen, pancreas, and adrenal glands appear normal. Kidneys are small though symmetric and without focal lesion or hydronephrosis. There is diffuse mesenteric edema with a small amount of perihepatic ascites. Edema within the subcutaneous tissues is also extensive. Findings are likely secondary to aggressive fluid resuscitation given clinical history of hypotension requiring pressors. The bowel overall appears within normal limits without evidence of obstruction. No focal loop of bowel demonstrates surrounding inflammation or wall thickening. The appendix is retrocecal and remains dilated measuring up to 9 mm, similar to prior (2:35). There is a proximal appendicolith. No periappendiceal fluid collection is identified to suggest developing abscess. There is no extraluminal air. The colon appears normal without signs of inflammation or obstruction. The abdominal aorta remains moderately calcified though non-aneurysmal. CT PELVIS WITHOUT INTRAVENOUS CONTRAST: A Foley catheter and a small amount of air are visualized within the bladder, which is otherwise unremarkable. The uterus and adnexa appear unremarkable. There is trace pelvic free fluid. OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is identified. Loss of vertebral body height at multiple lumbar levels appears unchanged from prior examination. IMPRESSION: 1. Diffuse mesenteric edema, trace ascites, bilateral pleural effusions and diffuse subcutaneous edema, findings consistent with third spacing secondary to recent volume resuscitation. 2. Persistently dilated fluid-filled appendix with surrounding fat stranding suggestive of chronic appendicitis in this patient who was treated medically for appendicitis in [2111-2-19]. Appendiceal mucocele remains a possibility given the duration of CT abnormalities. 3. Cholelithiasis. If there is concern for cholecystitis, this would be better evaluated by ultrasound. 4. Unchanged moderate-sized right pleural effusion with overlying rounded right lower lobe consolidation/rounded atelectasis. BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: Examination was limited secondary to patient's body habitus and inability to cooperate. The left calf veins could not be seen. [Doctor Last Name ] scale and Doppler son[Name (NI) 1417] of the bilateral common femoral, superficial femoral, and popliteal veins were obtained. The right posterior tibial and peroneal veins were also examined. There is normal flow and compressibility. Edema is seen within the subcutaneous tissues of the bilateral calves. IMPRESSION: No evidence of DVT in the lower extremities. Left calf veins not visualized. WRIST IMAGING: There are again seen severe degenerative changes of the first CMC joint with subluxation. This is similar to the prior study. No acute fractures are identified. There is generalized demineralization. There are also degenerative changes with joint space narrowing in the radiocarpal joint. There is prominent soft tissue swelling seen about the wrist, particularly along the dorsum of the hand. IMPRESSSION: No fracture. If there is concern for joint fluid or intra-articular abnormalities, MRI could be performed. RUQ U/S FINDINGS: Redemonstrated are large only rim calcified non-shadowing gallstones in the gallbladder without evidence of gallbladder distention. The wall measures 4 mm. The appearance of the gallbladder is unchanged from [2110-12-24]. There is no pericholecystic fluid and [Doctor Last Name 515] sign is negative. There is no intra- or extra-hepatic biliary dilation with the common bile duct measuring 5 mm. There are no focal hepatic lesions. The portal vein is patent with normal hepatopetal flow. There is no ascites. The partially visualized pancreas is normal. IMPRESSION: Rim-calcified non-shadowing gallstones in the gallbladder, but no evidence of pericholecystic fluid or gallbladder distention. The appearance of the gallbladder is unchanged from [Month (only) 404] [2110]. Negative [Doctor Last Name 515] sign. TTE The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). A septal occluder device is seen across the interatrial septum. There is a bidirectional color flow Doppler shunt across the interatrial septum at rest.. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis. Well seated atrial septal occluder with small bidirectional shunt. Pulmonary artery hypertension. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [2111-6-24], the severity of mitral regurgitation is reduced and a small bidirectional atrial septal shunt is now suggested. The estimated PA systolic pressure is now higher (may be related to better image quality during the current study rather than a true change). MICROBIOLOGY: [2111-6-23] 8:35 pm BLOOD CULTURE FINAL REPORT [2111-6-26] Blood Culture, Routine (Final [2111-6-26]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final [2111-6-24]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN [2111-6-24] AT 10:45AM. Anaerobic Bottle Gram Stain (Final [2111-6-24]): GRAM POSITIVE COCCI IN CLUSTERS. [2111-6-23] 9:35 pm URINE FINAL REPORT [2111-6-25] URINE CULTURE (Final [2111-6-25]): <10,000 organisms/ml. Respiratory Viral Culture (Final [2111-6-29]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [Telephone/Fax (1) 6182] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [2111-6-25]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. [2111-6-25] 7:48 am JOINT FLUID Source: right toe, left wrist, right wrist FINAL REPORT [2111-6-28] GRAM STAIN (Final [2111-6-25]): Reported to and read back by [First Name9 (NamePattern2) 13480] [Doctor Last Name 3078] @ 0955, [2111-6-25]. 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. FLUID CULTURE (Final [2111-6-28]): STAPH AUREUS COAG +. HEAVY GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [2111-6-25] 2:48 pm BLOOD CULTURE Source: Line-RIJ. FINAL REPORT [2111-7-1] Blood Culture, Routine (Final [2111-7-1]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # 350-1007F [2111-6-24]. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Anaerobic Bottle Gram Stain (Final [2111-6-29]): GRAM POSITIVE COCCI IN CLUSTERS. [2111-6-27] 2:16 pm SPUTUM Source: Endotracheal. FINAL REPORT [2111-7-1] GRAM STAIN (Final [2111-6-27]): [10-15] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [2111-7-1]): Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [2111-6-28] 3:47 am BLOOD CULTURE Source: Line-ALINE. FINAL REPORT [2111-7-4] Blood Culture, Routine (Final [2111-7-4]): NO GROWTH. Brief Hospital Course: 66 year old feamle with severe diastolic LV dysfunction and RV dysfunction, CKD, severe TR who presented with worsening lethargy and diffuse body pain, found to be hypotensive, with bandemia and worsening renal function with erythematous and edematous wrists (bilaterally) and right hallux, found to have polyarticular septic joints with Staphylococcus aureus causing overwhelming sepsis. The patient arrived to the MICU on pressors. On morning of admission, the patient's blood cultures returned positive with gram positive with GPCs. The patient was started broadly on antibiotics with Vancomycin and Zosyn upon admission. Rheumatology was consulted on the morning of admission and tapped the patient's left wrist. Gram stain returned showing large amount of Gram positive cocci. Plastic surgery became involved and tapped the patient's right wrist and right hallux which also showed evidence of septic joint with large amount of Gram positive cocci. ID was consulted in light of the patient's high-grade bacteremia. TTE that was done did not show evidence of vegetations. In light of her polyarticular septic joints, the patient was planned to be taken to the OR for joint wash-outs. However, as the patient was being wheeled for her procedures, she developed large-volume hematemesis and was subsequently intbuated for airway protection and concern for aspiration. Hepatology performed a bedside EGD and found bleeding, within the esophagus, stomach. The patient received 4 units of blood and 1 unit of FFP in the setting of her acute GI bleed. Interventional Radiology attempted embolization in light of the acute GI bleed, but the procedure was aborted secondary to dissection. The patient acutely stabilized. A repeat EGD on [6-26] showed evidence of ischemic gastritis with large ulcerations present in the esophagus, stomach, and duodenal bulb. The patient had epinephrine injections and one clip placed where a vessel was visible. Of note, because of the [Initials (NamePattern4) 228] [Last Name (NamePattern4) ], the patient was started on CVVH as well. Because of the patient's clinical instability and three-pressor requirement, Plastic surgery performed serial bedside taps of the involved joints at the bedside. Joint aspiration fluid and blood cultures returned with Staph aureus, and antibiotics were narrowed to Vancomcyin from Vancomycin and Zosyn. Through the patient's admission, the patient's family was updated regarding her clinical status. In light of her clinical course, a family meeting was held during which the decision was made to transition the patient to comfort measures only on [7-1], [2110]. CVVH and pressors were discontinued. The patient was not extubated, but ventilator settings were modified in a way to mimic atmospheric conditions. The patient expired peacefully with her family surrounding her at the bedside on [2111-7-1]. Medications on Admission: per OMR, patient unable to confirm all ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 inhalations(s) po four times a day as needed CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime EPINEPHRINE - 0.3 mg/0.3 mL (1:1,000) Pen Injector - inject once for allergic emergencies FLUOCINONIDE-EMOLLIENT - 0.05 % Cream - apply twice a day FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth once a day hs GUMMIE - - vitamin for adults daily HYDROXYZINE HCL - 10 mg Tablet - 1 Tablet(s) by mouth four times a day as needed for itching LEVOTHYROXINE - 125 mcg Tablet - 1 Tablet(s) by mouth daily MESALAMINE [APRISO] - 0.375 gram Capsule, Ext Release 24 hr - 2 Capsule(s) by mouth once a day on hold METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day before breakfast OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth four times a day as needed for pain POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1 Tablet(s) by mouth daily PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth once a day SPIRONOLACTONE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day TORSEMIDE - 20 mg Tablet - two Tablet(s) by mouth twice a day ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth three times a day ASPIRIN - (discharge med) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth DAILY (Daily) CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a day FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth twice a day LOPERAMIDE [IMODIUM A-D] - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for diarrhea MAGNESIUM - (Prescribed by Other Provider) - 200 mg Tablet - 2 Tablet(s) by mouth twice a day Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "444.21", "427.31", "V49.86", "785.51", "403.90", "428.0", "288.60", "584.5", "416.8", "995.92", "556.9", "287.5", "244.9", "359.81", "276.4", "585.9", "272.4", "274.9", "038.12", "397.0", "276.8", "532.90", "305.00", "530.20", "449", "711.09", "428.32", "275.41", "414.01", "535.41", "V15.1", "285.1", "531.40", "785.52", "542", "518.81", "276.1", "573.9", "311" ]	icd9cm	[ [ [] ] ]	[ "81.91", "45.13", "38.95", "38.91", "44.43", "39.95", "96.72", "96.04", "88.47" ]	icd9pcs	[ [ [] ] ]	21100, 21109	16151, 19049	384, 593	21160, 21169	3669, 3669	21225, 21235	2913, 2973		21068, 21077		21130, 21139		19075, 21045			21193, 21202									3013, 3616																			1982, 2016		293, 346							622, 1962							3685, 16128										2038, 2724	2740, 2897			3641, 3650
72,688	157,828	50657+59271	Discharge summary	report+addendum	Admission Date: [2196-5-11] Discharge Date: [2196-5-20] Date of Birth: [2125-4-21] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: asymptomatic Type A Aortic Dissection Major Surgical or Invasive Procedure: [2196-5-13] Bentall procedure with a 29 mm [Company 1543] free style prosthesis, serial #[Serial Number 105399]. Total aortic arch replacement with a 28 mm Vascutek multi branch graft, catalog #[Numeric Identifier 76915], lot # [Serial Number 105400], serial #[Serial Number 105401]. [2196-5-12] Cardiac catheterization History of Present Illness: 71 year old male that was found to have severe aortic insufficiency and an intimal flap in the ascending aorta on outpatient echo today. He reports a single episode of sharp chest pain while laying in bed [Location (un) 1131] approximately 3 months ago. It lasted for seconds and resolved on its own. He also reports fatigue at this time which resolved over the following weeks. Palpitations developed approximately 2 months ago. A new murmur was found on exam with his PCP and he was scheduled for an outpatient echo. Of note, the patient went mountain climbing this weekend without difficulty. He does relay occasional symptoms of peripheral claudication. Cardiac surgery evaluation is requested for further work-up of Type A Aortic Dissection and repair. Past Medical History: Hypothyroidism Prostate Cancer Bipolar Disorder Radical Prostatectomy Cholecystectomy Tonsillectomy Social History: Lives with: alone Occupation: retired, dabbles in real estate and writing Tobacco: none ETOH: [5-13]/week Family History: father died at 87yo of MI, w h/o Rheumatic Fever mother died at [Age over 90 ]yo Physical Exam: Pulse: 72 Reg Resp: 18 O2 sat: 100%RA B/P Right: 146/62 Left: 153/65 Height: 68" Weight: 155lb General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] no rash HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [2-14] syst, [4-13] diastolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: 2+ Left: 2+ radiation of cardiac murmur Brief Hospital Course: Presented for echocardiogram and was admitted after echocardiogram revealed question of flap in aorta and aortic insufficiency. He underwent CT scan that revealed chronic type A dissection and underwent preoperative workup. He was transferred to the intensive care unit for blood pressure management. He underwent cardiac catheterization which revealed no flow obstructing disease. On [5-13] he was brought to the operating room and underwent bentall procedure. See operative report for further details. He received vancomycin and cefazolin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. He remained intubated on vasoactive and inotropic medications that were progressively weaned off on post operative day one. He remained intubated and sedated on propofol due to agitation and volume overload. He was started on betablockers for heart rate and blood pressure management and lasix for duiresis due to volume overload. Over the next few days he continued to improve and on postoperative day three he was weaned and extubated. He continued to improve and was transferred to the floor on post operative day four. Physical therapy worked with him on strength and mobility. it was determined that a brief rehab stay (less than 30 days) was recommended prior to returning home. All instructions and appointments were advised. Medications on Admission: Lithium 300mg [Hospital1 ] MWF, Daily Tues/Thurs. Levothyroxine 25mcg daily Aspirin 325mg daily Vitamin D Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 2. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO BID(Q MON-WED-FRI) (). 10. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO DAILY(Q TUE-[Last Name (un) ]) (). 11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: Chronic type A aortic dissection Aneurysmal degeneration of the ascending aorta, aortic root and aortic arch secondary to chronic dissection Severe aortic regurgitation Secondary Prostate Cancer Bipolar Disorder Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema 1+ 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) 914], #[Telephone/Fax (1) 170], on [2196-6-14] at 1:30p Cardiologist: Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5543] [Telephone/Fax (1) 62] [2196-6-16] at 1:00p Urology: Dr [Last Name (STitle) ] [Telephone/Fax (1) 277] [2197-2-2] 10:30 Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) 3315] in [4-12] weeks [Telephone/Fax (1) 37171] 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:[2196-5-20] Name: [Known lastname 17158],[Known firstname ] Unit No: [Numeric Identifier 17159] Admission Date: [2196-5-11] Discharge Date: [2196-5-20] Date of Birth: [2125-4-21] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1543] Addendum: Sleep lab recommmendations: 1. If CPAP is provided by rehab, give him auto-CPAP [5-19] 2. [Hospital 2155] medical center will be providing CPAP. "Auto CPAP [5-19]; CPAP mask and supplies. Dx- sleep apnea" [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 17160] is our contact person from NAM if problems, cell [Telephone/Fax (1) 17161]. 3. Schedule outpt sleep clinic eval [Telephone/Fax (1) 1119], with Dr. [First Name8 (NamePattern2) 17162] [Last Name (NamePattern1) ] [2195-6-16] am [Location (un) 336] [Hospital ] medical specialties [First Name8 (NamePattern2) 17162] [Last Name (NamePattern1) ], M.D. KS B23, Division of Pulmonary, Critical Care and Sleep Medicine [Location (un) 6736] [Location (un) 42], [Numeric Identifier 5891] Phone: ([Telephone/Fax (1) 17163] Fax: ([Telephone/Fax (1) 17164] Past Medical History: Hypothyroidism Prostate Cancer Bipolar Disorder Radical Prostatectomy Cholecystectomy Tonsillectomy Sleep apnea Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 2. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO BID(Q MON-WED-FRI) (). 10. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO DAILY(Q TUE-[Last Name (un) ]) (). 11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. cholecalciferol (vitamin D3) 400 unit 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. "Auto CPAP [5-19]; CPAP mask and supplies. Dx- sleep apnea" Discharge Disposition: Extended Care Facility: [Hospital3 474]- [Location (un) 164] [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2196-5-20]	[ "276.69", "401.9", "296.80", "244.9", "327.23", "287.5", "424.1", "274.01", "285.1", "424.0", "447.73", "293.0", "286.9", "V10.46", "441.01", "458.29" ]	icd9cm	[ [ [] ] ]	[ "88.57", "39.54", "96.71", "88.56", "39.61", "38.45", "35.21" ]	icd9pcs	[ [ [] ] ]	10367, 10597	2626, 4024	348, 699	5833, 5991		6832, 8821	1766, 1853		8980, 10344		5597, 5812		4050, 4162			6015, 6809									1868, 2603																					270, 310							727, 1498																	8843, 8957	1638, 1750
82,649	194,291	36259	Discharge summary	report	Admission Date: [2138-5-29] Discharge Date: [2138-6-20] Date of Birth: [2111-3-27] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 4691] Chief Complaint: s/p train vs. pedestrian Major Surgical or Invasive Procedure: [2138-5-27] 1. Right retrograde brachial arteriogram. 2. Right antegrade subclavian arteriogram from the right femoral approach. 3. Thrombectomy of right distal axillary artery. 4. Repair of axillary artery with interposition graft of 6- 0 [Doctor Last Name 4726]-Tex. 5. Cutdown and repair of right brachial artery. [2138-5-28] 1. Washout and debridement of left open tibia fracture down to and inclusive of bone. 2. Closed reduction, left tibia fracture with manipulation. 3. Application multiplanar external fixator. 4. Graft thrombectomy. [2138-5-28] PROCEDURE PERFORMED: 1. Exploration of left hand lacerations with completion of left carpal tunnel release. 2. Irrigation and debridement left hand lacerations. 3. Repair of left hand laceration (8 cm). 4. Right hand fasciotomies including thenar, hypothenar and interossei releases. 5. Right carpal tunnel release. 6. Right volar and dorsal forearm compartment fasciotomies. 7. Upper arm fasciotomy. 8. Exploration of subclavicular brachial plexus avulsion with tagging of neural stumps. 9. Application of dressing over arm and wounds. [2138-5-29] PROCEDURE: 1. Open reduction internal fixation anterior pelvic ring with 2 plates, modifier 22. 2. Open reduction internal fixation right posterior ring sacroiliac joint, percutaneous 7.3 mm sacroiliac screw. 3. Placement of vacuum sponge over the wound. [2138-5-29] PROCEDURE: 1. Removal of external fixator. 2. Irrigation and debridement left open tibia fracture, staged. 3. Placement of intramedullary nailing. [2138-5-29] PROCEDURE: Right axillary artery repair after brachial arteriogram. [2138-6-4] PROCEDURE: Inferior vena cava filter. [2138-6-7] OPERATIONS: 1. Irrigation and debridement and closure of right lateral arm wound (10 cm). 2. Irrigation, debridement and application of VAC dressing, right volar forearm. 3. Simple closure of dorsal hand wounds. History of Present Illness: Mr [Known lastname 7173] is a 27 yr old gentleman who was hit by a train. He has no recollection of the event; loss of consciousness is unknown, but had a GCS of 14 at the scene. He was transferred to the ED by [Location (un) ]. Here, he complains of severe L leg and pelvic pain and pain in his R shoulder. He also reports being unable to feel or move his right arm. Past Medical History: None Social History: the patient lives with his wife and had been crossing the tracks multiple days before this accident, he denies heavby drug/substance abuse Family History: NC Physical Exam: Admission Physical: Gen: in obvious pain and distress, able to verbalize; airway intact HEENT: Pupils: 3-->2 b/l EOMs intact Neck: Supple. no tenderness Extrem: Left upper - warm and well-perfused. +2 brisk radial/ulnar pulses; Right upper - no palpable radial/ulnar pulses, pale and clammy Neuro: Mental status: Awake and alert x 3, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [Last Name (un) 938] G R 0 0 0 0 0 0 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: On bilateral lower extremitites and left upper extremity, the patient is intact to light touch, propioception, pinprick andvibration bilaterally. On RIGHT UPPER EXTREMITY - pt has complete sensory deficit below and including level of deltiod; pt does have inner axillary sensation intact. he does not withdraw to deep nailbed pressure or pinprick. Reflexes: B T Br Right 0 0 0 Left 2 2 2 Propioception intact on left, not intact on right Rectal exam normal sphincter control Discharge Physical: NAD RRR CTAB Soft NT/ND RUE: with evidence for necrosis at distal fingertips, completely insensate up to shoulder level with no evidence of movement. +2 radial pulse, +1 ulnar pulse LLE: wound c/d/i, staples removed, no evidence of infection; nvi Pertinent Results: [2138-5-28] 04:00PM BLOOD WBC-26.7* RBC-4.33* Hgb-13.9* Hct-39.6* MCV-91 MCH-32.2* MCHC-35.3* RDW-13.0 Plt Ct-328 [2138-5-29] 01:59AM BLOOD WBC-7.2# RBC-3.10# Hgb-9.9# Hct-27.7# MCV-90 MCH-32.0 MCHC-35.8 RDW-14.8 Plt Ct-193 [2138-5-29] 05:33AM BLOOD WBC-8.3 RBC-2.61* Hgb-8.3* Hct-23.5* MCV-90 MCH-31.8 MCHC-35.4* RDW-14.9 Plt Ct-178 [2138-6-15] 05:50AM BLOOD WBC-9.4 RBC-3.27* Hgb-10.0* Hct-31.1* MCV-95 MCH-30.4 MCHC-32.0 RDW-17.4* Plt Ct-457* [2138-6-16] 07:20AM BLOOD WBC-7.7 RBC-3.05* Hgb-9.4* Hct-28.7* MCV-94 MCH-30.8 MCHC-32.8 RDW-17.1* Plt Ct-492* [2138-6-8] 06:15AM BLOOD Neuts-73* Bands-1 Lymphs-12* Monos-5 Eos-4 Baso-0 Atyps-0 Metas-1* Myelos-3* Promyel-1* [2138-6-20] 10:45AM BLOOD PT-26.7* PTT-35.1* INR(PT)-2.7* [2138-6-19] 05:45PM BLOOD PT-25.0* PTT-34.8 INR(PT)-2.5* [2138-6-19] 06:50AM BLOOD PT-47.3* PTT-81.5* INR(PT)-5.3* [2138-6-18] 07:10AM BLOOD PT-43.4* PTT-77.6* INR(PT)-4.8* [2138-6-16] 07:20AM BLOOD Glucose-134* UreaN-10 Creat-0.6 Na-133 K-3.7 Cl-98 HCO3-24 AnGap-15 [2138-6-11] 07:15AM BLOOD Glucose-102 UreaN-18 Creat-0.5 Na-134 K-4.4 Cl-99 HCO3-26 AnGap-13 [2138-5-29] 05:33AM BLOOD Glucose-130* UreaN-15 Creat-0.8 Na-138 K-4.8 Cl-111* HCO3-19* AnGap-13 [2138-5-29] 01:59AM BLOOD Glucose-148* UreaN-15 Creat-0.9 Na-138 K-5.1 Cl-111* HCO3-20* AnGap-12 [2138-5-29] 01:59AM BLOOD CK(CPK)-[Numeric Identifier 2686]* [2138-5-29] 05:33AM BLOOD CK(CPK)-[Numeric Identifier 13237]* [2138-5-29] 09:47AM BLOOD CK(CPK)-[Numeric Identifier 82203]* [2138-6-1] 01:59PM BLOOD CK(CPK)-8654* [2138-6-2] 01:57AM BLOOD CK(CPK)-7346* [2138-6-3] 12:54AM BLOOD CK(CPK)-3246* [2138-5-28] 06:43PM BLOOD Type-ART pO2-374* pCO2-39 pH-7.32* calTCO2-21 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [2138-5-28] 08:01PM BLOOD Type-ART pO2-168* pCO2-33* pH-7.38 calTCO2-20* Base XS--4 Intubat-INTUBATED Brief Hospital Course: The patient was brought to the emergency room immediately after admission to the emergency room for R axillary artery transsection. He underwent the aforementioned procedures which he did not tolerate well, as it appeared that he thrombosed the graft and was taken back to the OR for a thrombectomy. On [5-29] he underwent ORIF pelvis, R SI screw and R tibial IM nail. He received multiple units of blood on [5-30] and [5-31], and his heparin gtt was d/c'ed. He spiked to 101.5 on [5-31] and was pancultured. He desaturated and was noted with copious secretions which was likely due to pneumonia. On [6-2] he re-spiked and was started on Vancomycin and Zosyn. On [6-3], cipro was added. On [6-4] he ws extubated and started on a lasix drip, Cipro/Vanc were d/c'ed, and ampicillin was started. On [6-4] he also received an IVC filter. On [6-7] he underwent I+D of his hand wounds, VAC placement to lateral right forearm and dorsal wound hand closure. On [6-11] it was noted that he had some decreased pulses in the evening. [Month/Year (2) ] was consulted immediately and decided that he should return to the OR. The patient, however, refused until the next day. Finally, he was brought to the OR on [6-12] for thrombectomy of right axillary graft and brachial artery angiogram followed by stenting. This caused significant return of pulses. He was immediately started on aspirin/plavix as well as an argatroban drip secondary to HIT positive antibody. He was on this for 8 days with intense monitoring of INR and PTT. Finally, his INR was therapeutic for 2 days and his argatroban drip was discontinued. He was discharged on coumadin with strict followup instructions. He continued to work with PT the entire stay and gained strength in mobility, though his RUE did not improve in strength/sensation. He remained essentially NWB on the right side with TTWB on the L for transfers. He was sent home in stable condition to the care of his family. He received a total of 10u pRBC and 3u albumin in his stay at [Hospital1 18]. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:180 Capsule(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO EVERY EVENING @ 4 PM. Disp:30 Tablet(s) Refills:2 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO AS DIRECTED ONLY: Take only as direted if additional doses are required based on your INR. Disp:30 Tablet(s) Refills:2 9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for sleep. Disp:60 Tablet(s) Refills:0 10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for bladder spasm. Disp:120 Tablet(s) Refills:0 12. Outpatient [Name (NI) ] Work PT/INR 1-2x weekly and prn based on maintaining INR goal between [2-18]. Call results to [Month/Day (3) ] Surgery [Telephone/Fax (1) 1237]. Dx: Right axillary and brachial plexus transections Discharge Disposition: Home Discharge Diagnosis: s/p Pedestrian struck by train Right axillary artery transection Right brachial plexus complete transection Left [Location (un) ] laceration Left open tibia/fibula fracture Open book pelvic fracture Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: Dressing changes to be performed twice per day: Cleanse with wound cleanser, apply sterile normal gauze and then cover with a dry sterile dressing. DO NOT put any weight on your right arm. You will need to continue with the Coumadin, As[orom and Plavix (blood thinners); your INR will need to be checked at least 1-2x per week at a [Location (un) ] close your home. A prescription is being provided to you to take when you go for your first visit which should be on Monday [2138-6-23]. Return to the Emergency room if you develop any fevers, chills, headaches, dizziness, shortness of breath, chest pain, pain, swelling in any any of your extremities,nausea, vomiting, diarrhea, and/or any other symptoms that are concerning to you. Followup Instructions: Follow up in 2 weeks in [Hospital 5498] clinic, call [Telephone/Fax (1) 1228] for an appointment. Provider: [Name10 (NameIs) ] [Apartment Address(1) 871] ([Doctor First Name ]) [Doctor First Name ] LMOB (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2138-7-30] 9:00 Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2138-7-30] 9:45 Completed by:[2138-6-23]	[ "041.5", "808.59", "E805.2", "996.74", "903.1", "997.31", "785.4", "903.01", "289.84", "882.0", "518.81", "823.32" ]	icd9cm	[ [ [] ] ]	[ "38.7", "86.28", "00.40", "04.43", "39.31", "88.49", "93.56", "79.36", "78.67", "88.44", "83.14", "79.66", "84.72", "86.59", "78.17", "38.03", "39.49", "96.6", "39.90", "96.72", "39.50", "82.12", "00.45", "79.39", "39.57", "79.06" ]	icd9pcs	[ [ [] ] ]	9813, 9819	6245, 8328	299, 2261	10066, 10147	4314, 6222	10939, 11412	2869, 2873		8351, 9790		9840, 10045					10171, 10916									2888, 3186																					235, 261							2289, 2669												3201, 4295					2691, 2697	2713, 2853
8,066	161,389	23586	Discharge summary	report	Unit No: [Numeric Identifier 60379] Admission Date: [2197-3-16] Discharge Date: [2197-3-20] Date of Birth: [2125-3-2] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Fever and abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old white male with a history of hypertension, Type 2 diabetes mellitus who in the last two weeks has undergone two endoscopic retrograde cholangiopancreatography for biliary obstruction secondary to choledocholithiasis. Approximately two weeks earlier the patient had experienced nausea and vomiting, was seen at [Hospital 882] Hospital. He underwent endoscopic retrograde cholangiopancreatography with biliary stone extraction and sphincterotomy on [2197-3-2]. He was discharged home after the endoscopic retrograde cholangiopancreatography however, he returned to the hospital with nausea and vomiting and jaundice with new onset ascites. His T Bili was elevated. He was transferred to [Hospital1 346] for endoscopic retrograde cholangiopancreatography which he underwent on [2197-3-10], this endoscopic retrograde cholangiopancreatography noted diffusely edematous duodenal wall and major papilla with tapering of the distal CVD and intrahepatic ductal dilatation. Findings raised concern for a small bowel microperforation. The patient was transferred back to [Hospital ] Hospital where he was treated with antibiotics and discharged home on Levaquin. However, the patient continued to experience recurrent fever with nausea and abdominal pain and presented to [Hospital1 69] on [2197-3-17]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Type 2 Diabetes mellitus. 3. Biliary obstruction, status post sphincterotomy, stone removal on [2197-3-2], status post endoscopic retrograde cholangiopancreatography with CVD stent placement on [2197-3-10]. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Paxil. 2. Lasix. 3. Glyburide. 4. Spironolactone. 5. Flomax. 6. Lisinopril. SOCIAL HISTORY: The patient lives alone, wife was recently deceased a few weeks before presentation. The patient reports a 30 pack year smoking history, he quit tobacco in [2161]. He denies alcohol or other elicit drug use. REVIEW OF SYMPTOMS: On presentation the patient reports fever, chills, nausea, with some vomiting and abdominal pain. He denies recent chest pain, shortness of breath or lightheadedness. PHYSICAL EXAMINATION: In general the patient is elderly, he appears ill. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light and accommodation. No scleral icterus, jugular venous distension, no lymphadenopathy noted. Cardiovascular: Regular rate and rhythm without murmur noted. Lungs: Mild crackles at the bases bilaterally. Abdomen: Moderately distended, soft, diffuse mild tenderness without rebound or guarding. Vital signs: Temperature 103.0, pulse 87, blood pressure 94/55, respiratory rate 18, O2 sat 100% on three liters nasal cannula. BRIEF HOSPITAL COURSE: As above the patient presented to [Hospital1 69] with complaints of fever with chills, nausea and abdominal pain. The vital signs obtained revealed the patient to be extremely febrile with hypotension and with a distended diffusely tender abdomen. The patient was admitted to the medical service with the diagnosis of sepsis secondary to recent endoscopic retrograde cholangiopancreatography instrumentation. He was started on broad spectrum antibiotics, fluid resuscitation was initiated and he was admitted to the medical intensive care unit service. The patient was started on intravenous antibiotics and fluid resuscitation. The patient remained stable in intensive care unit. The surgical team was consulted on [2197-3-17] and a paracentesis of the patient's ascitic peritoneal fluid was obtained, cultures were sent for specimen. A CT of the patient's abdomen and pelvis revealed diffuse pancreatitis with ascites. The patient continued to remainclinically stable. His fever defervesced, his blood pressue normalized with systolic pressures consistently in the 120's. He was transferred out of the unit on [3-18] to the floor. He did well overnight of [3-18] on the floor with the nasogastric tube still in place to wall suction. On the morning of [3-19] with the patient afebrile, in no pain, mentating well and requesting to have his nasogastric tube removed. The nasogastric tube was removed, the patient seemed to tolerate this well. However, in the afternoon of [2197-3-19] the patient after consuming some liquids the patient complained of increasing abdominal pain with nausea and vomiting. It was noted that he became hypotensive with systolic pressures into the 70's, fluid resuscitation was initiated by the medical service and the patient's pressure only responded transiently. He was transferred to the Unit to initiate more aggressive resuscitative efforts and a repeat CT scan of the abdomen and pelvis. Ongoing surgical consultation service saw the patient in the Intensive careunit it was felt that the patient on examination showed signs of altered mental status, he complained of severe abdominal pain. On examination he was noted to have rebound with involuntary guarding and peritonitis. The CT scan revealed air throughout the pancreas raising the suspicion for necrosis of the patient's pancreas. He was quickly taken to the operating room after consent was obtained, the patient underwent exploratory laparotomy and necrotic infected pancreatitis was found and debridement was initiated. During this exploration of the patient's abdomen it was noted that he had widespread necrosis of his pancreas and he became markedly unstable during the latter portions of the procedure. After resuscitative efforts were initiated, in combination with the surgical and anesthesia team a ACLS protocol was initiated, resuscitative efforts continued for for 3-4 hours before the patient's condition became unsalvageable and he died. The patient's family was notified, the medical examiner as well was notified and appropriate steps were taken following the patient's death. FINAL DIAGNOSIS: 1. Necrotizing infected pancreatitis 2. Septic shock 3. Mulitorgan system failure 4. Diabetes 5. Coronary artery disease [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 18475] Dictated By:[Last Name (NamePattern1) 16264] MEDQUIST36 D: [2197-3-20] 10:28:14 T: [2197-3-20] 11:02:57 Job#: [Job Number 60380]	[ "250.00", "584.9", "286.9", "401.9", "038.42", "995.92", "567.2", "785.52", "789.5", "285.9", "998.59", "577.0" ]	icd9cm	[ [ [] ] ]	[ "52.22", "99.04", "54.91" ]	icd9pcs	[ [ [] ] ]		3017, 6135													6152, 6548																						2445, 2993									196, 223							252, 1603																	1625, 2003	2020, 2422
3,011	108,292	47304	Discharge summary	report	Admission Date: [2103-1-10] Discharge Date: [2103-1-17] Date of Birth: [2027-9-7] Sex: F Service: [Doctor Last Name 1181]/MEDICINE CHIEF COMPLAINT: Shortness of breath, weakness. HISTORY OF PRESENT ILLNESS: The patient is a 75 year old white woman discharged from [Hospital1 188] one day prior to presentation. Previous discharge summary is reviewing in extensive detail her past medical history and previous hospital courses. The patient presented one day following discharge complaining of increased shortness of breath and weakness. She denied chest pain, abdominal pain, headache, fevers, sweating, orthopnea and paroxysmal nocturnal dyspnea. However, she did complain of nonproductive cough, nausea, and some diarrhea. PAST MEDICAL HISTORY: As reviewed in the OMR previously: 1. Hypertension. 2. Breast cancer, underwent lumpectomy and radiation therapy. 3. Status post thyroid surgery. 4. Status post hysterectomy. 5. Neuropathy. 6. Coronary artery bypass graft surgery with mitral valve repair. The coronary anatomy is reviewed in detail in the OMR. ALLERGIES: The patient is allergic to Penicillin which causes a rash and Compazine which causes neurologic symptoms. MEDICATIONS ON PRESENTATION: 1. Protonix 40 mg p.o. once daily. 2. Tylenol 325 mg as needed every four to six hours. 3. Sublingual Nitroglycerin although the patient states that she does not take this medication regularly. 4. Amiodarone 400 mg p.o. daily. 5. Metoprolol 12.5 mg p.o. twice a day. 6. Ambien 5 mg p.o. as needed p.r.n. for sleep. 7. Hydralazine 50 mg four times a day. 8. Levothyroxine 125 mcg once daily. 9. Warfarin 2 mg Monday, Wednesday and Friday. 10. Levofloxacin 250 mg p.o. daily as prescribed on discharge on [2103-1-9]. 11. Metronidazole 500 mg p.o. three times a day, again prescribed on discharge on [2103-1-9]. 12. Fluoxetine 40 mg p.o. once daily. 13. Erythropoietin 4000 units Monday and Friday although the patient does not take this medication regularly. 14. Clonazepam 0.5 mg p.o. three times a day as needed for anxiety. 15. Lorazepam, the patient could not recall the dose, but she also uses this second benzodiazepine occasionally for anxiety. FAMILY HISTORY: Significant for abdominal aortic aneurysm. SOCIAL HISTORY: The patient as reviewed in previous OMR notes has 24 hour nursing care. She has a remote history of tobacco use. She does not drink alcohol. PHYSICAL EXAMINATION: Vital signs - The patient had a heart rate of 80, blood pressure 155/70, respiratory rate 22, oxygen saturation 99% on two liters. Generally, the patient is tired appearing, depressed in no acute distress. She was alert and oriented times three. Head, eyes, ears, nose and throat is normocephalic and atraumatic. Dry mucous membranes. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Neck - jugular venous distention was seven centimeters. The thyroid was not palpable. There was no carotid bruit. Heart regular rate and rhythm, normal S1 and S2, no extra sounds. Lungs - She had decreased breath sounds over the lower lung fields bilaterally. She had dullness to percussion. Abdomen - The patient had normal bowel sounds, soft, nontender, nondistended. Liver edge and spleen were not palpated. Extremities - She had trace bilateral lower extremity edema. She had multiple hematomas. LABORATORY DATA: White blood cell count was 8.7, hematocrit 30.0, platelet count 279,000. Sodium 134, potassium 3.6, chloride 98, bicarbonate 21, blood urea nitrogen 27, creatinine 1.7, glucose 94. Electrocardiogram showed normal sinus rhythm, no acute changes. HOSPITAL COURSE: Psychiatry - The patient was evaluated by the psychiatry service and shown in OMR that her Clonazepam was discontinued. There were no further psychiatric issues. The other medications were not changed. Cardiopulmonary - The patient had a chest x-ray showing a small right sided pleural effusion and a left sided pleural effusion. She was continued on her antibiotics as described above. Specifically, she continued her Levofloxacin and Metronidazole. The patient's shortness of breath was initially attributed to possible pulmonary embolism. The patient underwent computed tomographic angiography after echocardiogram showed pulmonary hypertension. After having this procedure, however, the patient was found to not have pulmonary emboli, however, a thoracic type B aortic dissection was noted distal to the left subclavian artery extending four to five centimeters. The patient was transferred to the Coronary Care Unit for blood pressure management and evaluation by Cardiothoracic Surgery. The patient was deemed a poor surgical candidate and in consultation with her family, the patient opted against having any intervention other than medical management. While in the Coronary Care Unit, the patient underwent thoracentesis which showed a mixed transudative/exudative picture consistent with both congestive heart failure and parapneumonic effusion. Her breathing was much improved following the thoracentesis. Renal - The patient initially presented with her baseline creatinine of 1.5, however, she did have metabolic acidosis. She received intravenous bicarbonate with moderate correction. However, following the angiography, her creatinine increased to slightly over 2.0. This worsening function peaked at a creatinine of 2.1. As stated above, the patient's shortness of breath resolved. She was transferred to the medical floor following removal of her central line. After titration of beta blockade in the Coronary Care Unit, the patient was maintained on Labetalol 100 mg twice a day for a target blood pressure initially of 120 systolic, however, because of the patient's slightly decreased renal function, the upper limit of the target was set at 130 mmHg. The patient remained free of chest pain while on the medical floor. As reviewed with her family previously, the patient wished to have a DNR/DNI order implemented as she will not be a surgical candidate and does not want to be intubated or undergo any aggressive measures. The patient was evaluated by the physical therapy service who deemed it safe for her to go home provided that her home physical therapy be continued. The patient will also receive continuing visiting nurse care. MEDICATIONS ON DISCHARGE: 1. Mirtazapine 15 mg p.o. in the evening as needed for insomnia. 2. Calcium Carbonate one gram p.o. three times a day. 3. Metoclopramide 10 mg every six hours. 4. Labetalol 100 mg p.o. twice a day. 5. Erythropoietin 4000 units subcutaneous every Monday and Wednesday. 6. Lorazepam 0.5 to 1.0 mg every four to six hours as needed for nausea. 7. Pantoprazole 40 mg q24hours. 8. Amiodarone 400 mg p.o. daily. 9. Levothyroxine 125 mcg daily. 10. Nitroglycerin sublingual tablets 0.3 mg every five minutes as needed for pain times three. 11. Acetaminophen 325 mg p.o. q4-6hours as needed for pain. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Name8 (MD) 7102] MEDQUIST36 D: [2103-1-17] 16:18 T: [2103-1-17] 16:59 JOB#: [Job Number 100141]	[ "593.9", "441.2", "511.9", "427.31", "584.9", "276.2", "428.0", "458.2", "486" ]	icd9cm	[ [ [] ] ]	[ "34.91" ]	icd9pcs	[ [ [] ] ]							2247, 2291					6412, 7281		3709, 6386																							2475, 3692									186, 218							247, 773																	795, 2230	2308, 2452
40,305	118,754	54136	Discharge summary	report	Admission Date: [2176-9-6] Discharge Date: [2176-10-3] Date of Birth: [2112-6-4] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 14255] Chief Complaint: NASH cirrhosis Hepatocellular Carcinoma Major Surgical or Invasive Procedure: 9/1/12Deceased donor liver transplant; piggy-back, portal to portal vein, common hepatic artery to replace right hepatic artery, common bile duct to common bile duct. [2176-9-11]: [Last Name (un) 1372]-intestinal tube placement [2176-9-13]: Right Pleurovac placement [2176-9-18]: Nasointestinal tube placement [2176-9-23]: Nasointestinal tube placement [2176-9-23]: Tunneled dialysis catheter placement History of Present Illness: The patient is a 64-year-old male with NASH cirrhosis and hepatocellular carcinoma status post radiofrequency ablation with a tumor MELD of 28. A deceased donor organ became available which he opted to receive. Past Medical History: - NASH cirrhosis - HCC s/p ablation [2175-9-13] - HTN - DM2 Social History: Consumes approx 1 beer/month. Denies history of smoking. Denies illicit substance use. Family History: Mother w/ MI at age 55, died of PNA at age 87. Denies FHx of cancer, CVA, or other major medical disease. Physical Exam: Preop PE: 98.5 141/78 92 18 .98 on RA Gen: WN/WD, AAOx3, comfortable and relaxed HEENT: sclera aniceteric, oropharynx WNL, no lymphadenopathy, no carotid bruit CV: RRR, no m/r/g Pulm: CTAB Abd: BS(+), soft, NT, ND G/U: no CVAT MSK: no c/c/e Labs: 8.0>15.5/45.4<183 12.2/1.1/32.5 Na 139, K 4.2, Cl 100, HCO3 25, BUN/Cr 12/0.8, gluc 318 Ca [74].0, Mg 1.9, P 3.2 AST/ALT 43/54, phos 57, t.bili 0.8, alb 4.6 Imaging: CTA chest and abdomen w/ and w/o contrast, [2176-6-26]: 1. Post-RFA changes w/o significant change from prior study. At the junction of segment VI and VII, there is a 3 x 2.7cm hypodensity c/w post-RFA changes. 2. Right replaced hepatic artery arising from SMA, accessory left hepatic artery arising from the left gastric artery and a segment IV artery arising from common hepatic artery. Accessory left renal artery. 3. Patent portal vein with an accessory hepatic vein draining into the IVC. 4. Unchanged bilateral renal angiomyolipomas. 5. Stable tiny right lower lobe pulmonary nodules. Pathology: - Liver, needle core biopsy, [2175-10-3]: 1. Hepatocellular carcinoma, well differentiated, arising in a background of small cell dysplasia. 2. Background liver shows moderate predominantly macrovesicular steatosis. 3. Trichrome stain shows established cirrhosis with focal prominent sinusoidal fibrosis. 4. Iron stain shows moderate iron deposition in hepatocytes. Pertinent Results: [2176-10-3] 06:15AM BLOOD WBC-7.8 RBC-3.22* Hgb-9.8* Hct-29.5* MCV-91 MCH-30.5 MCHC-33.4 RDW-15.1 Plt Ct-239 [2176-9-30] 06:00AM BLOOD PT-11.7 PTT-26.5 INR(PT)-1.1 [2176-9-20] 02:55PM BLOOD QG6PD-17.7* [2176-9-20] 02:55PM BLOOD Ret Man-8.6* [2176-10-3] 06:15AM BLOOD Glucose-107* UreaN-61* Creat-7.6# Na-136 K-4.3 Cl-95 HCO3-25 AnGap-20 [2176-10-3] 06:15AM BLOOD ALT-59* AST-33 AlkPhos-358* TotBili-1.8* [2176-10-3] 06:15AM BLOOD Calcium-8.4 Phos-6.4# Mg-1.9 [2176-9-6] 4:20 pm URINE Source: CVS. FINAL REPORT [2176-9-7]* URINE CULTURE (Final [2176-9-7]): GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. [9-9], [9-12], [9-17] Blood cultures negative [2176-9-10] Urine culture negative [2176-9-6] VRE surveillance swab negative [2176-9-11] BAL negative [2176-9-17] stool-negative for c.diff [2176-9-18] urine culture: GRAM POSITIVE BACTERIA. ~1000/ML. Brief Hospital Course: On [2176-9-6], 64M with NASH cirrhosis and hx of HCC s/p RFA [9-/2175] with MELD of 28 admitted for liver transplant. On [2176-9-7], he underwent deceased donor liver transplant; piggy-back,portal to portal vein, common hepatic artery to replace right hepatic artery, common bile duct to common bile duct. Two JPs were placed intraop. Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]. Please refer to operative note for details. He received induction immunosuppression (solumderol and cellcept). Postop, he was admitted to the SICU for management, intubated. JP drains were non-bilious. LFTs increased. Hepatic duplex demonstrated patent hepatic vasculature with appropriate flow and no ductal dilatation. He was anuric with creatinine increase to 4.6. CVVHD was started via left temporary IJ line. He remained intubated for volume overload. CXR demonstrated opacity at the right lung base, potentially associated with moderate pleural effusion. Meropenem and Vancomycin were administed for empiric coverage. Cultures remained negative. LFTs continued to increase. Repeat hepatic duplex was unchanged. On [9-18], torso CT was done to evaluate elevated LFTs. This showed an irregular subcapsular hypodensity along the dome of right and left hepatic lobes extending down the posterior right lobe, concerning for infarction. Small fluid collections extended around the IVC anastomosis and caudate. On CT, right lower pulmonary lobe atelectasis and small effusion were noted. He was extubated on [9-13] (postop day 6), but continued to be tachypeic requiring O2. On [9-16], a thoracentesis was performed. Fluid was sent for cytology, gram stain and culture. Cytology noted rare very atypical epithelioid cells of uncertain significance. Gram stain had 111 wbc and 29 polys. Culture was negative. Vancomycin and Meropenem were stopped on [9-16] after 9 days. He continued to require O2 nasal cannula and was given inhalers with slight improvement. He had a couple of episodes of SOB at night that were felt to be related to volume overload. EKGs were unremarkable. Subsequent CXRs were notable for persistent RLL atelectasis. Unchanged enlargement of the cardiac silhouette. Review of CT by radiologist felt that enlargement of cardiac silhouette was likely due to mediastinal fat deposition. He remained anuric and CVVHD continued until [9-21] then CVVH was switched to hemodialysis. Nephrology felt that [Last Name (un) ] was likely secondary to ischemic insult from transient hypotension requiring bolus doses of phenylephrine and/or blood loss. A tunnelled right IJ HD line was placed on [9-23]. He continued to receive hemodialysis. Urine output increased around postop day 21 (200cc) and further increased to 1700cc by postop day 25. Nephrology was hopeful that renal function would continue to improve and need for hemodialysis would cease. An outpatient spot was arranged at [Location (un) ] dialysis center forn Monday-Wed-Friday sessions. He was dialyzed on [10-3] for 700cc ultrafiltrate. Next session was booked for [10-4] as an outpatient at [Location (un) ] Dialysis Center. JP drains were removed on postop day 15 and 18. LFTs decreased except the alk phos which remained elevated in the mid 300s. Abdominal incision was intact without redness. Staples were removed. Physical therapy worked with him and recommended rehab initially. However, he made improvements and was declared safe for discharge to home with PT at home. He was eating sufficient Kcals to meet his needs. Insulin was titrated to Glargine with sliding scale. Medication teaching went well with patient and family. VNA services of [Last Name (un) 52972] ([Telephone/Fax (1) 110956]) were arranged. He was discharged to home on [10-3]. Medications on Admission: - GLIMEPIRIDE 1 mg PO bid - METFORMIN 1,000 mg PO bid - OMEPRAZOLE 20 mg PO daily - SIMVASTATIN 20 mg Tablet PO daily - AMLODIPINE 5 mg PO daily - ASPIRIN 81 mg PO daily - CALCIUM CARBONATE-VITAMIN D3 600 mg calcium (1,500 mg)-400 unit PO bid - OMEGA-3 FATTY ACIDS-VITAMIN E Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY RX atovaquone [Mepron] 750 mg/5 mL 1500 mg by mouth once a day Disp #300 Milliliter Refills:6 2. Docusate Sodium 100 mg PO BID 3. Fluconazole 200 mg PO Q24H 4. Glargine 18 Units Bedtime Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) take 18 Units before BED; Disp #1 Not Specified Refills:3 RX insulin lispro [Humalog KwikPen] 100 unit/mL Up to 8 Units per sliding scale 2 Units before LNCH; Units per sliding scale 2 Units before DINR; Units per sliding scale four times a day Disp #1 Not Specified Refills:3 5. Ipratropium Bromide MDI 2 PUFF IH QID RX ipratropium bromide [Atrovent HFA] 17 mcg/actuation 1 inhalation every six (6) hours Disp #1 Inhaler Refills:0 6. Metoprolol Tartrate 25 mg PO BID Hold for HR < 60 or sBP < 100. RX metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 7. Mycophenolate Mofetil 1000 mg PO BID 8. Nephrocaps 1 CAP PO DAILY RX B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:3 9. Omeprazole 20 mg PO BID 10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 11. PredniSONE 17.5 mg PO DAILY start [9-27] 12. sevelamer CARBONATE 800 mg PO TID W/MEALS RX sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:3 13. ValGANCIclovir 450 mg PO 2X/WEEK (MO,TH) 14. Tacrolimus 4 mg PO Q12H 15. Insulin pen needles Supply: solostar nano for qid injection. daily Lantus and humalog with meals supply: 1month refill: 3 16. Simvastatin 20 mg PO DAILY 17. Aspirin 81 mg PO DAILY Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: NASH cirrhosis/HCC now s/p liver transplant Acute renal failure DM II R lower lobe atelectasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, incisional redness, drainage or bleeding, inability to tolerate food, fluids or take medications, dark/tarry stools, yellowing of skin or eyes, decreased urine outout swelling of abdomen or legs, or any other concerning symptoms. Please have your blood drawn every Monday and Thursday per transplant clinic protocol for lab monitoring. You will need hemodialysis for an unspecified time at Wehymouth Fresenius Dialysis on Monday -Wednesday-Friday Schedule. Please attend dialysis sessions as scheduled. Labwork and urine output will help the transplant clinic decide when it is safe for the dialysis to stop. The dialysis catheter is only to be cared for at the dialysis clinic for dressing changes and use of the catheter. Please do not drive while taking narcotic pain medication and until cleared by the surgeon to do so. No lifting greater than 10 pounds. no straining. You may shower, no tub baths or swimming. Allow the water to run over the incision and pat dry. Do not rub the incision or apply lotions or powders near the incision. Please avoid being in the sun without protective clothing and a hat, and always wear sunscreen when you go outdoors. Take all medications as prescribed, follow the prednisone taper. Any medication changes must be cleared by the transplant clinic Followup Instructions: Fresenius Dialysis [10-4] [Street Address(2) 35594] #1 [Location (un) ], [Numeric Identifier 2876] ([Telephone/Fax (1) 110957] ++++Call [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) 110958] Clinic Manager on Friday [2176-10-4] am to get appointment time (~3:45)++++ Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 14955], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2176-10-10] 1:15 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 14955], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2176-10-17] 3:15 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14254], [Name12 (NameIs) 1046] Phone:[Telephone/Fax (1) 673] Date/Time:[2176-10-17] 4:00 Completed by:[2176-10-4]	[ "573.4", "276.3", "511.9", "V58.67", "584.5", "518.51", "250.02", "571.5", "275.42", "155.0", "401.9", "518.0", "780.62" ]	icd9cm	[ [ [] ] ]	[ "34.91", "96.6", "33.24", "99.15", "50.59", "39.95", "00.93", "38.95", "96.72", "34.04" ]	icd9pcs	[ [ [] ] ]	9921, 9980	3893, 7751	342, 772	10118, 10118	2781, 3870	11732, 12557	1224, 1332		8077, 9898		10001, 10097		7777, 8054			10269, 11709									1347, 2762																					263, 304							800, 1014												10133, 10245					1036, 1102	1118, 1208
31,317	158,501	23016	Discharge summary	report	Admission Date: [2146-10-18] Discharge Date: [2146-10-29] Date of Birth: [2092-9-22] Sex: M Service: CARDIOTHORACIC Allergies: Morphine / Lisinopril / Pollen/Hayfever Attending:[First Name3 (LF) 1283] Chief Complaint: DOE, orthostatic hypotension Major Surgical or Invasive Procedure: CABG ([2146-10-18]) History of Present Illness: 53 yo M with known CAD s/p PCI with increasing fatigue, DOE and +ETT in [8-16]. Past Medical History: CAD-DES to LAD in [2143], IDDM, s/p L lung infection in [2137]-s/p L thorc., retinopathy, gastroparesis, smoke inhalation, s/p partial thyroidectomy, s/p R knee arthroscopy, s/p T+A, s/p laser surgery of R eye, s/p bil. cataracts [Doctor First Name ]. Social History: lives with wife and 2 daughters +tobacco cigarettes and cigars x 15 years- quit 12 years ago occ etoh no illicit durg use Family History: mother- dm brother- hypercholesterolemia Physical Exam: well appearing M in NAD Lungs CTAB Heart RRR no M/R/G Abdomen benign Extrem warm, no edema, 2+dp/pt pulses. Pertinent Results: [2146-10-25] 06:35AM BLOOD WBC-4.8 RBC-3.17* Hgb-9.3* Hct-28.6* MCV-90 MCH-29.2 MCHC-32.4 RDW-13.9 Plt Ct-597* [2146-10-25] 06:35AM BLOOD Plt Ct-597* [2146-10-25] 06:35AM BLOOD Glucose-139* UreaN-36* Creat-1.5* Na-142 K-4.1 Cl-96 HCO3-37* AnGap-13 CHEST (PA & LAT) [2146-10-25] 1:46 PM FINDINGS: The inferiormost sternal wire is laterally displaced when compared to previous exams. In addition, there is a midsternal stripe sign measuring approximately 4.5 mm in greatest diameter. These findings are concerning for sternal dehiscence. The bibasilar opacities have decreased. There are no focal consolidations identified. There is no pneumothorax. The pulmonary vasculature is unremarkable. IMPRESSION: Lateral displacement of most inferior sternal wire and midsternal lucency concerning for sternal dehiscence. Brief Hospital Course: He was taken to the operating room on [2146-10-18] where he underwent a CABG x 3. He was transferred to the ICU in critical but stable condition. He was extubated later that same day. He was transferred to the floor on POD #2. He developed sternal drainage and was started on vancomycin. He developed a sternal click, and CXR showed that the last sternal wire had pulled through. He remained in the hospital for observation of his wound and IV antibiotics. Pt stable to go home. PO AB with wound checks Medications on Admission: Metformin 1000', Lantus 36U qhs, Florinef 0.1', Lopid 600', Atenolol 25', Zocor 40', ASA 81', Humalog SS Discharge Disposition: Home With Service Facility: VNA of Greater [Location (un) 5871]/[Location (un) 6159] Discharge Diagnosis: CAD-DES to LAD in [2143] & now s/p CABG IDDM, s/p L lung infection in [2137]-s/p L thorc., retinopathy, gastroparesis, smoke inhalation, s/p partial thyroidectomy, s/p R knee arthroscopy, s/p T+A, s/p laser surgery of R eye, s/p bil. cataracts [Doctor First Name ]. Discharge Condition: Good. Discharge Instructions: Shower daily, no bathing or swimming for 1 month No creams, lotions, or powders to any incisions No driving for 1 month No lifting > 10 lbs. for 10 weeks [Last Name (NamePattern4) 2138]p Instructions: F/U with Dr. [Last Name (Prefixes) ] in 4 wks F/U with cardiologist in [2-12] wks F/U with Dr. [Last Name (STitle) 37063] in [2-12] wks Completed by:[2146-10-29]	[ "V45.82", "414.2", "998.32", "414.01", "E878.2", "250.00", "458.29" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.12" ]	icd9pcs	[ [ [] ] ]	2622, 2717	1959, 2467	337, 363	3038, 3046	1104, 1936		919, 961				2738, 3017		2493, 2599			3070, 3225				3276, 3460					976, 1085																					269, 299							391, 476																	498, 763	779, 903
21,046	149,042	9347	Discharge summary	report	Admission Date: [2142-8-3] Discharge Date: [2142-8-30] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old man with a history of coronary artery disease, asthma and aortic stenosis who presented with three weeks of cough and loss of voice. He was started on Cephalexin 250 mg qid by his physician at an outside hospital, however, experienced increased phlegm and pain approximately 1.5 weeks prior to admission. He saw his primary care doctor shortly before admission and chest x-ray showed a multilobar alveolar pattern consistent with pneumonia. The patient was started on Levaquin 5 days prior to admission. His shortness of breath continued to worsen so that he had to lie flat. He denied any hemoptysis or phlegm and he did not get any relief from his asthma inhalers. He was still able to walk upstairs. He denied any sick contacts. Denied recent travel. He denied nausea, vomiting, headache, myalgia, productive cough, pets at home. He had a past history of angina on exertion years ago but none currently. PAST MEDICAL HISTORY: Asthma. Supraclavicular lymphoma. ALLERGIES: No known allergies. MEDICATIONS: On admission, Atrovent, Serevent, Verapamil 180 mg q day. SOCIAL HISTORY: The patient lives at home with his wife, no tobacco for 28 years, occasional alcohol. Patient is a retired professor. LABORATORY DATA: On admission, labs revealed white count of 15.9, hematocrit 37.3, platelet count 281,000 with a differential of 85% polys, 7% lymphs and 6% monos, 2% eos. Sodium 138, potassium 4.7, chloride 102, CO2 20, BUN 16, creatinine .9, glucose 91. Blood cultures were pending. Chest x-ray revealed ill defined opacities in the right upper lobe, the lingula in the bilateral lower lobes. An EKG showed normal sinus rhythm with occasional atrial ectopy, left ventricular hypertrophy by voltage and nonspecific ST changes. An echocardiogram showed severe aortic stenosis and moderate mitral regurgitation, moderate pulmonary artery hypertension. PHYSICAL EXAMINATION: The patient was afebrile, blood pressure 170/90, pulse 82, respirations 20, oxygen saturation 86% on room air, 95% on two liters, heart was irregular with a 4/6 systolic murmur in all fields. Lungs revealed diffuse crackles. Neck revealed no jugulovenous distension, question of cervical lymphadenopathy. Abdomen was soft, nontender, slightly distended with normal bowel sounds. The patient was alert and oriented times three in no apparent distress on room air. Extremities revealed no clubbing, cyanosis or edema. HOSPITAL COURSE: The patient was admitted to the floor with a presumed pneumonia and treated with antibiotics. The patient's respiratory distress failed to improve and he was admitted to the MICU and intubated. He progressed on the ventilator and was extubated on [8-12] and transferred to the floor. On the floor he developed rapid atrial fibrillation with heart rates to the 150's. After several hours of this he became short of breath again and had to be reintubated and transferred back to the MICU. Cardiology was consulted and he was started on Amiodarone. It was unclear at this point if the patient still had a pneumonia or was in heart failure secondary to his rapid heart rate. [Month/Year (2) ] Ganz catheter was passed which revealed a normal wedge pressure although he had been diuresed prior to the [Last Name (LF) ], [First Name3 (LF) ] this was believed to rule out heart failure as a cause of his deterioration. He also was found to have a pleural effusion which was tapped and did not appear to be infected. He remained in normal sinus rhythm afterwards and again progressed on the ventilator and was extubated for a second time on [8-18]. Initially post extubation he did well. However, on [8-19] he developed increasing tachypnea and wheezing. He was started empirically on antibiotics and steroids to treat a presumed pneumonia and asthma flare. However, he did not improve and required increased non invasive ventilation and ultimately was electively reintubated on [8-21]. During that intubation the patient had a period of asystole as well as bradycardia which responded to Atropine. On [8-22] the patient developed shaking of his upper and lower extremities and concern for seizures led to a subsequent work-up which revealed a negative head CT and normal electrolytes. Neurology was consulted and the patient was felt by then to be in status epilepticus. He was started on Dilantin. In addition, on [8-22] the patient was noted to have the following hematocrit and platelet counts and elevated INR. Hematology was consulted and felt that the picture was consistent with thrombocytopenic purpura (TTP) and the patient was started on plasmapheresis. The patient responded well to plasmapheresis with increases in his hematocrit and platelet count and decreases in his LDH levels. He was continued to be supported on the ventilator. He was also continued on Dilantin and EEG ultimately did not show seizure activity. For his atrial fibrillation the Amiodarone was discontinued thinking that it may have contributed to his respiratory failure. He was continued on Verapamil. He was also supported with tube feedings. Despite the patient's slow improvement with the plasmapheresis, the patient's family ultimately felt that the patient's wishes would not have been for extended treatment, intubation, and convalescence. Ultimately the decision was made to withdraw care and the patient was made comfort measures only on [8-29]. The patient expired of respiratory failure secondary to TTP on [8-30]. FINAL DIAGNOSIS: 1. TTP. 2. Aortic stenosis. 3. Atrial fibrillation. 4. Respiratory failure. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 31943], M.D. [MD Number(1) 31944] Dictated By:[Last Name (NamePattern1) 11548] MEDQUIST36 D: [2142-11-24] 07:10 T: [2142-11-25] 21:43 JOB#: [Job Number 31945]	[ "V10.79", "493.90", "446.6", "780.39", "428.0", "427.31", "424.1", "486", "518.81" ]	icd9cm	[ [ [] ] ]	[ "88.72", "89.64", "96.04", "96.72", "34.91", "42.23", "96.71" ]	icd9pcs	[ [ [] ] ]														2618, 5692	5709, 6073																						2078, 2600																150, 1097																	1120, 1262	1279, 2055
22,475	155,723	45420	Discharge summary	report	Admission Date: [2151-3-18] Discharge Date: [2151-3-30] Date of Birth: [2083-12-25] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: SOB/DOE Major Surgical or Invasive Procedure: [First Name3 (LF) ] valve replacement with a 23mm CE pericardial valve History of Present Illness: 67 year old female, Jehovah's Witness with recent hospitalization for SOB without chest pain. History of abdominal wound infection. Took procrit and vitamin K preoperatively in anticipation of surgery Past Medical History: DM (hgb A1c 7%) dyslipidemia CAD s/p PCI to RCA and OM [3-31] followed by MI [7-31] due to stent thrombosis in OM, also restenosis in RCA which was stented along w/ the LAD w/ bare metal stents severe diastolic CHF - last CHF exacerb 5 wks ago severe pulm htn severe AS - prior plan for AVR, valve area 0.9 h/o incarcerated hernia [10-31] rheumatic fever as child morbid obesity (BMI 51) OA chronic low back pain h/o MRSA PNA [7-31] h/o UGIB - no EGD or c-scope on file PSHx: s/p appy s/p CCY '[18] s/p repair of incarcerated hernia requiring bowel resection [10-31] Social History: Lives in [Location 10022]. Former smoker: 2 ppd x 20 yrs, quit 40 yrs ago. Occasional beer w/ pizza (nothing recently). No drugs. Widow. 5 kids. Jehovah's Witness Family History: CAD, diabetes Physical Exam: 67yo F in bed NAD Neuro AA&Ox3, nonfocal Chest CTAB resp unlab median sternotomy stable, c/d/i no d/c, RRR no m/r/g chest tubes and epicardial wires removed. Abd S/NT/ND/BS+/protuberant EXT warm with trace edema, right groin with mild erythema, good granulation tissue present, no purulence Pertinent Results: [2151-3-30] 05:30AM BLOOD UreaN-12 Creat-0.8 K-4.5 [2151-3-18] 07:07PM BLOOD ALT-17 AST-19 LD(LDH)-223 AlkPhos-109 TotBili-0.4 RADIOLOGY Final Report CHEST (PORTABLE AP) [2151-3-27] 8:00 AM CHEST (PORTABLE AP) Reason: ? effusion [Hospital 93] MEDICAL CONDITION: 67 year old woman s/p AVR/ replacement asc. aorta- REASON FOR THIS EXAMINATION: ? effusion HISTORY: Effusion. Single portable chest radiograph again demonstrates cardiomegaly. There has been interval removal of the right internal jugular central venous catheter. The left costophrenic angle was excluded from the imaged field of view. There are probable small, bilateral, persistent pleural effusions. Bibasilar atelectasis persists. The patient is again seen to be status post median sternotomy. The trachea is midline. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6892] Approved: MON [2151-3-29] 4:47 PM Cardiology Report ECHO Study Date of [2151-3-19] PATIENT/TEST INFORMATION: Indication: Intraop TEE for AVR ascendind aorta replacement Status: Inpatient Date/Time: [2151-3-19] at 16:26 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW590-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) 412] [Last Name (Prefixes) 413] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 6.4 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) Aorta - [Last Name (Prefixes) ]: 4.1 cm (nl <= 3.4 cm) [Last Name (Prefixes) ] Valve - Peak Gradient: 54 mm Hg [Last Name (Prefixes) ] Valve - LVOT Diam: 2.2 cm [Last Name (Prefixes) ] Valve - Valve Area: 0.8 cm2 (nl >= 3.0 cm2) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Moderately dilated LV cavity. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - akinetic; basal inferolateral - hypo; mid inferolateral - akinetic; basal anterolateral - hypo; mid anterolateral - akinetic; anterior apex - hypo; septal apex - hypo; inferior apex - akinetic; lateral apex - akinetic; apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated [Last Name (Prefixes) 8813] root. Focal calcifications in [Last Name (Prefixes) 8813] root. Moderately dilated [Last Name (Prefixes) ] aorta. Focal calcifications in [Last Name (Prefixes) ] aorta. Simple atheroma in descending aorta. [Last Name (Prefixes) ] VALVE: Three [Last Name (Prefixes) 8813] valve leaflets. Severely thickened/deformed [Last Name (Prefixes) 8813] valve leaflets. Severe AS. Moderate (2+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Mild to moderate ([12-28]+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions: PRE-CPB Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include severe hypokinesis/akinesis of mid and distal inferior, lateral, and posterior walls. Right ventricular free wall motion is low normal. The [Month/Day (2) 8813] root is mildly dilated. The [Month/Day (2) ] aorta is moderately dilated. There are simple atheroma in the descending thoracic aorta. There are three [Month/Day (2) 8813] valve leaflets. The [Month/Day (2) 8813] valve leaflets are severely thickened/deformed. There is severe [Month/Day (2) 8813] valve stenosis. Moderate (2+) [Month/Day (2) 8813] regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([12-28]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild TR. Post-CPB The patient is receiving epinephrine by infusion. There is mild global LV systolic dysfunction with severe hypokinesis of mid to distal inferior, lateral, and posterior walls. LV EF= 35-40%. Normal RV systolic function. A bioprosthesis is located in the [Month/Day (2) 8813] position. It is well seated and displays normal leaflet function. There is no visible AI. There is no AS.([Location (un) 109]=1.7 cm2). There is mild MR. [First Name (Titles) ] [Last Name (Titles) 8813] graft is in situ. No new [Last Name (Titles) 8813] pathology is seen. UNILAT LOWER EXT VEINS RIGHT [2151-3-24] 9:34 AM UNILAT LOWER EXT VEINS RIGHT Reason: RT LEG PAIN. RECENT SURGERY. EVAL FOR DVT [Hospital 93] MEDICAL CONDITION: 67 year old woman with REASON FOR THIS EXAMINATION: r/o dvt HISTORY: 67-year-old woman with right groin pain and swelling. FINDINGS: [Doctor Last Name ]-scale and Doppler son[Name (NI) 1417] of the right common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation, compressibility, and waveforms are demonstrated. Intraluminal thrombus is not identified. IMPRESSION: No evidence of DVT. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 5004] THAM DR. [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Brief Hospital Course: Mrs. [Known lastname 44979] was admitted to the [Hospital1 18] on [2151-3-18] for further management of her dyspnea on exertion. She was known to have critical [Date Range 8813] stenosis by transthoracic echo from an OSH. Given the severity of her disease, the cardiac surgical service was consulted for surgical repair of her valve disease. She was worked-up in the usual preoperative manner including an echocardiogram which revealed severe [Date Range 8813] stenosis, 2+ [Date Range 8813] regurgitation and [12-28]+ mitral regurgitation. On [2151-3-19], Mrs. [Known lastname 44979] was taken to the operating room. She underwent an [Known lastname 8813] valve replacement using a 28mm [Last Name (un) ] [Doctor Last Name ] pericardial bioprosthesis and Replacement of [Doctor Last Name ] Aorta with a 28mm Gelweave graft. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, she awoke neurologically intact and was extubated. Beta blockade and aspirin were resumed. She was gently diuresed towards her preoperative weight. On POD 2 Her pressors were weaned, chest tubes were removed, and she was transferred to the cardiac stepdown unit. Beta blockade and aspirin were resumed. She was gently diuresed towards her preoperative weight. On POD 3 her epicardial wires were removed without incident. Flagyl was started for G. vaginalis present in her urine. The physical therapy service was consulted to assist with her postoperative strength and mobility. Her oxygen saturations improved to 100% on room air. The physical therapy service was consulted to assist with her postoperative strength and mobility. A lower extremity ultrasound was performed for Right leg swelling and pain that did not show any evidence of DVT. She developed a maceration of her right groin incision for which dry sterile dressings where applied. On POD 5 she developed alternating sinus bradycardia and atrial fibrillation. No evidence of heart block was seen and the atrial fibrillation was rate controlled. The electrophysiology service was consulted who recommended possible anticoagulation if persistnet afib. There was no indication pacemaker placement. On POD 6 heparin and coumadin were intiated for persistnet afib with an INR goal of 1.5-2.0. On POD 11 Mrs. [Known lastname 44979] her blood pressure was stable. Her sternotomy incision was clean, dry, and intact without evidence of infection. Her right groin incision had improved maceration. There was no purulence, fever, or elevated white blood cell count. She was discharged home on POD 12 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with her PCP and cardiologist in 2 weeks. She will follow up with Dr. [Last Name (STitle) 1290] in three weeks. Her INR will be followed by her cardiologist. Medications on Admission: Lasix 40' Protonix 40' Iron 65' MVI ASA 325' Zocor 40' Vit C 1gm' Zetia 10' KCl 20'' NPH 40U'' Colace 100'' Procrit 40qwk 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:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. 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 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). Disp:qs qs Refills:2 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:qs qs Refills:2 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty (40) Subcutaneous twice a day. Disp:15 bottles Refills:2 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Take as directed by Dr. [Last Name (STitle) ] for an INR goal of 1.5-2.0. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: AS CHF CAD HTN IDDM hypercholesteremia obesity OA s/p LOA, CCY, hernia repair Discharge Condition: Good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [Last Name (STitle) 1290] in three weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) ] in two weeks [Telephone/Fax (1) 3183] Dr. [Last Name (STitle) ] in two weeks [Telephone/Fax (1) 18684] Completed by:[2151-3-30]	[ "401.9", "395.2", "414.01", "715.90", "997.1", "427.31", "416.8", "272.0", "250.00", "278.00", "V58.67", "V45.82", "412" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	12503, 12562	7957, 10883	330, 407	12684, 12691	1797, 2044	13061, 13314	1455, 1471		11055, 12480	7285, 7308	12583, 12663		10909, 11032			12715, 13038					2831, 7248				1486, 1778																					283, 292	7337, 7934						435, 639																	661, 1255	1271, 1439
62,585	190,620	3556+55485	Discharge summary	report+addendum	Admission Date: [2192-5-1] Discharge Date: [2192-5-7] Service: CARDIOTHORACIC Allergies: Fosamax Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2192-5-1] - Coronary artery bypass grafting to three vessels. AVR (19mm [Doctor Last Name ] Pericardial Valve) History of Present Illness: This is a [Age over 90 ] year old female with aortic stenosis which is a relatively new diagnosis from [2190]. Approximately two months ago, she began developing dyspnea and chest pressure with walking upstairs, as well as intermittent mild pedal edema. A recent echocardiogram revealed severe aortic stenosis with an aortic valve area of <0.8cm2 and a mean gradient of 37mmHg. She has been referred for possible aortic valve replacement surgery. If surgery was deemed too high risk, Dr. [Last Name (STitle) 171] would like her evaluated for CoreValve trial of percutaneous aortic valve replacement. There was mention of a calcified aorta on a previous note. Past Medical History: HTN Hyperlipidemia Spinal stenosis osteoarthritis Osteoporosis CAD PVD s/p cholecystectomy s/p L4/5 laminectomy Social History: Lives at home with son. [Name (NI) ] tobacco/ETOH Family History: Non contributory Physical Exam: Pulse: 62 SR Resp: 18 O2 sat: 97/RA B/P Right: 148/68 Left:149/60 Height: 63inches Weight: 143lbs General: WDWN in NAD. Elderly Skin: Warm, dry and intact. Well healed abdominal incision. HEENT: NCAT, OD bind, OP benign, Teeth in fair repair. Upper dentures and lower native. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, IV/VI SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] 1+ non pitting Edema Varicosities: one small varicose vein on the left calf 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: ECHO [2192-5-1] Prebypass The left atrium is dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The estimated cardiac index is borderline low (2.0-2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. 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 critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Postbypass The patient is on a phenylephrine infusion and is A-paced. Biventricular systolic function remains normal. There is a new bioprosthetic valve in the aortic position. The valve is well-seated and there is trace aortic regurgitation without evidence of perivalvular leak. The mean gradient across the valve is 8 mmHg at a cardiac output 4.0 L/min. The mitral regurgitation is now mild-moderate. Tricuspid regurgitation remains trace. The thoracic aorta is intact post-decannulation. [2192-5-7] 05:55AM BLOOD WBC-8.4 RBC-3.56* Hgb-11.0* Hct-33.6* MCV-95 MCH-31.0 MCHC-32.8 RDW-16.3* Plt Ct-224 [2192-5-6] 04:52AM BLOOD WBC-8.4 RBC-3.42* Hgb-10.6* Hct-32.4* MCV-95 MCH-31.1 MCHC-32.8 RDW-16.0* Plt Ct-179 [2192-5-6] 04:52AM BLOOD PT-13.9* PTT-25.7 INR(PT)-1.2* [2192-5-3] 03:36AM BLOOD PT-14.8* PTT-31.3 INR(PT)-1.3* [2192-5-7] 05:55AM BLOOD Glucose-116* UreaN-28* Creat-1.3* Na-140 K-4.9 Cl-105 HCO3-26 AnGap-14 [2192-5-6] 04:52AM BLOOD Glucose-116* UreaN-31* Creat-1.4* Na-141 K-4.4 Cl-104 HCO3-28 AnGap-13 [2192-5-4] 03:10PM BLOOD Glucose-117* UreaN-32* Creat-1.6* Na-138 K-3.9 Cl-104 HCO3-24 AnGap-14 [2192-5-7] 05:55AM BLOOD Mg-2.2 [2192-5-4] 03:10PM BLOOD Mg-2.6 Brief Hospital Course: Ms. [Known lastname 16251] was admitted to the [Hospital1 18] on [2192-5-1] for surgical management of her aortic valve and coronary artery disease. She was taken directly to the operating room where she underwent three vessel coronary artery bypass grafting and an aortic valve replacement using a 19mm [Doctor Last Name ] pericardial valve. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next several hours, she awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. On postoperative day two, she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. She had brief episodes of afib and her betablocker was titrated up with good effect. Pacing wires were remove POD#5 without incident. The physical therapy service was consulted for assistance with her postoperative strength and mobility and they are recommending rehab. On POD 6 she was cleared for discharge to [Hospital 100] Rehab. All follow up appointments were advised. Medications on Admission: aspirin 81 mg/day, atenolol 100 mg/day, amlodipine 10 mg/day, Lasix 20 mg/day, allopurinol 200 mg/day, Losartan 25mg/day, Actonel, Omeprazole 20mg/day, Trusopt, Percocet, Xalantan, simvastatin 20mg/day, Calcium and vitamin D Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 12. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 1 week, then 400mg daily x 1 week, then 200mg daily. 14. metipranolol 0.3 % Drops Sig: One (1) Ophthalmic [Hospital1 ] (2 times a day). 15. bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). 16. sodium chloride 0.65 % Aerosol, Spray Sig: [12-4] Sprays Nasal QID (4 times a day) as needed for nasal dryness. 17. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 18. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 1 weeks. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: -Severe calcific aortic stenosis and CAD -Calcified Aorta -Hypertension -Dyslipidemia -Secondary pulmonary hypertension -Chronic Renal Insufficiency Creat 1.7 -Recent Pneumonia -Osteoarthritis and Gout -Right shoulder impingement syndrome and rotator cuff tendinosis, s/p subacromial corticosteroid injection -Chronic urine/stool incontinence, requires adult briefs -History of positive PPD - received BCG in the past -History of bilateral LE DVT following laminectomies/diskectomies -Osteoporosis -Nephrolithiasis -Right eye blindness -Glaucoma Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: 1) 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. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170], [2192-5-31] 1:15 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2192-6-25] 10:40 Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] [Telephone/Fax (1) 250] in [3-6] weeks Previously Scheduled Appointments: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. Phone:[Telephone/Fax (1) 250] Date/Time:[2192-6-6] 10:50 [Name6 (MD) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2192-9-6] 10:30 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:[2192-5-7] Name: [Known lastname 2563],[Known firstname 2564] Unit No: [Numeric Identifier 2565] Admission Date: [2192-5-1] Discharge Date: [2192-5-7] Date of Birth: [2101-11-6] Sex: F Service: CARDIOTHORACIC Allergies: Fosamax Attending:[First Name3 (LF) 741] Addendum: Lopressor increased to 25 mg [Hospital1 ] for better BP control/HR control Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - [Location (un) 1409] [Name6 (MD) ] [Name8 (MD) 747] MD [MD Number(2) 748] Completed by:[2192-5-7]	[ "428.0", "416.8", "272.4", "414.01", "733.00", "424.1", "V43.64", "403.90", "427.31", "585.9", "530.81", "440.20", "458.29", "276.2", "V12.51" ]	icd9cm	[ [ [] ] ]	[ "35.21", "39.61", "36.15", "36.12" ]	icd9pcs	[ [ [] ] ]	10873, 11081	4490, 5619	239, 361	8352, 8573	2112, 4467	9547, 10850	1285, 1303		5895, 7654		7783, 8331		5645, 5872			8597, 9524									1318, 2093																					180, 201							389, 1061																	1083, 1196	1212, 1269
52,441	148,137	41508	Discharge summary	report	Admission Date: [2105-8-3] Discharge Date: [2105-8-12] Date of Birth: [2041-4-5] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5790] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: [2105-8-3]: Minimally-invasive [First Name9 (NamePattern2) 12351] [Doctor Last Name ] esophagectomy; laparoscopic jejunostomy tube; and pericardial fat pad buttress. History of Present Illness: The patient is a 64-year-old gentleman who has a very early esophageal cancer as well as Barrett's esophagus. He presents for resection after discussing the option of possible endomucosal resection, which was thought by the interventional gastroenterologist not to be feasible due to scarring from the previous radiofrequency ablation. Past Medical History: Hyperlipidemia DM II- diet controlled GERD with Barretts HGD Social History: Married lives with family. Tobacco: 60-90 pack-year quit 15 years ago. ETOH none Retired police officer Family History: Mother- alive 91 Father- DM [Name (NI) 8962] sister died of metastatic breast cancer age 62 Physical Exam: VS: T: 96.5 HR: 76 SR BP: 104-119/60 Sats: 95% RA General: 64 year old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: decreased breath sounds faint bibasilar crackles GI: abdomen soft, non-distended. J-tube site clean intact Extre: warm no edema Incision: right Vats site clean dry intact Neuro: awake, alert oriented Pertinent Results: [2105-8-12] WBC-11.2* RBC-4.82 Hgb-14.6 Hct-41.4 Plt Ct-496* [2105-8-11] WBC-13.3* RBC-4.69 Hgb-14.3 Hct-40.5 Plt Ct-430 [2105-8-9] WBC-10.3 RBC-4.52* Hgb-13.8* Hct-39.2 Plt Ct-327 [2105-8-3] WBC-14.3# RBC-5.00 Hgb-15.7 Hct-43.0 Plt Ct-199 [2105-8-12] Glucose-120 UreaN-20 Creat-0.6 Na-135 K-4.5 Cl-98 HCO3-30 [2105-8-11] Glucose-104* UreaN-21* Creat-0.6 Na-137 K-4.6 Cl-100 HCO3-29 [2105-8-9] Glucose-154* UreaN-23* Creat-0.6 Na-141 K-3.9 Cl-102 HCO3-29 [2105-8-3] Glucose-136* UreaN-11 Creat-0.7 Na-139 K-3.7 Cl-104 HCO3-27 [2105-8-9] Calcium-8.3* Phos-3.0 Mg-2.3 Micro: MRSA SCREEN (Final [2105-8-6]): No MRSA isolated. CXR: [2105-8-10]: The patient is status post esophagectomy procedure. Interval removal of J-tube and chest tube with no evidence of pneumothorax or pneumomediastinum. Cardiomediastinal contours are similar in appearance except for a new air-fluid level visualized within the neo-esophagus. Within the lungs, they are improving multifocal opacities in the left upper and both lower lobes, likely improving multifocal pneumonia. Small right pleural effusion is noted. Biapical thickening is unchanged. [2105-8-9]: The patient is status post esophagectomy procedure. Unchanged position of drain and tube projecting over the mediastinum. Stable postoperative appearance of cardiomediastinal contours. Increasing opacities in the left mid and left lower lung, as well as a persistent area of confluent opacity at the right lung base. In combination with findings on recent CTA of the chest of [2105-8-8], these findings may represent multifocal aspiration and/or aspiration pneumonia. Small pleural effusions are again demonstrated, right greater than left. Chest CT [2105-8-8]: . No PE. 2. Left upper lobe opacity, likely consistent with pneumonia. 3. Bibasilar opacities might represent atelectasis and possible superimposed pnemonia (aspiration). 4. Fatcontaining soft tissue density inferior to the left liver lobe, likely represents fatnecrosis, less likely poorly organized collection. 5. Hypodense liver and pancreatic head lesion might be further worked up with Esophagus: [2105-8-10]: 1. No evidence of anastomotic leak or holdup. 2. Gross aspiration of thin barium, cleared spontaneously by cough. Brief Hospital Course: Mr. [Name14 (STitle) ] was admitted [2105-8-3] for Minimally-invasive [First Name9 (NamePattern2) 12351] [Doctor Last Name ] esophagectomy; laparoscopic jejunostomy tube; and pericardial fat pad buttress for esophageal cancer. He was extubated in the operating room, transfer to the ICU on FM 40%, a right chest tube, JP drain, NGT, J-tube and Bupivacaine/Hydromorphone Epidural managed the acute pain service. His ICU course was uneventful. J-tube feeds were started POD1, he ambulated to chair. He transfer to the floor Respiratory: slow to titrate off oxygen with aggressive nebs, pulmonary toilet, incentive spirometer he titrated off oxygen with sats of 94% at rest & activity Drain/Tubes: NGT removed [2105-8-8], chest-tube and JP removed [2105-8-10] following negative esophagus study. Esophagus: study done [2105-8-10] with no evidence of anastomotic leak or holdup. Gross aspiration was noted. Speech & Swallow: consulted for possible aspiration. Video-swallow done [2105-8-11] showed aspiration of thin and nectar thick liquids in head neutral. appears deficits are both associated with discoordation/weakness as well as reduced L vocal cord movement. He was placed on a soft solid diet nectar thick liquids with chin tuck maneuvers. ENT: On discharge he was seen by ENT to evaluate the left vocal cord. Nutrition: followed by nutrition. Jevity full strength was started POD1 increase to Goal of 115 ml/18 hrs and once taking PO decreased to 85 mL x 18 hours. Card: prophylaxis beta-blockers for atrial fibrillation were started PO1. He remained in sinus rhythm 60-80's. Blood pressure 100-120 stable. ID: increase yellow sputum low grade temps, CT done [2105-8-8] bilateral opacities concerning for pneumonia. A 14 day course of Levofloxacin was started [2105-8-8]. Pain: Epidural managed by the acute pain migrated out [2105-8-8]. He transition to Roxicet via J-tube and Dilaudid PCA with good pain control. Disposition: he was seen by physical therapy and ambulated in the halls indepently. He continued to make steady progress and was discharge to home with partners [Name (NI) 269] and home solutions for tube feeds. He will follow-up with Dr. [Last Name (STitle) ] and ENT and Speech as an outpatient. Medications on Admission: Omeprazole 40 mg [Hospital1 ], MVI, fish oil and flax seed daily Discharge Medications: 1. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:8 Tablet, Rapid Dissolve(s) Refills:0 2. Jevity Full Strength Goal Rate 115 mL/18 hrs Flush J-tube with 1 cup of water before starting and stopping tube feeds and NOON 3. oxycodone 5 mg/5 mL Solution Sig: [3-31] mL PO every 4-6 hours as needed for pain. Disp:400 mL Refills:0 4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:4 Tablet(s) Refills:0 5. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: open capsule and empty into apple sauce. 6. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day): hold for loose stools. 7. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Esophageal Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience: -Fevers greater than 101 or chills -Increased shortness of breath, cough or chest pain -Nausea, vomiting (take anti-nausea medication) -Increased abdominal pain -Incision develops drainage -Chest tube cover site with a bandaid Pain -Roxicet via J-tube as needed for pain -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No driving while taking narcotics -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily BED: Place a wedge under your mattress to keep the head of the bed elevated approximately 30 degress Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [0-0-] Date/Time:[2105-8-18] 2:00 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center [Location (un) ] Chest X-Ray [Location (un) ] Radiology 30 minutes before your appointment Provider: [First Name4 (NamePattern1) 156] [Last Name (NamePattern1) ], MS SLP Phone:[Telephone/Fax (1) 3731] Date/Time:[2105-8-27] 10:45 in the [Location (un) ], [Location (un) ] DYSPHAGIA AND MOTILITY UNIT Completed by:[2105-8-12]	[ "272.4", "458.29", "507.0", "250.00", "511.9", "530.3", "787.20", "V15.89", "530.81", "150.8" ]	icd9cm	[ [ [] ] ]	[ "46.32", "96.6", "42.51", "42.41" ]	icd9pcs	[ [ [] ] ]	7282, 7331	3943, 6231	326, 506	7393, 7393	1622, 3920	8360, 8891	1094, 1192		6350, 7259		7352, 7372		6257, 6327			7544, 8337									1207, 1603																					269, 288							534, 873												7408, 7520					895, 957	973, 1078
29,971	100,021	31610	Discharge summary	report	Admission Date: [2109-8-17] Discharge Date: [2109-10-16] Date of Birth: [2054-10-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: B/L ankle fractures, s/p fall Major Surgical or Invasive Procedure: [8-18] . 1. Closed reduction of left pilon fracture. 2. Application of multi-planar external fixator left lower extremity. 3. Closed treatment of calcaneus fracture with mild amount of manipulation. 4. External fixation of Right Pilon fracture . [8-30] Adjustment of external fixator of R pilon fracture . [9-17] ORIF right intra-articular distal tib-fib fracture R History of Present Illness: 54 year old Spanish speaking male, in the US on vacation, with a questionable PMH of liver disease presents after jumping?falling? out a window. Per his daughter he was drinking alcohol with his son and reported feeling that someone was out to kill him. He locked himself in a second-story bedroom and was later found by his daughter crawling outside. He was initially seen at [Hospital3 ] and found to have opiates and cocaine on UA in the emergency department there. He was transported to [Hospital1 18] with b/l ankle fractures. Per family, the pt has been confused at home. In [Name (NI) ], pt was aggitated and received haldol and ativan. He was later somnolent. EKG demonstrated atrial flutter with HRs in 110-140's, rate controlled in the ED with IV diltiazem. Patient is a poor historian, most information obtained from his daughter ROS: + b/l ankle pain, -CP, -SOB, -Abdominal pain Past Medical History: "Gets yellow" High ammonia HTN questionable anginal history depression, family states he see a psychiatrist Social History: EtOH abuse, polysubstance abuse, one ppd for mayn years Urine positive for cocaine and opiates in ED Not married Daughter is involved in care Family History: Noncontributory Physical Exam: Vitals: 96.7 140/90 76 16 99% on 2L NPO/1000 Physical Exam: General: sleepy but arousable, oriented to place and person, able to name the months of the year forwards, but not backwards, not oriented to current month/year HEENT: icteric sclerae, dry MM, + c-collar CVS: irregular rate, tachy, no murmurs/rubs/gallops appreciated Pulm: CTA b/l, no wheezes, rales or rhonchi Abd: soft, NT, mild hepatosplenomegaly, +BS Ext: b/l ankle splints, mild bruising over b/l knees, - for asterixis GU: + foley Pertinent Results: CT C-Spine: negative for fracture Left tib/fib: Comminuted fracture of the calcaneus. Dense sliver of bone along the medial aspect of the proximal fibula, seen only on a single view. This could represent additional calcification of the intraosseous ligament, a small cortical fracture fragment, or a foreign body. Right tib/fib: Comminuted, intraarticular, impacted, and displaced fractures of the distal tibia as well as fracture of the distal fibula as detailed above. . CT bilat LE 1. Comminuted intra-articular distal right tibial fracture. 2. Comminuted distal right fibular fracture with displacement. 3. Comminuted left calcaneal fracture. . RUQ U/S: FINDINGS: The liver is coarse in echotexture without evidence of focal lesion. The gallbladder is not distended due to nonfasting stage. No evidence of gallstones. No evidence of intra- or extra-hepatic biliary ductal dilatation and the common duct measures 3 mm. The pancreas is not well visualized due to bowel gas. There is no evidence of free fluid. The main portal vein is patent with antegrade flow. IMPRESSION: No evidence of cholecystitis. . Head CT ([8-21]) IMPRESSION: No evidence of acute intracranial pathology, including no sign of intracranial hemorrhage. . CXR ([8-21]) No previous studies for comparison. Low lung volumes. Heart size is difficult to evaluate in this semi-upright AP film. There could be some LVH but no evidence for CHF and the lungs are clear. Questionable slight impression on the right margin of the tracheal air column which can be better evaluated by standard PA and lateral chest films when condition permits. . Chest CT ([8-23]): 1. No juxtatracheal mass or left upper lobe lesion as questioned on chest radiograph report. 2. Three foci of ground glass, right upper lobe, not detectable on routine radiographs, a nonspecific finding. Six- month CT follow up is recommended to look for change, because bronchoalveolar cell carcinoma, though unlikely, cannot be excluded. 3. Borderline size mediastinal and hilar lymph nodes should be checked on followup CT. 4. Mild atherosclerotic coronary artery calcification. Chest CTA ([8-24]): 1. No pulmonary embolism. 2. Relatively unchanged appearance of multiple ill-defined opacities and tiny nodules in the right upper lobe. Follow-up stated on the examination from 1 day prior is again recommended. 3. New foci of opacification present at the lung bases compared to examination from one day prior likely related to aspiration. Layering debris present within the right main stem bronchus most suggestive of aspiration as well. Clinical correlation is recommended. 4. Recommend advancing NG tube at least 4-5 cm. The current position elevates the risk of further aspiration. . CT RLE with contrast ([8-24]): IMPRESSION: Comminuted distal tibial and fibular fractures with intra- articular involvement of the tibial plafond and lateral displacement of the talus with respect to the tibia. Posterior displacement of the distal fibular fragment. . CT LLE without contrast ([8-24]) Comminuted left calcaneal fracture. Lentiform area of fluid attenuation at the skin on the posterolateral aspect of the left foot. The significance of the latter finding is uncertain, but may be due to a skin blister or possibly dressing material within the cast. Clinical correlation requested. . CXR ([8-26]) 1. NG tube could be advanced several centimeters for standard positioning, as described in prior exams. 2. New perihilar opacities, likely due to acute aspiration in the superior segments. . Head CT ([9-3]) IMPRESSION: There is no evidence of hemorrhage or CT evidence of acute infarct. . CT abd/pelvis ([9-22]): IMPRESSION: No CT evidence of pyelonephritis or abscess within the abdomen/pelvis. . CT LLE without contrast ([9-26]) 1. Markedly comminuted fracture of the calcaneus with wide distraction and dispersal of the fracture fragments as above. 2. Non-displaced fractures of the sustentaculum tali and of the middle facet of the talus. 3. No fracture identified of the medial malleolus. 4. Non-displaced fractures of the anterior aspect and of the inferior aspect of the lateral malleolus. 5. Non-displaced fracture of the cuboid. 6. No fracture identified of the navicular. 7. No other fractures identified within the remainder of the mid foot or the forefoot. 8. Lateral subluxation of the peroneal tendons with respect to the fibula. 9. Probable tear of the anterior talofibular ligament. . Echo ([9-26]): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Brief Hospital Course: During course of hospitalization, pt was put on CIWA scale for EtOH withdrawal and given thiamine, folate and a multivitamin, his AFib with RVR was initially treated with metoprolol, then diltiazem, his high ammonia levels were treated with lactulose. His b/l ankle fractures were followed by orthopedics. The patient was severely agitated on more than one occassion during this hospitalization, requiring three codes puples to be called as well as requiring restraints for protection of both the patient and the staff. The patient was originally sent from the floor to the MICU with delirium of unknown cause and severe agititation. He required increased amounts of sedation and was returned to the floor after a NG tube was placed. Once returned to the floor, the patient required less sedation, was taken off of any benzodiazipines and only intermittently needed restraints. The patient remained somnolent and delerious. He pulled out his NG tube. He was also febrile and rhoncorous on the floor. He was initially treated with vancomycin and flagyl, which was changed to azithro/ceftriaxone/flagyl. He was scheduled to return to the OR for revision of his right external fixation. In preop holding, he was found to be hypoxic and sent to the MICU. MICU COURSE: Morning of [8-28], patient scheduled to return to OR for revision of externally fixated RLE. Upon transport to PACU, patient became more somnolent and had reported "agonal breathing". O2 sats 83% on 2LNC and NRB applied with O2 sats to 100%. BP in 90s/60s, HR in 80s, RR 17-19. ABG drawn: 7.38/58/90. During stay in MICU, patient coughed up large amount of thick sputum with improved respiratory status. Surgery postponed and patient transferred to MICU for further monitoring. In the MICU, respiratory status has remained stable with Sp02 in the high 90s on room air. Pt is hemodynamically stable in chronic a-flutter. Called out to floor on [8-29]- no further intensive care needs identified. In the MICU, patient was started on Zosyn and restarted on Vancomycin wiht marked improvement in his respiratory status. Within a few days of returning to the floor, Vancomycin and zosyn were stopped as CXR showed resolution of questionable aspiration pneumonia - this was felt to be more likely pneuomonitis which resolved. . After the MICU, patient's delirium started to improve, but then worsened when he returned to the OR for removal of external fixation. He developed fevers to 102F post-operatively which likely worsened delirium. Source of fevers unclear - of note patient had recently developed VRE in his urine but infectious disease did not feel this was an active infection. he received three days of antibiotics (daptomycin and then linezolid). When these were stopped he became afebrile and delirium began to lift. . #Aggitation was mostly controlled with haldol. Zyprexa was tried for two weeks but it did not seem to help acute aggitation. QTc was monitored while patient was on antipsychotics and was stable at approximately 420-440msec. Overall etiology of delirium has remained unclear but was thought to be multifactorial due in part to chronic alcohol use, hepatic encephalopathy, benzodiazepine use, and post-operative delririum. Although spanish-speaking 1:1 sitters and interpreters were employed as much as possible, language also likely contributed to persistance of delirium. Delirium has completely resolved patient is now restraint and sitter free. All haldol has been stopped. He has past the period of etoh withdrawal. It is recommended that patient follow up with alcohol abuse counseling. . #Afib/flutter While febrile, his afib/flutter was complicated by more frequent episodes of rapid ventricular rate. This was controlled with IV metoprolol when needed but also by increasing PO metoprolol and diltiazem. Treating fever with tylenol also seemed to help. He was briefly put on therapeutic lovenox for atrial fibrillation, but this was stopped as he was not felt to be eligible by CHADS criteria and also because of high fall risk. Patient was transitioned off of beta blockers and placed on Diltiazem 120mg daily. . #Urinary retention patient failed several voiding trials. He also pulled out his foley on several occasions, causing hematuria. Intermittent straight catheterization was tried to reduce infection risk of long-term indwelling foley. However given delirium and aggitation this was untenable. This resolved with reductions in haldol. Patient now able to void freely on his own. History of VRE on urine culture, but no signs of infection, dyruria, increased urinary frequency. There is no evidence based literature or other clinical indications to treat this asymptomatic bacteuria at this time. . #Fractures patient followed by orthopedics during admission. L ankle fractures treated with casting, however repeat plain films and CT scan 4-6 weeks post-op showed fractures which were not initially visualized. Orthopedics felt casting was still appropriate and that there was no indication for surgery. R pilon fracture managed initially with external fixation system because of skin breakdown making internal fixation difficult. One month into hospitalization ex-fix removed and tibial and fibular plates were placed. He is to remain Non-weight bearing for a total of one month after his hospital discharge. Patient has completed the necessary course of lovenox.He has a follow up appointment scheduled with his orthopaedic surgeon Dr. [Last Name (STitle) ] for [11-28] at 1030am, at [Hospital3 ] [Hospital Ward Name ], [Location (un) 1385] of the [Hospital Ward Name 23] building. . Transfer to [Hospital ] Rehab Hospital. Medications on Admission: Diltiazem 180 mg one daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:30 Tablet, Chewable(s) Refills:0 5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:1 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Primary: 1) Bilateral Lower Extremity fractures a. Closed left tibial plafond fracture/pilon fracture. b. Dislocation left tibiotalar joint. c. Right calcaneus fracture, intra-articular 2) Persistent agitated delirium ?????? resolved 3) Aspiration Pneumonitis - resolved 4) Alcoholism ?????? continuous 5) Delirium Tremens 6) Polysubstance Abuse (cocaine, opiates, alcohol) 7) Atrial Fibrillation/Atrial Flutter 8) Abnormal CT chest ?????? follow-up ([2111-1-5]) recommended 9) Liver Failure ?????? presumed secondary to alcoholism (No evidence for HBV or HCV infection) a. Thrombocytopenia presumed secondary to thrombopoitin deficiency. No evidence for splenomegaly on imaging. 10) Elevated AFP level ?????? etiology as yet undetermined Secondary: 1) Hypertension 2) Urinary retention ?????? resolved 3) Bactiuria ?????? asymptomatic, colonized with Vancomycin resistant enterococcus Contact information: [First Name8 (NamePattern2) ] [Known lastname 1794] (daughter): [Telephone/Fax (1) 74301] [Female First Name (un) 74302] & [First Name9 (NamePattern2) 74303] [Known lastname 1794](son) cell [Telephone/Fax (1) 74304] For Follow-up: 1) Repeat CT scan of chest in [2111-1-5] to f/u 3 foci of ground glass in the RUL as well as borderline mediastinal and hilar lymphadenopathy 2) Assess etiology of elevated alpha-fetoprotein 3) Further evaluate etiology of pancyctopenia ?????? consider bone marrow aspirate as well as HIV testing Discharge Condition: Stable, Non-weight bearing in both legs for one month starting [10-15] Discharge Instructions: You were transferred to [Hospital1 18] emergency room after a large fall. You were found to have bilateral ankle fractures. You had a CT scan of your head which did not show any acute bleed. When you came into the emergency room your heart rate was fast, and you were given medications to help slow it down. . On [8-18] you had an operation on your left leg for a heel and ankle fracture, you had several pins placed in your left leg. Your left leg was then casted. . On [8-30] you had an operation on your R tibula fibula fracture that stabilized the leg externally. . On [9-17] you had an operation on your right tibula and fibula and screws were placed to help your leg heal. . During your hospital stay. You were very confused and placed on many psychiatric medications, you became very agitated at times,and had to be restrained at times. This has resolved you are no longer on any psychiatric medications. . While in the hospital you developed some breathing problems. [Name (NI) ] spent time in the intensive care unit, because there was some worry that you might have a pneumonia, you were started on antibiotics, but your breathing problems improves, and your chest xray improved. It was thought that you did not have a pneumonia and the antibiotics were normal. . You were also found to have some bacteria in your urine called VRE, because you were not having, any burning with urination. The infectious disease doctors thought that the bacteria should not be treated. . You are being transferred to a rehab facility. It is important that while at that rehab facility you, follow up and get counseling for your problems with alcohol abuse. . You have follow up appointments schedule with both orthopaedics and a new primary care physician. [Name10 (NameIs) ] is important that you follow up with both of these appointments. . It is also important that you do not put any weight on your legs for next month. Please return to the hospital or the emergency room if your condition worsens in any way. You had an abnormal chest x-ray/CT scan and should have this repeated in [2111-1-5] to make sure you don't have lung cancer. Your blood counts were low but stable during your hospitalization. You should see a Hematologist (Blood Doctor) about this and consider testing for HIV. You had an elevation of a marker in your blood called AFP (alpha fetoprotein). The significance of this is not know. It may be related to your underlying liver disease but should be further evaluated by a specialist. You should absolutely refrain from further use of alcohol, cocaine or any illicit drugs not explicitly prescribed to you by a physician. Ten??????as una exploraci??????n anormal [Doctor First Name ] pecho x-ray/CT [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (un) 7214] esto repetido en diciembre de [2110] para cerciorarse de t?????? no [Last Name (un) 7214] pulm??????n c??????ncer. Tus cuentas de sangre [Doctor First Name ] [First Name9 (NamePattern2) 74305] [Last Name (un) ] [First Name9 (NamePattern2) 74306] [Last Name (un) 33761] tu hospitalizaci??????[Initials (NamePattern4) ] [Last Name (NamePattern4) 7213] [Last Name (un) ] a un hemat??????logo (el doctor [Last Name (Titles) ] [Last Name (Prefixes) 74307]) sobre esto y considerar el probar para el VIH. Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP (alfa fetoprotein). [Name Prefix (Prefixes) ] [Last Name (Prefixes) 74308]??????n de esto no es saber. Puede ser relacionado con tu enfermedad [Doctor First Name ] higado [First Name9 (NamePattern2) 74309] [Last Name (un) ] debe ser m??????s futuro evaluado por un especialista. [Last Name (un) 7213] refrenarse absolutamente [Doctor First Name ] uso adicional [Doctor First Name ] alcohol, de [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]??????na o de cualquier droga il??????cita prescritos no expl??????citamente a ti por un m??????dico. Followup Instructions: Ten??????as una exploraci??????n anormal [Doctor First Name ] pecho x-ray/CT [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (un) 7214] esto repetido en diciembre de [2110] para cerciorarse de t?????? no [Last Name (un) 7214] pulm??????n c??????ncer. Tus cuentas de sangre [Doctor First Name ] [First Name9 (NamePattern2) 74305] [Last Name (un) ] [First Name9 (NamePattern2) 74306] [Last Name (un) 33761] tu hospitalizaci??????[Initials (NamePattern4) ] [Last Name (NamePattern4) 7213] [Last Name (un) ] a un hemat??????logo (el doctor [Last Name (Titles) ] [Last Name (Prefixes) 74307]) sobre esto y considerar el probar para el VIH. Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP (alfa fetoprotein). [Name Prefix (Prefixes) ] [Last Name (Prefixes) 74308]??????n de esto no es saber. Puede ser relacionado con tu enfermedad [Doctor First Name ] higado [First Name9 (NamePattern2) 74309] [Last Name (un) ] debe ser m??????s futuro evaluado por un especialista. [Last Name (un) 7213] refrenarse absolutamente [Doctor First Name ] uso adicional [Doctor First Name ] alcohol, de [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]??????na o de cualquier droga il??????cita prescritos no expl??????citamente a ti por un m??????dico. Please follow up with Dr. [Last Name (STitle) ] from orthopedic surgery you have an appointment scheduled for [2112-11-28]:30 am, [Location (un) 1385] of the [Hospital Ward Name 23] building on the [Hospital Ward Name ] of [Hospital1 771]. Please call [Telephone/Fax (1) 9769] if would like to change this appointment. Please follow up with your new primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 15259] on [2109-11-19] at 3pm in the [Hospital Ward Name 23] Center on the [Location (un) ] of the [Hospital Ward Name 516] [Hospital1 1170]. You had an abnormal chest x-ray/CT scan and should have this repeated in [2111-1-5] to make sure you don't have lung cancer. Your blood counts were low but stable during your hospitalization. You should see a Hematologist (Blood Doctor) about this and consider testing for HIV. You had an elevation of a marker in your blood called AFP (alpha fetoprotein). The significance of this is not know. It may be related to your underlying liver disease but should be further evaluated by a specialist.	[ "V15.81", "788.20", "E884.9", "304.21", "825.0", "287.5", "427.31", "304.01", "E878.8", "799.02", "041.3", "E849.0", "281.9", "041.04", "291.81", "E849.7", "507.0", "401.9", "996.49", "780.09", "427.32", "518.0", "572.2", "572.8", "599.0", "571.2", "303.01", "824.8", "599.7" ]	icd9cm	[ [ [] ] ]	[ "78.47", "79.07", "78.17", "96.07", "94.62", "79.06", "79.36", "84.72" ]	icd9pcs	[ [ [] ] ]	14339, 14412	7799, 13501	346, 739	15931, 16008	2540, 7776	20109, 22616	1988, 2005		13578, 14316		14433, 15910		13527, 13555			16032, 20086									2081, 2521																					277, 308							767, 1681																	1703, 1812	1828, 1972
78,168	153,246	39145	Discharge summary	report	Admission Date: [2191-8-18] Discharge Date: [2191-9-1] Date of Birth: [2121-12-28] Sex: F Service: CARDIOTHORACIC Allergies: Phenytoin / Nsaids Attending:[First Name3 (LF) 4679] Chief Complaint: Fever, Shortness of Breath, Cough Major Surgical or Invasive Procedure: Thoracentesis Removal of Pleurex Catheter from left chest History of Present Illness: The patient is a 69F wtih a history of cerebral palsy, developmental delay with cognitive impairment, and recurrent left pleural effusion s/p placement of pleurx catheter ([3-/2191]) who presents with cough, shortness of breath and fever. Patient with recurrent left sided pleural effusion dating back to late [2190] of unclear etiology, symptomatic secondary to trapped lung. She underwent a pleur-x catheter placement for this in [Month (only) ] of this year. At that time biopsy and pleural fluid sampling demonstrated exudative lymphocytic pleural fluid of unclear etiology as pathology only with reactive mesotheialial cells c/w chronic inflammation (pleuritis). She was recently seen in [Hospital ] clinic on [2191-8-16] for catheter drainage x2 weeks. Could not flush/drain catheter in clinic so instilled tPA and then able to drain 50cc fluid. She returned to nursing home but today noted to have progressively worsening non-productive cough and febrile to 100.9. Went to [Hospital3 ], noted to be 88%RA, CXR with worsening pleural effusion on left. 225cc fluid drained there. She was then transferred by ambulance to [Hospital1 18]. . In the ED initial vitals were: 99.9 94 100/39 18 98 3L NC. IP saw here noted to be sicker looking and coughing but without any complaints. Labs unremarkable (WBC of 9, lactate of 1.4). CT scan was performed. IP saw and drained 550cc of serosanguinous fluid, studies sent. She was given vanc 1mg IV and zosyn 4.5mg IV. Past Medical History: Developmental delay with cognitive impairment. Cerebral palsy. Spastic quadriplegia. Seizure disorder. Unsteady gait. Hypertension and hypotenstion. GERD. MI in [2182] CHF Depression hx of hypokalemia hx of hyponatremia hx of hyperlipidemia hx of intermittent constipation. history of peripheral edema. hx aspiration PNA hx UTI's Social History: [obtained per H and P from [Hospital3 ]] Pt without hx of substance abuse. Denies physical abuse. She resided in a nursing care facility for 8 years. Community placement was attempted in late [2190], but patient developed failure to thrive and admitted to acute care almost immediately. Family History: Both parents are deceased, mother died of [Name (NI) 2481] disease and dementia. It is unknown how father died. Physical Exam: VS:99.7 112/66 71 20 100 3LNC GEN: Chronically ill appearing, lying in bed NAD HEENT:dry mucosa, sclera anicteric Neck: JVP at clavicle sitting upright Lung: unlabored respirations, decreased air movement left base, rhonchi L>R, pleurx catheter in place anterior left chest covered in gauze and tegaderm C/D/I CV: S1, S2 regular rhythm, normal rate Abdomen: soft NTND EXT: bilateral 1+ edema, warm, distal pulses intact Pertinent Results: [2191-8-30] CBC: WBC: 4.4 Hgb: 8.9 HCT: 26.6 Plts: 323 [2191-9-1]: Na 139 K 3.9 Chl: 101 HC03 25 BUN 10 Cre 0.8 [2191-8-19] 07:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2191-8-19] 07:20AM BLOOD HCV Ab-NEGATIVE . Urine Analysis: . [2191-8-21] 09:34PM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.024 [2191-8-21] 09:34PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2191-8-21] 09:34PM URINE RBC-0-2 WBC-[7-21]* Bacteri-FEW Yeast-NONE Epi-0-2 [2191-8-21] 09:34PM URINE AmorphX-MANY Microbiology: # [2191-8-18] BLOOD CULTURE: No Growth # [2191-8-18] CULTURE: No Growth # [2191-8-21] CULTURE: No Growth x 2 # [2191-8-18] 3:57 pm Pleural Fluid GRAM STAIN: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN; NO MICROORGANISMS SEEN FLUID CULTURE: STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=2 S LEVOFLOXACIN---------- =>16 R OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- =>8 R ANAEROBIC CULTURE: No Growth # [2191-8-18] 6:59 pm Pleural Fluid: GRAM STAIN Negative, FLUID and ANAEROBIC CULTURES No Growth # [2191-8-22] 11:30 am Pleural Fluid: GRAM STAIN Negative, FLUID and ANAEROBIC CULTURES PND # [2191-8-24] 4:30 pm Pleural Fluid: GRAM STAIN: 2+ POLYMORPHONUCLEAR LEUKOCYTES, NO MICROORGANISMS FLUID and ANAEROBIC CULTURES No growth # [2191-8-21] URINE: No Growth Pertinent Imaging: [2191-8-18]: CXR New large left pleural effusion and left basilar consolidation, possibly representing atelectasis, but infection cannot be excluded. Tiny locules of gas projecting over the left lung base are likely within the pleural space. Left Pleurx catheter in unchanged position. . [2191-8-18]: CT CHEST 1. Marked enlargement of probably loculated left pleural effusion with features suggestive of superimposed infection, possibly empyema. Rounded foci of air within the collapsed basal left lower lobe may communicate with similar foci in the complex subpulmonic fluid collection raising concern for bronchopleural fistula. Left transthoracic drainage catheter as above. 2. New small right pleural effusion. CXR: [2191-8-31]: As compared to the previous radiograph, there is a minimal increase in extent of the right-sided pleural effusion, leading to a blunting of the right medial cardiophrenic space and increased right basilar atelectasis. On the left, there is a small increase in pleural effusion, one of the three left-sided chest tubes has been removed in the interval. No other changes, notably no evidence of newly appeared focal parenchymal opacities indicative of pneumonia. [2191-8-23]: CXR Two loculations within moderate left pleural effusion, which in the right clinical setting would raise concern for empyema. [2191-8-21]: The left pleural effusion is currently loculated. There is no change since [8-18], but there is significant decrease since [8-18] and 9. There is loculated air within the right upper pleura. Bibasal opacities are present, unchanged. No interval development of consolidation worrisome for progression of infectious process has been currently demonstrated. Cardiomediastinal silhouette is unchanged as well. [2191-9-1]: Left upper Extremity Doppler: No evidence of acute left upper extremity DVT. Left IJ appears chronically occluded which appears to have been present on [2191-8-18] CT. Brief Hospital Course: Ms. [Known lastname 52] is a 69 year old woman with a history of cerebral palsy, developmental delay with cognitive impairment, and recurrent left pleural effusion s/p placement of Pleu-x catheter ([3-/2191]) who presents with cough, shortness of breath and fever. . #FEVER: The patient frequently had low grade fevers overnight, especially on [8-18] and [8-21] when blood cultures were sent. Her WBC count fell from 9 on admission to 3.4 on hospital day 6. The differential for her fever is wide and includes infectious and noninfectious etiologies. In a patient this age with incontinence suspicion for UTI was high and supported by a urinary analysis with 6-10 WBCs and bacteria. By hospital day 3, she had developed suprapubic tenderness. Pulmonary infections were also considered including empyema in the setting of an increasing lymphocytic exudative pleural effusion with loculation. However, interventional pulmonology reported that the foci of air on CT was likely related to manipulation of the catheter. The patient is at risk for aspiration due to swallowing difficulty and presents with a cough making pneumonia a consideration. However, the cough seemed to involve the upper respiratory tract with no abnormal lung sounds, normal serum WBC, and serum lactate. Wounds and skin lesions were assessed, cleaned, and redressed regularly. No erythema or induration. Pt did not have any diarrhea or abdominal pain or rigidity. . Noninfectious causes were unlikely, but includes pulmonary embolism in a patient presenting with fever and dyspnea. However, there was no dyspnea or tachypnea throughout her hospital course and heart rate remained within a normal range with no changes in blood pressure. DVT was considered in the context of low mobility, lower extremity edema, and localized warmth of skin. Finally, post-ictal state was considered given her history of seizure disorder. However, after talking to her family, such a prolonged post-ictal state with gradual onset is uncharacteristic. . The pt's urinary tract infection was treated on a three day regiment of Bactrim. However, suprapubic pain persisted. Upon admission she was started on empiric broad coverage with Zosyn and vancomycin. However, Zosyn was changed to Levaquin on hospital day 1. Blood and urine cultures were sent and were found to be negative for any growth. Legionella antigen was also sent and found to be negative. The only positive culture came from pleural fluid drained on [8-18] which was positive for coagulase negative staphylococcus (likely contaminant). By the third day on Vanc/Levaquin, the patient was found to be afebrile overnight with minimal symptoms such as cough. Therefore, the regimen was continued... . #RECURRENT PLEURAL EFFUSION: Pt has history of a trapped lung s/p thoracoscopy, pleural biopsy and pleur-x catheter placement. Patient also underwent left tPA placement via the Pleu-x and now presents with fever and cough. Upon presentation, pleural fluid was drained and showed a lymphocytic exudative pleural effusion. The etiology is unclear as only one culture was positive for coagulase negative staphylococcus (likely contaminant) and pathology negative for malignancy. CT scan showed loculated effusion with foci of air, not being accessed by the Pleu-x catheter. Interventional pulmonology was consulted and the Pleur-x removed. They recommended continuing antibiotic coverage for upper respiratory tract infection and attempted a subsequent drainage of the collection which only produced 20cc of fluid. Thoracic surgery was consulted about performing a pleurodesis with VATS and the HCP agreed with this plan. The VATS procedure was conducted on hospital day 6 and the patient was transferred to the ICU under the thoracic surgery service. The patient underwent left VATS with washout and decortication. Her pleural fluid cultures were unyielding for organisms. Her three chest tubes were removed over. She was followed by serial chest films. . #SEIZURE DISORDER: The patient's cousin [Name (NI) 382] describes her seizure episodes as generalized tonic-clonic seizures followed by somnolence with confusion as alertness increases. The last seizure was 5-6 months ago before she was stabilized on her current anti-convulsant regiment. While in the hospital, the patient was continued on divalproex and Keppra. . #DYSPHAGIA: The patient presented with an aspiration precaution requiring pureed foods. Throughout her course, she had upper respiratory tract mucous build up so an induced sputum culture was sent but was contaminated. After concerns were raised about her ability to take PO medications, she was evaluated by speech and swallow and sent for a fluoroscopic swallow study. It was determined that she could continue to consume pureed foods, thin liquids, and crushed medications while sitting up. . #HYPERTENSION: BP ranged 90-100's therefore her hypertensive medications were held. She remained in sinus rhythm 60-70's. . #HYPERLIPIDEMIA: The patient was continued on her home regiment of simvastatin. . #GERD: The patient was continued on her home regiment of omeprazole. No reported symptoms of acid reflux. . #ANEMIA: Unclear baseline (27-30), but was stable throughout hospital course with guaiac negative stools and no signs of bleeding. She was transfused 2 units of PRBC for HCT 25. On dishcarge her HCT 27. #Renal: volume overloaded responded to IV Lasix. Renal function was normal. Foley remained in place to monitor output closely. . Disposition: She was return to [Hospital 6979] Hospital on [2191-9-1]. Code: Full as discussed w/ HCP Contact: HCP [Name (NI) ] [Name (NI) 86721] [Telephone/Fax (1) 86722] Medications on Admission: -Acetaminophen 325mg Q4prn -bisacodyl dosage uncertain -calcium and vitamin D -divalproex 750mg Q12 -fluoxetine 40mg daily -folic acid 1mg daily -lasix 20mg daily -levetiracetam 750mg QHS -omoeprazole 20mg daily -simvastatin 20mg adily -MOM -MVI Discharge Medications: 1. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO Q12 (). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 4339] Discharge Diagnosis: Primary Diagnoses: Left-Sided Pleural Effusion Urinary Tract Infection . Secondary Diagnoses: Hypertension Hyperlipidemia Seizure Disorder NOS Gastroesophageal Reflux Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Significant Findings: Pt tapered from supplemental oxygen and SaO2 >96% on room air by hospital day 6. Low grade fevers overnight to 100-101. Discharge Instructions: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] if you experience -Fever > 101 or chills -Increased shortness of breath cough or sputum production -Left thoracotomy incision develops drainage -Chest tube site remove dressings and cover site with a bandaid until healed. Should site drain cover with clean dressing and change as needed to clean and dry. -You may shower. No tub bathing or swimming until incision healed Followup Instructions: Please follow up with your primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. You can schedule an appointment by calling [Telephone/Fax (1) 86723]. . In addition, the interventional pulmonology service would like to follow your progress as an outpatient. They will notify you of your scheduled outpatient appointment after your discharge. Please call Dr.[Name (NI) 5067] office for a follow-up appointment when seen by interventional pulmonology Completed by:[2191-9-2]	[ "530.81", "334.1", "518.0", "412", "285.29", "345.10", "786.2", "511.1", "315.9", "458.29", "428.0", "599.0", "401.9", "780.60" ]	icd9cm	[ [ [] ] ]	[ "34.91", "34.51", "33.23", "97.41" ]	icd9pcs	[ [ [] ] ]	13580, 13628	6700, 12427	319, 379	13847, 13847	3158, 6677	14637, 15155	2585, 2703		12723, 13557		13649, 13722		12453, 12700			14175, 14614									2718, 3139	13743, 13826																				246, 281							407, 1898												13862, 14151					1920, 2256	2272, 2569
76,841	173,944	42340	Discharge summary	report	Admission Date: [2123-8-19] Discharge Date: [2123-9-2] Date of Birth: [2048-1-21] Sex: F Service: SURGERY Allergies: Gadolinium-Containing Agents Attending:[First Name3 (LF) 371] Chief Complaint: Abdominal pain, vomiting Major Surgical or Invasive Procedure: [2123-8-19]: Exploratory laparotomy, small bowel resection, and primary anastomosis History of Present Illness: Ms. [Known lastname 16968] is a 75F with h/o stage IV NSCLC diagnosed [2121], s/p chemo, XRT, and recent STEMI s/p LAD BMS placement [2123-7-30], presenting with acute onset LLQ pain associated with nausea and vomiting. Symptoms began the early on the morning of admission, and woke her from sleep. She reports several episodes of nonbloody, bilious emesis at home prior to being transported to [Hospital1 18] ED by EMS. She remembers passing flatus during the event, and reports having had a normal bowel movement overnight. She denies fevers or worsening shortness of breath. Past Medical History: Past Medical History: CAD s/p MI, LAD BMS [2123-7-30], CHF EF 30%, HLD, NSCLC stage IV s/p chemo/XRT, HTN, GERD, macular degeneration, anxiety, recent fall with spine fracture, managed nonoperatively Past Surgical History: None Social History: She lives in [Location 8391] with her son. [Name (NI) ]: 1ppd for years, but she has not smoked in many years, no EtOH, no illicts. She is widowed, her husband passed away from lung cancer. Family History: Mother passed away for CAD, heart failure in her 80s. Father passed away at 62 yo from complications of diabetes. Sister has CAD, heart failure (in her 80s). Had 7 brothers (2 died at 44 yo, one at 55 yo and one at 60 yo and had lung disease but she doesn't know anything more specific. 1 brother died as a baby. 1 brother had [Name2 (NI) 499] cancer and is well. Her only son is physically handicapped. Physical Exam: Physical Exam on Admission: Vitals: 97.9 98 130/94 28 100% GEN: A&O, uncomfortable but nontoxic, conversant HEENT: No scleral icterus, mucus membranes moist CV: Regular, tachycardic to 100s, +systolic murmur PULM: Increased, rales bilaterally ABD: Soft, moderately distended, +TTP in the suprapubic and LLQs with voluntary guarding. No rebound tenderness. No palpable masses. No scars. NG with scant output. DRE: normal tone, no gross or occult blood Ext: Trace LE edema, LE warm and well perfused Physical Examination upon discharge: VS: 98.1, 84, 126/54, 20, 100/RA GEN: Sitting up in chair, NAD. HENNT: No scleral icterus, mucus membranes moist CARDIAC: Normal S1, S2 RRR No MRG. PULM: Lungs diminished at bases. No W/R/R. ABD: Soft/nontender/mildly distended. Healing abdominal incision, erythema marked. EXT: + pedal pulses.+ trace edema. Well perfused. No cyanosis, clubbing. Pertinent Results: [2123-8-19] Radiology CT ABD & PELVIS WITH CO IMPRESSION: 1. Small bowel obstruction with a transition point in left lower quadrant. Just proximal to the transition point there is a 2.6 x 4.1 cm lobulated small bowel mass concerning for a metastasis with a primary small bowel tumor in the differential diagnosis. 2. Interval increase in the size of the left adrenal metastasis. 3. Resolution of a right pleural effusion with a persistent small left pleural effusion. 4. Small amount of pelvic free fluid. [2123-8-25] PORTABLE ABDOMEN FINDINGS: Supine and decubitus views of the abdomen demonstrate air-filled small and large bowel loops without frank pneumoperitoneum or pneumatosis. Patient is status post recent exploratory laparotomy with anterior abdominal surgical staples in place. No air-fluid levels or focal bowel dilatation. IMPRESSION: Findings suggest a component of postoperative ileus. [2123-8-25] 04:59AM BLOOD WBC-11.4* RBC-3.62* Hgb-9.6* Hct-30.1* MCV-83 MCH-26.4* MCHC-31.8 RDW-16.5* Plt Ct-413 [2123-8-24] 05:56AM BLOOD WBC-12.9* RBC-3.88* Hgb-10.1* Hct-32.1* MCV-83 MCH-26.0* MCHC-31.4 RDW-16.4* Plt Ct-444* [2123-8-23] 05:54AM BLOOD WBC-11.5* RBC-3.63* Hgb-9.5* Hct-30.3* MCV-84 MCH-26.1* MCHC-31.2 RDW-16.7* Plt Ct-428 [2123-8-19] 07:35AM BLOOD Neuts-87.3* Lymphs-5.6* Monos-4.0 Eos-2.8 Baso-0.2 [2123-8-25] 04:59AM BLOOD Glucose-123* UreaN-9 Creat-0.5 Na-142 K-3.7 Cl-106 HCO3-27 AnGap-13 [2123-8-24] 05:56AM BLOOD Glucose-130* UreaN-12 Creat-0.5 Na-142 K-3.0* Cl-103 HCO3-29 AnGap-13 [2123-8-23] 05:54AM BLOOD Glucose-68* UreaN-17 Creat-0.5 Na-141 K-4.0 Cl-106 HCO3-23 AnGap-16 [2123-8-19] 07:35AM BLOOD Glucose-130* UreaN-21* Creat-0.7 Na-138 K-4.1 Cl-103 HCO3-25 AnGap-14 [2123-8-25] 04:59AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.5* [2123-8-24] 05:56AM BLOOD Calcium-7.8* Phos-2.2* Mg-1.8 [2123-8-23] 05:54AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9 [2123-8-20] 12:50AM BLOOD Calcium-8.2* Phos-4.6* Mg-1.5* [2123-8-19] 07:35AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.1 Mg-1.8 [2123-8-20] 12:57AM BLOOD Lactate-1.2 [2123-8-19] 12:08PM BLOOD Lactate-1.6 [2123-8-19] 11:21PM BLOOD Hgb-7.5* calcHCT-23 O2 Sat-98 [2123-9-1] 04:29AM BLOOD WBC-11.6* RBC-3.36* Hgb-9.6* Hct-29.1* MCV-87 MCH-28.5 MCHC-33.0 RDW-17.6* Plt Ct-391 [2123-8-31] 05:25AM BLOOD WBC-12.2* RBC-3.46* Hgb-9.7* Hct-29.9* MCV-87 MCH-28.0 MCHC-32.4 RDW-17.3* Plt Ct-397 [2123-8-30] 01:22AM BLOOD WBC-10.9 RBC-3.23* Hgb-9.3* Hct-27.4* MCV-85 MCH-28.8 MCHC-34.0 RDW-16.6* Plt Ct-319 [2123-8-29] 02:30AM BLOOD WBC-13.1* RBC-3.48* Hgb-10.0* Hct-28.9* MCV-83 MCH-28.7 MCHC-34.5 RDW-16.1* Plt Ct-321 [2123-9-1] 04:29AM BLOOD Glucose-70 UreaN-7 Creat-0.6 Na-132* K-4.3 Cl-101 HCO3-21* AnGap-14 [2123-8-30] 01:22AM BLOOD Glucose-113* UreaN-9 Creat-0.4 Na-135 K-3.9 Cl-107 HCO3-23 AnGap-9 [2123-9-1] 04:29AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.7 [2123-8-31] 05:25AM BLOOD Calcium-7.4* Phos-3.5 Mg-1.8 [2123-8-30] 01:22AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.9 Brief Hospital Course: Ms. [Known lastname 16968] is a 75F with h/o stage IV NSCLC diagnosed [2121], s/p chemo, XRT, and recent STEMI s/p LAD BMS placement [2123-7-30], presenting with acute onset LLQ pain associated with nausea and vomiting. The patient was admitted to the acute care surgery service on [8-19] after imaging revealed that she had a small bowel obstruction. Her INR was reversed with 1mg IV vitamin K and 2u FFP to 1.5. After appropriate preparation, Ms. [Known lastname 16968] [Last Name (Titles) 8783]t exploratory laparotomy and small bowel resection, which was uncomplicated. Post-operatively she was transferred to the SICU for monitoring and extubation, given her EF of 30% and intra-operative volume resuscitation. On [8-20], she was successfully extubated without complication. She was continued on her aspirin, plavix, and beta blockade perioperatively. Her NGT was kept to suction awaiting return of bowel function. She was well-saturated on room air, and deemed stable for transfer to the surgical floor. After patient was transferred to the floor, her nasogastric tube was discontinued and she was advanced to clear liquids. She was restarted on her coumadin, and had daily INR draws. On POD 6, her INR was 2.9 and coumadin was held. The patient complained of nausea and had emesis so diet wasn't advanced past clear liquids. She underwent an abdominal Xray and imaging revealed no air however [Month/Year (2) 499] had dilatation. The patient received Dulcolax suppositories. On POD 7, INR had increased to 10.1 and patient received Vitamin 5mg to reverse. Her hematocrit trended from 30.9, 27.7, 23.9 and patient was transfused with 2 units packed red blood cells at which time she was transferred back to the ICU for a lower GI bleed. She has three large melena stools before transfer. Cardiology was consulted and recommended discontinuing warfarin secondary to risks outweighing the benefits, and holding aspirin and plavix until bleeding has resolved. The patient's hematocrit increased to 26 status post transfusion. Patient had serial hematocrits drawn, and on POD 8 her hematocrit was 23 and she received an additional 2 units packed red blood cells. She was kept NPO and given zofran and phenergan for nausea. Her urine culture grew Klebsiella so the patient was started on appropriate antibiotics. Aspirin and Plavix were restarted in the ICU prior to patient's transfer back to the floor, when her hematocrit was 28.9 and stable. Upon arrival to the floor, the patient's vitals remained stable and patient was afebrile. She was tolerating a regular diet but complained of intermittent nausea. She was voiding a large amount of urine appropriately. On the day of discharge, we marked the erythema on your abdominal incision in order to monitor if it worsens. The patient will continue on PO Bactrim for 3 more days for her urinary tract infection. The patient will follow up with Cardiology outpatient as well as the [Hospital 2536] Clinic in 2 weeks. Medications on Admission: Aspirin 81' plavix 75' coumadin 2.5' omeprazole 40' atorvastatin 80' benzonatate 100''' PRN folate 1' ativan 0.5 q6 PRN metoprolol XL 150' quinapril 10' Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Metoprolol Succinate XL 150 mg PO DAILY 6. Quinapril 10 mg PO DAILY 7. Sulfameth/Trimethoprim DS 1 TAB PO BID 8. Senna 1 TAB PO BID:PRN constipation 9. Acetaminophen 1000 mg PO Q6H 10. Bisacodyl 10 mg PR DAILY:PRN constipation 11. Caphosol 30 mL ORAL QID:PRN oral mucositis Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 731] - [Location 8391] Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to the hospital for abdominal pain. Upon imaging, it was revealed that you had a small bowel obstruction and you were taken to the operating room for a small bowel resection. Post-operatively, you developed a gastrointestinal bleed and you were transfused with several units of blood. You will be going to rehab for physical therapy and you will continue your antibiotics for your urinary tract infection. You will followup in the [Hospital 2536] Clinic, as well as with Hemaotologist and a new Cardiologist. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. 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 lifting weights greater than [4-8] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical 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: Department: CARDIAC SERVICES When: WEDNESDAY [2123-9-15] at 9:40 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2123-9-16] at 4:15 PM With: ACUTE CARE CLINIC with Dr [First Name4 (NamePattern1) 5877] [Last Name (NamePattern1) 16471] Phone:[Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2123-9-7*]	[ "V15.3", "560.89", "998.11", "362.50", "V15.82", "197.4", "599.0", "272.0", "414.01", "V58.66", "162.3", "414.8", "428.0", "401.9", "E878.2", "V58.61", "V87.41", "198.7", "300.00", "V15.88", "041.3", "428.22", "530.81", "V45.82", "E934.2", "410.12" ]	icd9cm	[ [ [] ] ]	[ "38.97", "45.62" ]	icd9pcs	[ [ [] ] ]	9553, 9670	5919, 8930	311, 400	9738, 9738	2857, 5896	12177, 12898	1519, 1933		9136, 9530		9691, 9717		8956, 9113			9846, 11645							11661, 12154	1279, 1286	1948, 1962																					247, 273						2489, 2838	428, 1027										1976, 2473		9753, 9822					1072, 1255	1302, 1503
81,146	103,290	39669	Discharge summary	report	Admission Date: [2188-8-1] Discharge Date: [2188-8-8] Date of Birth: [2110-2-13] Sex: M Service: MEDICINE Allergies: Cardura Attending:[First Name3 (LF) 2009] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Colonoscopy [2188-8-2], [2188-8-8] Esophagogastroduodenoscopy (EGD) [2188-8-8] History of Present Illness: The patient is a 78 year-old male with DM, HTN, HLD, history of diverticular bleed s/p clipping who presented with continued maroon stools. The patient was hospitalized at OSH from [Date range (1) 87437] for diverticular bleed with a colonoscopy showing a site of active diverticular bleeding estimated at 45cm. No other active sites were identified to the level of the cecum. 5 clips were placed at the site of diverticular bleeding and epinephrine was injected. An EGD did not reveal blood from above. The patient reportedly became hypoxic during the colonoscopy, thought to be due to an aspiration event. He was transferred to [Hospital1 18] for further care from [Date range (1) 87438]. At [Hospital1 18], he remained HD stable and was transfused 2 units packed RBCs, with his HCT remaining stable. He completed a course of levofloxacin and flagyl and was transitioned to Zosyn for aspiration pneumonitis. His respiratory status continued to improve and he was discharged on [7-30]. . This morning of his current admission, the patient awoke and had two episodes of maroon stools. He had no light-headedness at the time, but endorsed crampy abdominal pain. In the ED, he became very dizzy and light-headed. He had some dyspnea on exertion, but denied nausea, vomiting, fever, chills, continued cough, constipation, straining, or tenesmus. He was admitted to the MICU for further management of his presumed continued lower GI bleed. . In the ED, VS T 98.2 HR 80 BP 153/62 RR 20 O2Sat 100% on RA. Pt was complaining of light-headedness but no abdominal pain. Denied cp. Three peripherals placed (20 G, 16 G, 18 G). Seen by GI with plan to rescope on Monday. Originally admitted to floor but had another episode of dark red stool and was light-headed so transferred to MICU. . In the MICU, he reports no light-headedness, sob, cp, abd pain, n/v, diarrhea. . Review of systems: per HPI Past Medical History: CAD Type II DM HTN HLD Obesity Distal Adominal Aortic Dissection on CT scan ([2187-5-23]) Thoracic Aortic Aneurysm measuring 4.8cm on CT Scan ([2187-5-23]) RAS Bladder Cancer GERD Barrett's esophagus (endoscopy [2180]) Diverticular disease Chronic Anemia Lumbar disc Disorder Social History: Lives with wife. Two Children. Retired from the paper mill business. Tobacco: quit 20 years prior. Alcohol: endorses occasional EtOH use. Illicits: none. Family History: Father - MI. Mother - diabetes. Physical Exam: Vitals: T: 98.8 BP: 148/54 P: 85 R: 18 O2: 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mucous membranes Dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: good air movement throughout, with mild crackles in left lower lobe CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: bowel sounds present, soft, non-tender, non-distended, no rebound tenderness or guarding Ext: warm, well perfused, 2+ DP pulses, 1+ edema to mid shin bilaterally, no clubbing, cyanosis Neuro: CN II-XII grossly intact, moving all extremities Pertinent Results: ADMISSION LABS WBC-9.3# RBC-3.24* Hgb-9.5* Hct-29.2* MCV-90 MCH-29.4 MCHC-32.6 RDW-15.8* Plt Ct-477# Neuts-77.9 Lymphs-17.8* Monos-2.9 Eos-1.1 Baso-0.4 PT-13.9* PTT-28.6 INR(PT)-1.2* Glucose-88 UreaN-10 Creat-1.0 Na-141 K-4.0 Cl-109* HCO3-21* AnGap-15 Calcium-8.0* Phos-3.9 Mg-1.7 STUDIES COLONOSCOPY [2188-8-2]: A single sessile 4 mm polyp of benign appearance was found in the 30 cm. Multiple diverticula with mixed openings were seen in the sigmoid and descending colon; scattered diverticula in the right colon and cecum. Diverticulosis appeared to be of moderate severity. Three Hemoclips were present in the sigmoid colon 30 cm. There also appeared to be evidence of previous [Country ] ink injection at approximately 35 cm. No evidence of active bleeding or stigmata of recent bleeding. Impression: Diverticulosis of the sigmoid and descending colon; scattered diverticula in the right colon and cecum Three Hemoclips were present in the sigmoid colon 30 cm. There also appeared to be evidence of previous [Country ] ink injection at approximately 35 cm. Polyp in the 30 cm. No evidence of active bleeding or stigmata of recent bleeding. TAGGED RBC SCAN [2188-8-4]: Following intravenous injection of autologous red blood cells labeled with Tc-[Age over 90 ]m, blood flow and dynamic images of the abdomen were obtained for 77 minutes. A left lateral view of the pelvis was also obtained. Blood flow images show no evidence of active GI bleed. Dynamic blood pool images show no evidence of active GI bleed. COLONOSCOPY [2188-8-8]: Large internal hemorrhoids with stigmata of recent bleeding were noted. Multiple non-bleeding diverticula were seen in the whole colon. Diverticulosis appeared to be of moderate severity. Surgical anastamosis in the distal right colon was seen. The terminal ileum was intubated and appeared normal. 3 clips were seen in the sigmoid colon with mild ulceration but no stigmata of recent bleeding. Impression: Surgical anastamosis in the distal right colon was seen. The terminal ileum was intubated and appeared normal. Diverticulosis of the whole colon. Internal hemorrhoids. 3 clips were seen in the sigmoid colon with mild ulceration but no stigmata of recent bleeding. Otherwise normal colonoscopy to cecum. EGD [2188-8-8]: A hiatal hernia was seen, displacing the Z-line to 39 cm from the incisors, with hiatal narrowing at 41 cm from the incisors. Mucosa: Normal mucosa was noted in the whole esophagus. Stomach: Nodularity of the mucosa without evidence of bleeding. Duodenum: A single irregular, sessile, 10-15 mm non-bleeding polyp of benign appearance was found in the second part of the duodenum. Cold forceps biopsies were performed for histology at the second part of the duodenum. Impression: Nodularity of the mucosa without evidence of bleeding. Polyp in the second part of the duodenum (biopsy). Hiatal hernia. Normal mucosa in the whole esophagus. Otherwise normal EGD to third part of the duodenum. DISCHARGE LABS WBC-5.5 RBC-3.84* Hgb-11.2* Hct-34.0* MCV-89 MCH-29.2 MCHC-33.0 RDW-16.9* Plt Ct-242 Glucose-134* UreaN-8 Creat-1.0 Na-142 K-3.7 Cl-108 HCO3-27 AnGap-11 Mg-2.3 Brief Hospital Course: The patient is a 78 year-old male with DMII, HTN, HLD, history of diverticular bleed s/p clipping who presented with continued maroon stools. The patient was hospitalized from [Date range (1) 87439]. Brief hospital course is detailed below. 1. GI Bleed: at the time of discharge, the source of the patient's maroon stools remained unknown. Upon presentation, the patient was hemodynamically stable, but in the setting of orthostasis, was transferred to the MICU. Hematocrit was monitored, and nadired at 22.4. He received a total of 6 units of packed RBCs and underwent colonoscopy, which was negative for acute bleeding. EGD was not repeated, as his EGD at the OSH was negative. The patient was transferred to the floor, where he continued to have maroon stools. He required only one unit of RBCs throughout the remainder of his hospital course. He was maintained on IV pantoprazole and was followed with serial HCTs. In the context of his continued bleeding, GI, IR, and surgery were consulted. A tagged RBC was performed, which did not show evidence of active bleed. A second colonoscopy and EGD were performed because of concern for upper, rather than lower GI bleed, but these studies again did not show evidence of acute bleeding. He was noted to have extensive diverticulosis and a duodenal polyp (biopsied). At the time of discharge, the patient had not had maroon stools for ~48 hours. He was hemodynamically stable and his had HCT stabilized. His aspirin was held and not restarted. Omeprazole was increased from 20mg to 40mg daily. He was discharged with follow up with GI for a capsule endoscopy, and with instructions to return to the emergency department for dark or bloody stools. He was also instructed to follow a low residue diet. He was instructed to have a repeat hematocrit checked with his primary care physician within one week of discharge. He was advised to discuss restarting aspirin low dose with his PCP after completion of evaluation for GI bleeding. The patient's following chronic medical problems remained stable and were treated as follows. 1. Hypertension: in the setting of presumed GI bleed, the patient's home regimen of lisinopril, metoprolol, and chlorthalidone were held. As he stabilized, his lisinopril and metoprolol were re-introduced. He was discharged on his home regimen. 2. Diabetes: the patient's home glyburide and metformin were held, and he was maintained on a HISS. On discharge, he was restarted on his home regimen. 3. GERD/Barretts: in the setting of concern for GI bleed, the patient was maintained on IV pantoprazole. Omeprazole was increased to 40mg daily on discharge. 4. Asthma: the patient was maintained on his home regimen of albuterol and fluticasone-salmeterol. Medications on Admission: . Simvastatin 40 mg 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 . 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:90 Tablet Sustained Release 24 hr(s) Refills:0 4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation twice a day. 8. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: Two (2) Inhalation four times a day as needed for shortness of breath or wheezing. 9. Chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:1 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. 12. Omega-3 Fatty Acids 1,250 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) inhalation Inhalation twice a day. 6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. 8. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Outpatient Lab Work Please have your CBC (blood counts) checked with your primary care provider on Tuesday, [2188-8-12]. 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 11. Chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY Gastrointestinal bleed Anemia SECONDARY Hypertension Diabetes mellitus Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 69] for blood in your stools. You were cared for by gastrointestinal physicians, surgeons, and general medicine doctors. [First Name (Titles) ] [Last Name (Titles) 8783]t two colonoscopies, one EGD, and a tagged red blood cell scan that looked for active bleeding in your intestines. These tests did not show evidence of active bleeding in your esophagus, stomach, or colon. You will need to follow up with a GI physician to undergo further workup. We have made the following changes to your medications: - INCREASED your omeprazole - STOPPED your aspirin Please be sure to keep your appointments, as listed below. Followup Instructions: The following appointments have been made for you. Please keep these as scheduled. Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: [Hospital ] MEDICAL ASSOCIATES Address: [Street Address(2) 75551] [Apartment Address(1) ], [Location (un) ],[Numeric Identifier 87435] Phone: [Telephone/Fax (1) 65542] Appointment: Tuesday [2188-8-12] 10:45am You are planned to have a capsule endoscopy as an outpatient. You will be contact[Name (NI) ] regarding scheduling this appointment. You will need a small bowel follow through prior to the capsule endoscopy. Please call ([Telephone/Fax (1) 10796] to schedule this study. Completed by:[2188-8-12]	[ "493.20", "211.2", "278.00", "441.01", "401.9", "250.00", "530.85", "530.81", "455.0", "562.10", "211.3", "V10.51", "722.93", "553.3", "578.9", "272.4", "285.1", "414.01" ]	icd9cm	[ [ [] ] ]	[ "45.16", "45.23" ]	icd9pcs	[ [ [] ] ]	11655, 11661	6670, 9412	275, 368	11792, 11792	3480, 6647	12628, 13366	2817, 2851		10632, 11632		11682, 11771		9438, 10609			11943, 12464									2866, 3461																		12493, 12605	2306, 2316		227, 237							396, 2287												11807, 11919					2338, 2627	2643, 2801
41,830	118,355	33070	Discharge summary	report	Admission Date: [2197-8-1] Discharge Date: [2197-8-10] Date of Birth: [2121-5-5] Sex: M Service: NEUROSURGERY Allergies: Morphine / Augmentin / lisinopril / Aldactone Attending:[First Name3 (LF) 1835] Chief Complaint: Hyperglycemia after starting dexamethasone Major Surgical or Invasive Procedure: [2197-8-4]: LEFT FRONTAL CRANIOTOMY FOR MENIGIOMA RESECTION History of Present Illness: Mr. [Known lastname 60843] is a 76 year old man with a history of CAD s/p MI in [2188] (subsequent normal cath in [2193]), CVA w/o residual defecits, sCHF, DMII, OSA (nonadherant with bipap), who is admitted for preoperative hyperglycemia management prior to meningioma removal scheduled for [2197-8-4]. Per the patient and patient's family, he was in his usual state of health until this spring when he and his family noticed headaches and generalized cognitive decline. He began forgetting dates and mixing up his medications. He then went to [Hospital3 ] on [2197-6-15] where an MRI revealed a large frontal meningioma. He was then seen by neurosurgery there who recommended surgery, however, he decided to come to [Hospital1 18] for a second opinion. He then established care here with neurooncology who noted RLE edema and obtained an U/S which revealed a DVT. He was started on lovenox. It is unclear if this is provoked or not. He was started on dexamethasone and Keppra for his meningioma but he has developed hyperglycemia as a result. His neurosurgeons therefore decided the patient should be admitted to medicine for hyperglycemia management prior to the operation. Of note, his aspirin and plavix were discontinued on [7-24] in preparation of surgery. 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. Also denies focal weakness, visual problems. [Name (NI) ] DOES report unsteady gate and memory difficulties. Past Medical History: 1. Meningioma 2. CAD s/p MI in [2188]. Repeat cath here in [2193] revealed patent coronaries 3. sCHF (no echo in our system but [2194] admission at OSH for CHF) 4. Diabetes 5. Hypertension 6. Dyslipidemia 7. Left ear infection, hearing loss, had surgery 8. Colon polyps removed 9. Bilateral LE blood clots 10. Sleep apnea, does not tolerate CPAP 11. Prostatism 12. Cognitive decline Social History: He is married and lives with his wife. [Name (NI) ] is a retired sheet metal worker, and had asbestos exposure in the shipyard. He is retired. He smoked [1-8] ppd for 60 years Family History: No family history of brain cancer, otherwise non-contributory Physical Exam: Admission exam: VS: 97.8 124/74 88 18 95%RA FS 240 GENERAL: Well-appearing man in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no rh/wh, good air movement, resp unlabored. Bibasilar crackles. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. Scar from colectomy for polyps (precancerous). EXTREMITIES: WWP, no c/c, 2+ peripheral pulses. 1+ edema on RLE. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-11] throughout UE/LE flexion/extension with subtle RLE weakness on knee flexion and extension, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait but with limp favoring right and + rhomberg sign. States days of week backward correctly without delay and states he is in hospital for meningioma to be removed. Discharge exam: Unchanged Pertinent Results: Admission labs: [2197-8-1] 09:45AM BLOOD WBC-9.7 RBC-4.59* Hgb-14.8 Hct-43.4 MCV-95 MCH-32.4* MCHC-34.2 RDW-12.7 Plt Ct-199 [2197-8-1] 09:45AM BLOOD Neuts-78.8* Lymphs-14.6* Monos-4.8 Eos-1.2 Baso-0.6 [2197-8-1] 09:45AM BLOOD Plt Ct-199 [2197-8-1] 09:45AM BLOOD PT-12.1 PTT-26.3 INR(PT)-1.0 [2197-8-1] 09:45AM BLOOD UreaN-14 Creat-0.6 Na-143 K-4.3 Cl-103 HCO3-29 AnGap-15 [2197-8-1] 09:45AM BLOOD Calcium-10.0 [2197-8-1] 09:45AM BLOOD %HbA1c-8.2* eAG-189* [2197-8-1] 09:45AM BLOOD CRP-14.1* [2197-8-4] ct brain FINDINGS: The patient is status post post-left frontal craniotomy, with changes related to excision of the previously described left frontal mass. A moderate amount of pneumocephalus is noted in the left frontal region. Trace amount of dense material is seen layering in the resection cavity, compatible with subarachnoid blood. The sulci of the left frontal lobe are mildly effaced as is the frontal [Doctor Last Name 534] of the left lateral ventricle. Subtle left-to-right shift of midline structures is seen, with the maximum displacement measuring 3 mm in the transverse plane (2; 15). Otherwise, there is no large subdural collection, hydrocephalus, or intraventricular hemorrhage. Small amount of subcutaneous gas is seen along the left aspect of the scalp in the region of the surgical intervention. The visualized paranasal sinuses and mastoid air cells are clear. Incidental note is made of a hearing aid on the left ear. IMPRESSION: Immediately status post resection of left frontovertex extra-axial mass, with moderate post-procedural pneumocephalus and trace subarachnoid blood at the operative bed; mild effacement of sulci and the left frontal [Doctor Last Name 534], with 3 mm rightward shift of midline structures, is unchanged from the pre-operative studies. [2197-8-5] MRI FINDINGS: The patient is status post left frontal craniotomy, with post-surgical changes in the left frontal region as well as the adjacent parenchyma of the left frontal lobe. Pneumocephalus and blood products and fluid are noted. There is moderate surrounding FLAIR hyperintense signal that is not significantly changed from the preop study. Areas of increased signal intensity are noted on the DWI sequence in the periphery of the resection cavity with decreased signal on the ADC sequence, which may relate to blood products/areas of ischemia or infarction in the adjacent tissue. Attention on followup can be considered (series 502, image 20). Evaluation for enhancing areas is limited, given the pre-contrast T1 hyperintense areas. However, there is slightly vague enhancement surrounding the surgical resection cavity. No areas of abnormal enhancement are noted elsewhere in the brain. Small fluid collection is noted in the left subdural space, in the frontal region. There is also soft tissue swelling with fluid collection in the soft tissues overlying the left frontal and the parietal bones (series 6, image 21) along with blood products. Mild enhancement of the overlying dura in the left side. Multiple FLAIR hyperintense foci are also noted in the cerebral white matter, likely related to small vessel ischemic changes. There is mass effect on the frontal [Doctor Last Name 534] of the left lateral ventricle, with mild rightward shift of the midline structures and subfalcine herniation measuring approximately 5 mm. The major intracranial arterial flow voids are noted, with a diminutive distal vertebral and Basilar artery with a fetal PCA pattern. There is increased signal intensity in the mastoid air cells on both sides and in the petrous apices from fluid/mucosal thickening. IMPRESSION: 1. Surgical changes in the left frontal region and in the left frontal lobe parenchyma with presence of blood products as described above. Unchanged appearance of the surrounding FLAIR hyperintense signal in the left frontal lobe. Interval development of an area of decreased diffusion surrounding the blood products, which may relate to infarction/ischemic changes in the parenchyma. Assessment for infarction is limited given the presence of blood products adjacent. Consider followup as clinically indicated for better assessment. 2. While there is no significant abnormal enhancement to suggest an obvious residual tumor, followup evaluation can be considered to assess residual tumor, after resolution of the post-surgical changes. 3. Mucosal thickening/fluid, in the mastoid air cells on both sides and in the petrous apices. Persistent mass effect on the left frontal [Doctor Last Name 534] and mild rightward shift of midline structures not significantly changed. Brief Hospital Course: 76M with CAD s/p MI, chronic diastolic CHF (EF 50%), T2DM, h/o CVA and recently diagnosed DVT who was admitted for pre-operative glycemic control in the setting of dexamethasone. #Meningioma - Patient noted having gait instability and difficulty with his memory, was diagnosed with a left frontal meningioma by MRI at an OSH. Was started on dexamethasone and Keppra for seizure prophylaxis. He had resection of the meningioma on [2197-8-4] by neurosurgery. This was done without complication. Post op head CT was without hematoma. Post op MRI revealed good resection. #T2DM - Patient reports that his diabetes had not been well controlled prior to starting dexamethasone, was reporting sugars in the 200s previously. Since starting dex, his glycemic control even worsened and was reporting glucose in the 400s. He was admitted for pre-operative glycemic control. We held his home glipizide and started him on insulin. By the day of surgery, his sugars remained elevated but were improved from prior to admission. His insulin regimen was Lantus 15 units and sliding scale Humalog. During his post-operative course he was on dexamethazone and his sugars were difficult to control. He was placed on an insulin drip for > 24 hours. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Diabetes consult was obtained. He was transferred to a sliding scale and PO meds were discontinued. His sliding scale insulin and Morning Lantus doses were adjusted and weaned [First Name8 (NamePattern2) ] [Last Name (un) ] consult in the setting of steroid taper. #DVT - He reports having a history of at least 2 prior DVTs. Was diagnosed with DVT prior to admission, had been on Lovenox. Was placed on a heparin gtt during this admission given his pending surgery. Heparin was turned off approximately 6 hours prior to his surgery. Post operative day #1 he was asa was restarted and on post-operative day #2 his plavix was restarted. On [8-10] he was started on Coumadin. #CAD s/p MI - Had cardiac cath in [2193] which did not show any significant lesions. He was continued on his home metoprolol, valsartan and amlodipine. He was continued on his cardiac meds on the day of the operation. #Diastolic CHF - TTE from OSH showed an EF of 50%. There were no clinical signs of volume overload, was given gentle fluids on the day of surgery while he was NPO. #OSA - Was continued on CPAP while he was an inpatient. On [2197-8-10] he was cleared for discharge home after being seen by PT. Pain was well controlled, tolerating a PO diet, voiding without difficulty and ambulating independently. He received Insulin training prior to discharge and will have VNA at home for furhter training. Family was in agreement with this plan. Medications on Admission: 1. Simvastatin 80 mg qday 2. Glipizide 10 mg po bid 3. Irbesartan 300 mg daily 4. Amlodipine 5 mg daily 5. Furosemide 20 mg daily 6. Dexamethasone 4 mg daily 7. Phenytoin 100 mg tid 8. Aspirin 81 mg daily 9. Clopidogrel 75 mg daily 10. Metoprolol XR 100 mg 11. Omeprazole 20 mg po daily 12. Aspirin 81 mg daily 13. Keppra 1000mg PO BID 14. Lovenox 120 SC BID Discharge Medications: 1. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). [Date Range ]:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). [Date Range ]:120 Tablet(s) Refills:2 5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Check INR on [8-12] or [8-13]. Further dosing by PCP. [Name Initial (NameIs) ]:30 Tablet(s) Refills:2 11. dexamethasone 1 mg Tablet Sig: taper Tablet PO taper for 4 days: 1mg PO Qday on [8-10] & [8-11]. 0.5mg PO Qday on [8-17] then d/c. [Month/Day (4) ]:qs Tablet(s) Refills:0 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. insulin glargine 100 unit/mL Solution Sig: Fifty Five (55) units Subcutaneous once a day: Decrease to 35 units daily when taking 1mg Dexamethasone daily and decrease to 25 units daily when taking 0.5mg Dexamethasone daily. [Month/Day (4) ]:1 vial Refills:3 14. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous before meals. [Month/Day (4) ]:1 vial Refills:2 15. diabetic supplies, miscellan. Kit Sig: One (1) kit Miscellaneous as directed. [Month/Day (4) ]:1 kit Refills:2 16. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). [Month/Day (4) ]:30 Patch 24 hr(s) Refills:2 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary diagnoses: Meningioma s/p resection Hyperglycemia Secondary diagnoses: CAD Diastolic CHF OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound closure uses dissolvable sutures, you may shower after 3 days. ?????? 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, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [7-16] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [Hospital 341] Clinic on [2197-9-4] at 1PM. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. ?????? You need to follow up with your primary care physican early next week (mon or tues) to check on coumadin dosing/INR and blood sugars. You were seen in house by [Last Name (un) ] Diabetes. You should follow up with Dr. [Last Name (STitle) 818] for titration of the insulin as you stop the steroids (decadron). The timing and need for this can be discussed with your PCP. [Name10 (NameIs) ] phone number at [Last Name (un) ] Diabetes is [Telephone/Fax (1) 47802]. Completed by:[2197-8-10]	[ "305.1", "V58.61", "428.0", "250.02", "428.32", "225.2", "348.4", "V58.65", "414.01", "327.23", "272.4", "453.41", "401.9" ]	icd9cm	[ [ [] ] ]	[ "01.51", "02.12", "00.39" ]	icd9pcs	[ [ [] ] ]	13749, 13800	8542, 11308	351, 417	13945, 13945	3863, 3863	15588, 16922	2744, 2807		11717, 13726		13821, 13880		11334, 11694			14096, 15565									2822, 3817	13901, 13924					3833, 3844															269, 313							445, 2108							3879, 8519					13960, 14072					2130, 2527	2543, 2728
27,117	139,226	34134	Discharge summary	report	Admission Date: [2164-3-9] Discharge Date: [2164-3-16] Date of Birth: [2106-7-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Unstable Angina Major Surgical or Invasive Procedure: [2164-3-12] - Off pump coronary artery bypass grafting to two vessels. (Left internal mammary artery->Left anterior descending artery, Saphenous vein graft->Distal circumflex artery.) [2164-3-9] Cardiac Catheterization History of Present Illness: This 57 year old male has a history of a STEMI in [2163-5-29] and was treated with PCI to the mid-LAD with a driver stent and micro driver to D1. In [2163-7-29], he developed recurrent chest pain with elevated cardiac enzymes. A repeat cardiac catheterization was done which revealed a 40% LAD stenosis distal to the previous stent, a 50% instent restenosis of the D1 and a 90% ostial thrombotic OM2 lesion. The RCA was not injected at that time. The patient was treated with PTCA and placement of a Xience drug eluting stent. The patient reports that since [Month (only) 216], he had been doing well until a few weeks ago when he started to experience recurrent chest pain related to activity. The pain has occurred after going up and down stairs or walking the dog. This went on for about a week intermittently, with each episode resolving after 1 ntg. These symptoms have not recurred in the last 2 weeks. The patient denies claudication, edema, orthopnea, PND and lightheadedness. The patient was referred for a stress test done on [2164-3-8]. The official report is not yet available, however according to Dr .[Doctor Last Name 1911] with exercise, the patient??????s ekg revealed an IVCD with right axis deviation and the patient developed significant angina at 6 minutes. Nuclear imaging was significant for a large reversible inferior wall defect. Patient presented to the hospital this morning for elective cardiac cath to reexamine coronary arteries. Patient was found to have severe 2 VD. The decision was made not to perform an intervention but to consult CT surgery for CABG evaluation. On presentation to the floor after cardiac catheterization, patient denies any chest pain or shortness of breath. He does admit to some mild back discomfort that he attributes to positioning during cath today. Past Medical History: - Coronary artery disease, s/p myoardial infarction with 2 bare metal stents to LAD and OM1 in 6/'[62] - Hypertension, diagnosed ~5 years ago - Dyslipidemia - Sydenham Chorea at age 12, hospitalized for 1-2 months Social History: -Tobacco history: noted on admission note as 20 pack years, but patient reports 5 pack year smoking history (x10 years); quit 10 years ago. -ETOH: A couple glasses of red wine per week. -Illicit drugs: Denies. -Patient lives at home, recently separated from wife. Reports moderate activity level at home. Family History: There is no family history of premature coronary artery disease or sudden death. However his maternal grandmother and uncle had [Name (NI) 5290] in their 70s. [Name (NI) ] father had HTN as well. No FHx of DM. Physical Exam: VS: T 98.4 BP 115/73 HR 62 RR 20 SpO2 97% Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate, in bed rest from cardiac cath. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi heard anteriorly (posterior exam deferred as patient is in bed rest). Abd: +bs, Soft, NTND. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2164-3-9] 12:30PM BLOOD WBC-6.5 RBC-4.70 Hgb-14.9 Hct-41.4 Plt Ct-168 [2164-3-9] 08:20AM BLOOD PT-13.8* INR(PT)-1.2* [2164-3-9] 12:30PM BLOOD Glucose-108* UreaN-18 Creat-0.9 Na-137 K-4.0 Cl-106 HCO3-23 AnGap-12 [2164-3-9] 12:30PM BLOOD ALT-29 AST-23 AlkPhos-38* Amylase-35 TotBili-1.2 [2164-3-9] 12:30PM BLOOD Albumin-4.2 [2164-3-9] 12:30PM BLOOD %HbA1c-6.2* [2164-3-9] Cardiac Cath: 1. Selective coronary angiography of this left dominant system revealed severe 2 vessel coronary artery disease. The LMCA was normal. The LAD had a ostial 70% stenosis, with mild instent narrowing distally. D1 was small with a patent stent but diffuse mild restenosis. The LCX was a large dominant vessel; the stent from the LCX into OM1 was patent with mild disease. There was >90% stenosis in the main AV LCX just distal to the previous stent. The RCA was a small nondominant vessel with a 50% stenosis in the mid portion. 2. Limited resting hemodynamics revealed elevated left sided filling pressures with a LVEDP of 20 mm Hg. Left ventriculography revealed preserved ejection fraction at 62% with small segment lateral mild hypokinesis. There was no mitral regurgitation. There was no significant gradient across the aortic valve. There was mild systemic arterial hypertension with a central aortic pressure of 140/84 mm Hg. [2164-3-10] Echocardiogram: The left atrium is dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is 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 number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [2164-3-16] 07:00AM BLOOD WBC-10.7 RBC-4.04* Hgb-13.0* Hct-35.8* MCV-89 MCH-32.1* MCHC-36.3* RDW-13.5 Plt Ct-221 [2164-3-16] 07:00AM BLOOD Glucose-108* UreaN-16 Creat-1.1 Na-135 K-4.0 Cl-97 HCO3-31 AnGap-11 [2164-3-9] 12:30PM BLOOD ALT-29 AST-23 AlkPhos-38* Amylase-35 TotBili-1.2 Brief Hospital Course: Mr. [Known lastname 78694] was admitted and underwent cardiac catheterization. Coronary angiography revealed a left dominant system and severe two vessel coronary artery disease - please see result section for further details. Given the findings, cardiac surgery was consulted and preoperative evaluation was performed. Risks and benefits were discussed with the patient regarding surgical revascularization, and he wished to proceed. Given the patient was on [Known lastname ], surgery was delayed for several days to allow for washout. His preoperative course was otherwise uneventful and he was cleared for surgery. Given his inpatient stay was greater than 24 hours prior to surgical intervention, Vancomycin was utilized for perioperative antibiotics. On [3-12], Dr. [First Name (STitle) ] performed off pump coronary artery bypass grafting surgery. For surgical details, please see operative note. Following the operation, he was brought to the cardivascular surgical intensive care unit for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He maintained stable hemodynamics and transferred to the step down floor on postoperative day one. His chest tubes were removed and a subsequent set of chest radiographs reveals small stable bilateral apical pneumothoraces. His epicardial wires were removed. He was seen in consultation by the physical therapy service. On his third post-operative day he mentioned that he occasionally felt a sternal click, but it was unable to be elucidated by the surgical team and there was no sternal drainage. Sternal precautions were reviewed with Mr. [Known lastname 78694]. By post-operative day four he was ready for discharge to home. Medications on Admission: [Known lastname ] 75mg daily Lisinopril 20mg daily Toprol 150mg daily Aspirin 325mg daily Crestor 40mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while taking pain medication for constipation. Disp:60 Capsule(s) Refills:2 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 4. 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 5. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Coronary Artery Disease s/p Coronary artery bypass grafting Hyperlipidemia Hypertension Obesity 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 from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] (cardiac surgery) in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) 1911] (cardiology) in 2 weeks. Please follow-up with Dr. [Last Name (STitle) ] (primary care provider) in [1-31] weeks. Scheduled appointments: Provider: [Name10 (NameIs) 1918] [Name11 (NameIs) ] Phone:[Telephone/Fax (1) 11767] Date/Time:[2164-5-14] 9:40 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2164-3-16]	[ "272.4", "V45.82", "401.9", "411.1", "278.01", "414.01", "564.00", "429.3", "412" ]	icd9cm	[ [ [] ] ]	[ "37.22", "36.11", "88.56", "36.15", "88.53" ]	icd9pcs	[ [ [] ] ]	9309, 9377	6495, 8239	335, 564	9517, 9524	3907, 6472	10323, 10916	3008, 3228		8402, 9286		9398, 9496		8265, 8379			9548, 10300									3243, 3888																					280, 297							592, 2427																	2449, 2669	2685, 2992
62,734	125,072	7080	Discharge summary	report	Admission Date: [2120-1-16] Discharge Date: [2120-1-20] Date of Birth: [2055-5-5] Sex: M Service: SURGERY Allergies: Tetanus Toxoid,Adsorbed Attending:[First Name3 (LF) 668] Chief Complaint: Left retroperitoneal bleed Major Surgical or Invasive Procedure: [2120-1-16] Embolization of distal branch of left renal artery feeding lower pole History of Present Illness: 64M w hx of PKD, s/p failed kidney transplant on [12-3]. He is being evaluated for potential second kidney transplant. He recently underwent cardiac cath which showed 3 vessel disease. Now he is s/p CABG x 3 on [12-5]. Patient presented to [Hospital ] Med Center ED w L back/flank pain. CT scan shows blood around native L kidney in the retroperitoneum. He is anticoagulated on coumadin for his hemodialysis port (INR 4 at OSH). He was hemodynamically stable on arrival the the OSH, HCT 27. He received 4U FFP and was transfered to the [Hospital1 18] ED. Past Medical History: PMH: Hypertension, Polycystic kidney disease, Kidney Allograft failure from BK nephropathy, Hemodialysis MWF -> Right Subclavian tunneled catheter and a non-matured left arm AV fistula, Gout, Anemia, Incarcerated Hernia as an infant (Surgically repaired), Skin cancer s/p excision on back PSH: kidney transplant [12-3], CABG x 3, Left arm AV Fistula placement, Right chest subclavian port/Hemodialysis catheter x3, Left Knee Reconstruction, s/p inguinal hernia repair as child Social History: married, works in a sales, denies alcohol, tobacco, or drug use Family History: Mother and son with PKD. Physical Exam: On Discharge: Afebrile, VSS No distress, Alert and oriented x 3 PERLA, EOMI, anicteric Neck supple RRR Lungs clear Abdomen soft, nontender, nondistended Groin soft, no hematoma LE: no edema, palpable pulses Pertinent Results: [2120-1-16] 11:55AM BLOOD WBC-6.4 RBC-2.46* Hgb-6.5# Hct-21.5 MCV-88 MCH-26.6* MCHC-30.4* RDW-16.1* Plt Ct-214 [2120-1-16] 05:26PM BLOOD Hct-23.1* [2120-1-16] 07:36PM BLOOD WBC-7.5 RBC-2.83* Hgb-7.9* Hct-25.2* MCV-89 MCH-28.0 MCHC-31.4 RDW-15.7* Plt Ct-209 [2120-1-17] 07:00AM BLOOD WBC-10.7 RBC-3.00* Hgb-8.3* Hct-26.2* MCV-87 MCH-27.6 MCHC-31.6 RDW-16.3* Plt Ct-229 [2120-1-17] 10:45AM BLOOD WBC-10.1 RBC-2.76* Hgb-7.8* Hct-23.8* MCV-86.3 MCH-28.1 MCHC-32.6 RDW-16.2* Plt Ct-209 [2120-1-17] 06:37PM BLOOD WBC-11.7* RBC-3.83# Hgb-10.9# Hct-32.9# MCV-86 MCH-28.4 MCHC-33.0 RDW-15.9 Plt Ct-182 [2120-1-17] 10:05PM BLOOD Hct-31.6* [2120-1-19] 02:43AM BLOOD WBC-10.4 RBC-3.98* Hgb-11.2* Hct-33.6* MCV-84 MCH-28.2 MCHC-33.5 RDW-17.8* Plt Ct-199 [2120-1-19] 09:16AM BLOOD Hct-34.0* [2120-1-19] 02:33PM BLOOD Hct-37.5* [2120-1-20] 09:15AM BLOOD Glucose-101* UreaN-38* Creat-6.6# Na-142 K-4.4 Cl-98 HCO3-30 AnGap-18 Brief Hospital Course: Mr. [Known lastname ] was transferred to [Hospital1 18] with a left retroperitoneal bleed. A repeat CT scan with IV contrast was performed here and this showed active extravasation from the left kidney. He immediately went to interventional radiology for intervention. They were able to coil a small branch of the left renal artery that was feeding the lower pole of his left kidney. He was transferred to the SICU for close monitoring and serial hematocrits. His serial hematocrits and INR were monitored and he received transfusions as needed. He received a total of 8 units of packed RBCS and 6 units of FFP. He did received dialysis on M/W/F as per his outpatient schedule. On Post procedure days [2-29] his hematocrits remained stable and he was transferred out of the ICU. His diet was advanced, which he tolerated without difficulty. He was discharged home after his hematocrits remained stable for another 24 hours on the surgical floor. Medications on Admission: Wafarin 6 mg QD, Aspirin 81 mg QD, ranitidine 150 mg QD, colace 100 mg [Hospital1 ], leflunomide 20 mg [Hospital1 ], amlodipine 5 mg [Hospital1 ], cinacalcet 30 mg QD, Calcium Acetate 667 mg x 4 tabs TID, atorvastatin 10 mg QD, colchicine 0.6 mg PO twice a week Mon/Thurs, metoprolol 100 mg [Hospital1 ], lasix 80 mg [Hospital1 ] Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO bid (). 6. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain/fever. Discharge Disposition: Home Discharge Diagnosis: Ruptured left renal cyst with active extravasation. Acute blood loss anemia. Discharge Condition: Good, Alert and oriented x 3, ambulating without difficulty Discharge Instructions: Call your physician or return to the ED if you experience: fever > 101, chills, persistent nausea or vomiting, lightheadedness, palpitations, or pain. You may resume your home medications. You may resume your coumadin but you need to follow up with your physician to have your dose adjusted because it was too high when you came to the hospital. Followup Instructions: Follow up with Dr. [First Name (STitle) ] in [12-30] weeks. Call his office at ([Telephone/Fax (1) 12944] to schedule your appointment. . Continue your dialysis as you were prior to your hospitalization. . Provider: [Known firstname 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2120-1-23*] 1:00	[ "V58.61", "585.6", "E878.0", "753.12", "996.81", "V45.81", "568.81", "274.9", "403.91", "285.9", "V10.83", "V45.11" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.29", "88.45" ]	icd9pcs	[ [ [] ] ]	5025, 5031	2853, 3821	308, 396	5152, 5214	1869, 2830	5610, 5969	1601, 1627		4221, 5002		5052, 5131		3847, 4198			5238, 5587									1642, 1642															1656, 1850						242, 270							424, 999																	1021, 1504	1520, 1585

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