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63,771	118,227	41375	Discharge summary	report	Admission Date: [2151-3-18] Discharge Date: [2151-4-1] Date of Birth: [2076-11-21] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2151-3-22] 1. Aortic valve replacement with a 27-mm [Company 1543] Ultra aortic valve bioprosthesis, serial number [Serial Number 90067]. 2. Aortic annulus enlargement with a bovine pericardial patch lot number [Telephone/Fax (5) 90068], reference number [Serial Number 89688]. 3. Limited concomitant Maze procedure with pulmonary vein isolation only using the AtriCure Synergy system and resection of left atrial appendage History of Present Illness: This 74 year old male has a history of aortic stenosis and atrial fibrillation, and he has been followed by his cardiologist. He has been having occasional chest pain twinges which last for a few seconds and are non exertional. He decided to proceed with an aortic valve replacement and underwent cardiac cath at [Hospital6 3105] today which revealed non obstructive placque of the LAD, dominant LCX, and minor diffuse placque of the RCA. His [Location (un) 109] was 0.4 cm2 and he has 1+AI with a mean gradient of 50mmHg and 2+MR. [Name13 (STitle) ] is now transferred for AVR/MAZE. Past Medical History: Aortic stenosis and Atrial fibrillation s/p Aortic valve replacement and MAZE procedure Past medical history: Hypertension Hyperlipidemia Hypothyroidism Mitral regurgitation s/p appy s/p IHR s/p hemorrhoid surgery Social History: Race: Caucasian Last Dental Exam: few years ago Lives with: wife Occupation: retired machine operator Tobacco: none-quit 40 yrs ago ETOH: 2 glasses wine/day Family History: Father died MI, mother CA Physical Exam: T 98.6 Pulse:87 Resp:18 O2 sat: 97%-RA B/P Right: 110/60 Left: Height: 68 in Weight: 146 lbs General:NAD lying in bed Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no JVD Chest: Lungs clear bilaterally [x] no rales/rhonchi Heart: RRR [] Irregular [x] Murmur 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact, nonfocal exam Pulses: Femoral Right:cath Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit- none Pertinent Results: [2151-3-19] Carotid U/S: Right ICA no stenosis. Left ICA no stenosis. [2151-3-22] Echo: Moderate to severe spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the ascending aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([12-13]+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([12-13]+) mitral regurgitation is seen. Post Bypass: The patient is now s/p a [Company 1543] 27 bioprosthetic porcine valve replacement. The patient is on a neosynephrine drip at 1mcg/kg/min. The Cardiac index is 2.1. There is now a well seated bioprosthetic aortic valve with no paravalvular leaks and a mean gradient of 4mmhg. The LV function is preserved and is similar to prebypass. The aorta is intact post decannulation. [2151-4-1] 04:35AM BLOOD WBC-9.8 RBC-3.01* Hgb-9.6* Hct-28.1* MCV-94 MCH-31.8 MCHC-34.0 RDW-14.4 Plt Ct-373 [2151-3-30] 04:50AM BLOOD WBC-10.4 RBC-2.99* Hgb-9.8* Hct-28.0* MCV-94 MCH-32.7* MCHC-34.8 RDW-14.3 Plt Ct-303 [2151-4-1] 04:35AM BLOOD PT-23.8* INR(PT)-2.2* [2151-3-31] 04:45AM BLOOD PT-22.7* INR(PT)-2.1* [2151-3-30] 04:50AM BLOOD PT-21.1* INR(PT)-1.9* [2151-3-29] 01:52AM BLOOD PT-18.2* PTT-22.7 INR(PT)-1.6* [2151-3-28] 01:48AM BLOOD PT-15.6* PTT-26.4 INR(PT)-1.4* [2151-3-27] 03:28AM BLOOD PT-14.4* PTT-24.5 INR(PT)-1.2* [2151-3-26] 12:53AM BLOOD PT-13.7* PTT-25.1 INR(PT)-1.2* [2151-3-25] 12:22AM BLOOD PT-14.1* PTT-28.6 INR(PT)-1.2* [2151-3-24] 02:33AM BLOOD PT-15.0* PTT-31.2 INR(PT)-1.3* [2151-3-23] 07:13PM BLOOD PT-15.8* PTT-32.0 INR(PT)-1.4* [2151-3-22] 12:22PM BLOOD PT-15.9* PTT-37.0* INR(PT)-1.4* [2151-3-22] 11:11AM BLOOD PT-16.4* PTT-39.7* INR(PT)-1.4* [2151-3-21] 10:53AM BLOOD PT-14.7* PTT-24.4 INR(PT)-1.3* [2151-4-1] 04:35AM BLOOD Glucose-101* UreaN-26* Creat-0.7 Na-139 K-4.2 Cl-107 HCO3-24 AnGap-12 [2151-3-30] 04:50AM BLOOD Glucose-100 UreaN-34* Creat-0.8 Na-136 K-3.9 Cl-101 HCO3-25 AnGap-14 [2151-3-29] 01:52AM BLOOD Glucose-96 UreaN-25* Creat-0.8 Na-136 K-4.0 Cl-103 HCO3-23 AnGap-14 Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 7280] was transferred from outside hospital to [Hospital1 18] for surgical management. Upon admission he underwent surgical work-up while receiving medical management (including Heparin bridge for atrial fibrillation). Work-up included dental clearance. On [2151-3-22] he was ready for surgery and was brought to the operating room where he underwent an aortic valve replacement and MAZE procedure including LAA ligation. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring. POD 1 found the patient extubated, alert and oriented. Lasix drip was initiated for pulmonary edema resulting in hypoxia. This resolved and he was transitioned to PO Lasix. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support by POD 3. Beta blocker was initiated as well as amiodarone and coumadin for chronic atrial fibrillation. Diamox was given for contraction alkalosis. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. He was evaluated by thoracic surgery (Dr. [Last Name (STitle) ] for a pulmonary nodule. He will follow up in clinic as an outpatient. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 10 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Amiodorone 200 mg PO daily Amoxicillin with dental procedures Coumadin 2 mg PO daily Lovastatin 40 mg PO daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take Titrate for goal INR between 2.0 - 2.5. Disp:60 Tablet(s) Refills:1 5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:1 month supply Refills:2 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. potassium chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). Disp:30 Packet(s) Refills:2 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Outpatient Lab Work Labs: PT/INR for atrial fibrillation Goal INR 2.0 - 2.5 First draw [2151-4-2] Results to phone [Telephone/Fax (1) 17355], Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] fax: [Telephone/Fax (1) 90069] Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Aortic stenosis and Atrial fibrillation s/p Aortic valve replacement and MAZE procedure Past medical history: Hypertension Hyperlipidemia Hypothyroidism Mitral regurgitation s/p appy s/p IHR s/p hemorrhoid surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Surgeon: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914] [Telephone/Fax (1) 170] Date/Time: [2151-4-13] 2:45 Cardiologist: Dr. [Last Name (STitle) ] [4-26] at 9:00am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] [Telephone/Fax (1) 17355] in [3-16] 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 atrial fibrillation Goal INR 2.0 - 2.5 First draw [2151-4-2] Results to phone [Telephone/Fax (1) 17355], Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] fax: [Telephone/Fax (1) 90069] Completed by:[2151-4-1]	[ "401.9", "793.1", "276.3", "244.9", "458.29", "496", "515", "276.69", "520.6", "396.2", "783.21", "427.31", "287.5", "514", "998.12", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "39.61", "37.33", "35.21", "35.33" ]	icd9pcs	[ [ [] ] ]	8153, 8228	4988, 6651	288, 734	8486, 8652	2516, 4965	9575, 10352	1792, 1819		6812, 8130		8249, 8338		6677, 6789			8676, 9552									1834, 2497																							238, 250						762, 1363															8360, 8465	1618, 1776
51,135	197,524	39306	Discharge summary	report	Admission Date: [2134-9-4] Discharge Date: [2134-9-24] Service: MEDICINE Allergies: Tylenol / Ibuprofen / Percodan / Capsaicin/Peppermint Oil/Anise Attending:[First Name3 (LF) 896] Chief Complaint: Bile duct obstruction Major Surgical or Invasive Procedure: ERCP History of Present Illness: Mrs. [Known lastname ] is a [Age over 90 ] yo F with history of CAD, dCHF EF 60%, AF on coumadin, CKD, COPD and HTN who is being transfered to [Hospital1 18] for ERCP. Patient was in her usual state of health until yesterday when she began feeling unwell, was having chills, abdominal pain and nausea, and decided to go to [Hospital3 10310] Hospital. At AGH a RUQ U/S revealed intrahepatic biliary duct dilation and CT abd/pel revealed an obstructing mass in the head of the pancreas. On admission she was found to have AST 569, ALT 255 and normal WBC. On HD 2 this increased to 27 and 4/4 bottles of blood cultures became positive for GNR's. She had been started on Unasyn on admission but this was changed to Zosyn after the cultured came back (+) and she was transfered to [Hospital1 18] for ERCP. On the floor, patient is feeling better after. Review of systems: (+) Per HPI. Low appetite since feburary, loss appetite and weightloss, [Location (un) ] L>R, back adn L hip pain. (-) Denies cough, shortness of breath. Denies chest pain, chest pressure, palpitations. Denies dirrhea, changes in bowel habits. Past Medical History: 1. Coronary artery disease 2. Congestive heart failure, diastolic (EF 60%) 3. Atrial fibrillation 4. Chronic kidney disease 5. Left hip arthrititis 6. Hypertension 7. COPD 8. Shingles Social History: Lives by herself and does ADL's without problem. - Tobacco: ~100 pk/yr history, quit at 45 yo - Alcohol: Denies - Illicits: Denies Family History: Father: [Name (NI) 3495] disease Mother: CVA Physical Exam: Vitals: T: 96.7 BP: 114/55 HR: 85 R: 23 O2: 93% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI Neck: supple, JVP not elevated, no LAD Lungs: Crackles ~[1-17] way up CV: Irregularly irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, TTP throughout (mostly epigastric and RUQ), non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, 2+ edema up to knees L>R On discharge: Decreased breath sounds at left base Assymetric lower extremity edema (left > right) Pertinent Results: Discharge Labs: WBC-8.6 RBC-4.18* Hgb-11.4* Hct-35.8* MCV-86 MCH-27.2 MCHC-31.8 RDW-16.2* Plt Ct-653* PT-16.1* INR(PT)-1.4* Glucose-92 UreaN-14 Creat-1.1 Na-135 K-3.8 Cl-92* HCO3-35* AnGap-12 ALT-73* AST-35 LD(LDH)-202 AlkPhos-537* TotBili-1.4 Peak LFT values ([2134-9-18]): ALT-223* AST-418* AlkPhos-943* TotBili-3.3* Please creatinine ([2134-9-15]): 1.7 ERCP ([2134-9-6]): Surgical clips are noted in the gallbladder fossa. Dilated common bile duct with evidence of either distal narrowing or extrinsic compression. Biliary stent was placed. Minimal opacification of the remainder of the biliary tree was performed given concern for cholangitis. ERCP ([2134-9-17]): A plastic stent previously placed in the biliary duct was found in the major papilla. A small sphincterotomy was performed in the 12 o'clock position using a needle-knife over previously placed plastic biliary stent. The plastic stent was then removed with a snare and sent for cytology. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. A single stricture that was approximately 1cm long was seen contained in the intra-ampullary portion of the CBD. Two round stones ranging in size from 5 mm to 6 mm were seen at the biliary tree. An extension sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. The two stones and some sludge were extracted successfully using a balloon catheter. Excellent drainage of bile and contrast was noted. Extensive cold forceps biopsies were performed of the ampulla for histology. It is possible that the stricture may be due to inflammation and scarring related to stone passage, however, this will not explain the mass seen on CT scan. Since the intra-ampullary stenosis was completely opened with the sphincterotomy with excellent drainage, there was no need to place another stent. Brief Hospital Course: 1. E. COLI SEPSIS: Pansensitive E coli, cultures grown from outside hospital. The patient was on antibiotics but had low grade temperatures even following initial ERCP with plastic stent placement in an area of stenosis related to a pancreatic head mass. She underwent a second ERCP on [9-17] which revealed new gallstones in the common bile duct. She underwent a sphincterotomy which relived this obstruction. Following this procedure her LFTs increased and slowly trended downward. A course of ciprofloxacin was completed. 2. PANCREATIC MASS: Initial brushings with atypical cells. Repeat brushings and biopsy from [9-17] showed inflammation but no evidence of malignancy. Given that the patient and family would likely not pursue any further work-up should this be a cancer, further evaluation (e.g. CT abdomen) was deferred. 3. CHRONIC DIASTOLIC CHF: Given sepsis lasix and lisinopril initially were held. Following reintroduction of these medications at her home doses she became hypotensive to an SBP of 80 and had acute renal failure with a Cr of 1.7. She was treated with IVF. Eventually after holding diuretics and with 2 units of FFP on [9-17] she became dyspneic and had pulmonary edema, she was given 40mg IV lasix on [9-19] and transitioned to her home dose of lasix 40mg po daily on [9-20]. Her lisinopril was not reintroduced given hypotension. She also experienced morning dyspnea on [9-22] and [9-23] for which QHS MS Contin was introduced; this decreased the symptomatic dyspnea. 4. Atrial fibrillation: Patient with AF on coumadin. INR 2.2 on admission, coumadin held for ERCP and restarted post ERCP. At discharge, INR was 1.4. 5. LOWER EXTREMITY JOINT PAINS: likely secondary to osteoarthritis, worsened secondary to immobility as well as to infection / fevers. This improved with physical therapy and with treatment of infection but the patient will require further physical therapy upon discharge to improve mobility to the point at which she can become independent again. Gabapentin, lidocaine patch and tramadol were started (allergy to tylenol and ibuprofen) with improvement in her symptoms, in addition she had low dose morphine for breakthrough pain. Medications on Admission: Atenolol 50 mg qam, 25 mg qpm Diltiazem CD 180 mg daily Lasix 40 mg daily Colace 100 mg [Hospital1 ] KCl 10 mEq daily Spiriva IH daily Coumadin 1 mg SMWTF, 1 mg TS Lisinopril 10 mg daily Gabapentin 200 mg qhs Oxycodone prn Miralax Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for Shoulder pain. 3. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 4. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 5. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 8. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q6H (every 6 hours) as needed for pain. Disp:1 bottle Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 10. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 14. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal [Hospital1 ] PRN () as needed for anal itch. 15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 19. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID PRN () as needed for pain. 20. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). Disp:30 Tablet Sustained Release(s) Refills:0 Discharge Disposition: Extended Care Facility: LIFECARE Center of [Location (un) 3320] Discharge Diagnosis: Pancreatic mass with biliary obstruction E Coli Sepsis Congestive heart failure, diastolic Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with an infection of your blood stream and an obstruction of your biliary tract. You also experienced congestive heart failure during your hospitalization. Followup Instructions: Please be sure to follow-up with Dr. [Last Name (STitle) 86927] within 2-3 weeks after discharge.	[ "V58.61", "414.01", "574.51", "403.90", "576.1", "428.33", "427.31", "584.9", "333.94", "585.3", "496", "428.0", "577.9", "038.42" ]	icd9cm	[ [ [] ] ]	[ "51.87", "51.14", "51.88", "97.55", "51.85" ]	icd9pcs	[ [ [] ] ]	9097, 9167	4487, 6716	291, 297	9302, 9302	2542, 2542	9685, 9790	1837, 1887		7001, 9074		9188, 9281		6742, 6978			9485, 9662				2558, 4464					1902, 2422														2436, 2523				1215, 1466					230, 253						325, 1196									9317, 9461						1488, 1673	1689, 1821
4,588	153,755	43981	Discharge summary	report	Admission Date: [2114-5-29] Discharge Date: [2114-6-1] Date of Birth: [2073-1-19] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 1936] Chief Complaint: hyperglycemia, cough Major Surgical or Invasive Procedure: None History of Present Illness: See detailed NF H&P. In summary, Mr. [Known lastname 12226] is a 41 yo M with a history of alpha 1 antitrypsin deficiency, COPD (> 5 exacerbations over past year), and DMII p/w malaise fatigue, polyuria, polydypsia, lightheadedness, poorly controlled hyperglycemia, cough, change in sputum character. . Of note, pt has had fasting BGs of > 400 x ~ 2wks. He was recently d/ced from [Hospital1 18] for COPD in [3-12] on 30U Lantus and his SS. Was also recently started by his endocrinologist on 5mg Prednisone for ? adrenal suppression having been essentially on chronic steroids for COPD exacerbations. His Insulin was changed by [Last Name (un) ] to 15U [Hospital1 ] of lantus and SS, this however did not improve BG control. . His respiratory sx have been active over 5 days PTA. Also has L sided CP w/ inspiration and movement. He has been treated w/ Levofloxacin/Azithro over the past 4 admissions. Has had Klebsiella, E.Coli and MRSA in his sputum. In addition to above, c/o of myalgias, generalized malaise bu no fevers. In addition to [Hospital1 18], was recently hospitalalized at OSH for COPD exacerbation. No PFTs in system, but last CT suggestive of far advanced disease. . He was asked by covering physician to call EMS and come to hospital. In the emergency department, initial vitals: Temp 96.7 HR 120 BP 115/81 RR 20 Pox 100, pt was given empiric Azythro 500, Albuterol/Ipratropium nebulizer, and 125 IV Solumedrole. Aspirin and Zofran was given as well. he was given 10 units s.c humalog and 10 units iv regular insulin for persistent FS>500. He was given 500ccNS in ED Past Medical History: 1. Chronic Pain- jaw, knees and back, metal plate in jaw after struck with crowbar, baseball bat to knee caps. 2. Alpha 1 antitrypsin disease, diagnosed in [2104]. - complicated by COPD and cirrhosis - follows at [Hospital1 112] with Dr. [First Name8 (NamePattern2) 12395] [Last Name (NamePattern1) 6174] for enzyme treatments 3. Substance Abuse History of alcohol, IVDU including cocaine, and tobacco use. 4. COPD - on 4L home O2 5. Diabetes dx [2091] on insulin since 6. Hypothyroidism dx [2087] 7. Panic Attacks 8. Depression 9. GERD 10. Hepatitis C never treated 11. Bronchiectasis Social History: EtOH: reports abstinence for several years, previously used to drink primarily beer Drugs: h/o IVDU including cocaine. Last used cocaine IV 6 days prior to admission Tobacco: quit. ~ 25 PPY smoking history. Currently disabled, previously moved furniture. Family History: Father: died of throat/mouth cancer (46 yo) Grandfather/Uncle: [Name (NI) 3730] Physical Exam: VS: 96.9 BP 95/62 HR 90 RR 18-22 96 4L GENERAL: NAD with pain on movement NECK: supple, no JVD, no cervical, supraclavicular or axillary lymphadenopathy HEENT: No scleral icterus. Pupils equal and round. EOMI. OP clear. MMM. Right temple tender to palpation [2-5] metal plate. CARDIAC: RRR. Nl S1, S2. No m/r/g. Reproducible CP in L [6-11] ribs, laterally. LUNGS: poor air movement no crackles, no wheezes ABDOMEN: +BS. Soft, NT, ND. No HSM EXTREMITIES: No c/c/e, 1+ dorsalis pedis/ posterior tibial pulses. NEURO: a/ox3, CN 2-12 grossly intact, neuropathy on right LE up to mid-shin (impaired touch and position), impaired finger to nose, intact rapid alternating movements, 5/5 strength throughout. Pertinent Results: Labs: . [2114-5-29] 08:30PM BLOOD WBC-7.1 RBC-4.71 Hgb-14.2 Hct-40.9 MCV-87 MCH-30.2 MCHC-34.7 RDW-13.8 Plt Ct-203 [2114-6-1] 08:00AM BLOOD WBC-6.4 RBC-4.53* Hgb-13.7* Hct-39.3* MCV-87 MCH-30.3 MCHC-34.9 RDW-14.3 Plt Ct-196 . [2114-5-29] 08:30PM BLOOD Neuts-44.2* Lymphs-48.8* Monos-3.7 Eos-2.6 Baso-0.7 [2114-5-29] 08:30PM BLOOD PT-14.1* PTT-33.1 INR(PT)-1.2* . [2114-5-29] 08:30PM BLOOD Glucose-482* UreaN-16 Creat-1.0 Na-127* K-4.6 Cl-89* HCO3-25 AnGap-18 [2114-6-1] 08:00AM BLOOD Glucose-129* UreaN-7 Creat-0.8 Na-140 K-3.8 Cl-98 HCO3-32 AnGap-14 . [2114-5-30] 04:35AM BLOOD ALT-93* AST-34 LD(LDH)-149 CK(CPK)-122 AlkPhos-105 TotBili-0.4 [2114-5-29] 08:30PM BLOOD CK(CPK)-240* [2114-5-30] 04:35AM BLOOD Lipase-8 [2114-5-30] 04:35AM BLOOD CK-MB-5 cTropnT-<0.01 [2114-5-29] 08:30PM BLOOD cTropnT-0.02* [2114-6-1] 08:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.5* [2114-5-31] 03:29AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.7. . [2114-5-30] 04:35AM BLOOD %HbA1c-10.9* [2114-5-30] 04:35AM BLOOD TSH-0.91 [2114-5-29] 08:39PM BLOOD Lactate-1.0 . Urine Cultures: . [2114-5-30] 09:07AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.021 [2114-5-30] 09:07AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2114-5-30] 09:07AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS mthdone-POS . Microbiology: . Rapid Respiratory Viral Antigen Test (Final [2114-5-31]): Respiratory viral antigens not detected. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. Refer to respiratory viral culture for further information. . Imaging: . CXR on admission: IMPRESSION: Interval improvement in previously noted right middle lobe and lingular opacities. No new consolidation or evidence of pulmonary edema. Brief Hospital Course: A/P: 41 yo man w/ COPD, DM, Polysubstance abuse, here w/ COPD exacerbation and poorly controled glucose. . #Diabetes: patient has a history of fragile diabetes, poor control and a sensitivity to glucocorticoids. On admission he was hypovolemic [2-5] hyperglycemia osmotic diuresis. He is followed by the [Last Name (un) ] and they are seeing him in the hospital. His current HgA1C=10.9. A urine tox screen was positive for cocaine. See substance abuse below. Cocaine and prednisone caused the extreme disturbance in his glucose control. His steroid course was quickly tapperd in order to improve his glucose control. However, before discharge his blood sugar was 129 and he was sent home on NPH 20 [Hospital1 ] and HISS plus his sliding scale. He was instructed to keep close monitoring of his sugars for the next week and to attend his follow up [Hospital1 4314] next week. He was instructed to call [Last Name (un) ] for assistance if needed. . #COPD exacerbation: Patient has extensive COPD secondary to alpha 1 antitrypsin deficiency and presented with shortness of breath and a flare of his COPD. No new oxygen requirment. He has been hospitalized 5 in last 9mo for exacerbations, responds to levofloxacin/azithro . The CXR was not consistent with infection however he has a history of multiple PNA admissions, likely has bronchitis vs. a viral etiology (influenza). Ruled out influenza A/B, adeno, parainfluenza and RSV on rapid screen. Unclear whether this is natural hx or there is an underlying reason for frequent exacerbations (? crack use or other illicit use, as cocaine positive). He was treated with a seven day course of levofloxacin 750mg PO daily. Fluticasone propionate and fluticasone-salmeterol were continued. Standing ipratropium Q6H and Xopenex Q6H nebs were given. His course of prednisone was tapered down from 40mg to 5mg (D/C on 20mg). He will stay on 5mg until his adrenal function can be assessed in the outpatient setting. . #Substance Abuse: Patient presented with blood glucose levels in the 400s that were not responsive to insulin. This was found to be [2-5] cocaine use as evident by UA. After confrontation patient admitted x1 use 6 days prior to admission. He was educated about the side effects and dangers of not reporting substance use when being treated in the hospital. . #Alpha 1 antitrypsin deficiency: has complications of COPD and cirrhosis. During his stay his ALT was elevate to 93 from baseline of 30; AST, Tbili and INR were normal during his stay. He is followed at [Hospital1 112] and receives weekly aralast infusions on Thursday. . #Psych: anxiety and depression. Currently stable, followed by Dr. [Last Name (STitle) ]. Maintained with risperidone and amitriptyline . #Hypothyroidism: TSH=0.91. Continue levothyroxine . #Chronic Pain: Currently on methadone and oxycodone, amitriptyline, and Neurontin. Currently well controlled on the above regimen. . #GERD: no symptoms during stay, continue omeprazole. Medications on Admission: MEDICATIONS per OMR and confirmed with patient: 1. Docusate Sodium 100 mgPO [Hospital1 ] 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [Hospital1 ] 3. Methadone 20 mg Tablet PO TID 4. Calcium Carbonate 500 mg Tablet PO TID (not to be take at the same time as levothyroxine) 5. Senna 8.6 mg Tablet PO BID 6. Cholecalciferol (Vitamin D3) 800 unit Tablet PO DAILY 7. Risperidone 2.5 mg Tablet PO HS (at bedtime) as needed for insomnia/anxiety 8. Citalopram 20 mg Tablet PO DAILY - this has been discontinued. 9. Risperidone 2 mg Tablet PO BID as needed for anxiety 10. Levothyroxine 200 mcg Tablet PO DAILY 11. Omeprazole 40 mg Capsule PO BID 12. Methadone 40 mg Tablet PO HS (at bedtime) 13. Amitriptyline 50 mg PO HS 14. Gabapentin 400 mg PO Q8H 15. Fluticasone 50 mcg/Actuation Spray, 2 Spray Nasal DAILY 16. Pravastatin 10 mg Tablet PO DAILY 17. Oxycodone 15 mg Tablet PO BID 18. Methylphenidate 20 mg Tablet Sustained Release PO QAM 19. Atrovent HFA 17 mcg/Actuation Inhalation every 6 hours as needed 20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol [1-5] Inhalation every 4-6 hours as needed 21. Terbinafine 1 % Cream Topical [Hospital1 ] 22. Lantus 13 units [Hospital1 ] 23. Humalog ss; 3U w/ each meal and 1U of Humalog for every 80U above BG > 120. 24. Aralast 500 mg Suspension for Reconstitution Sig: One (1) Intravenous once a week: continue as before with home therapy. 26. oxygen, home oxygen therapy as before admisison, 4 liters 27. Prednisone 5mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Disp:2 container Refills:2 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 1 days: take on [2114-6-2]. Disp:1 Tablet(s) Refills:0 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:2 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation four times a day as needed for shortness of breath or wheezing. Disp:360 ml Refills:2 8. Nebulizer Kit Sig: One (1) kit Miscellaneous once a day. Disp:1 kit Refills:2 9. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Methadone 10 mg Tablet Sig: Four (4) Tablet PO QHS (once a day (at bedtime)). 11. Oxycodone 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for pain. 12. Amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 13. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 14. Methylphenidate 20 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 15. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Risperidone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 17. Risperidone 1 mg Tablet Sig: 2.5 Tablets PO at bedtime. 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 20. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 21. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 22. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. 23. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:2 Tablet(s) Refills:0 24. Aralast 500 mg Suspension for Reconstitution Sig: One (1) Intravenous QTHURSDAY (). 25. Lantus 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous twice a day: start [2114-6-3]. 26. Lantus 100 unit/mL Solution Sig: Seventeen (17) units Subcutaneous twice a day for 1 days: take on [2114-6-2]. 27. Humalog 100 unit/mL Solution Sig: See sliding scale see sliding scale Subcutaneous see sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary: Hyperglycemia, poorly controlled; COPD exacerbation Secondary: Chronic Obstructive Pulmonary Disease/Alpha 1 antitrypsin defficiency, Diabetes Discharge Condition: Hemodynamically stable, improved glucose control, at baseline oxygen requirement. Discharge Instructions: You were admitted with fatigue, high blood glucose, cough and chills. You had poor control of you blood sugar due to use of cocaine and prednisone. You required a temporary treatment in the intensive care unit. We have adjusted you insulin dosing and your blood sugar control improved. You were also diagnosed with a COPD exacerbation. For this you were treated with steroids and inhalers. With this treatment, your symptoms improved and your oxygen level returned to [Location 213]. The following changes were made to you medications: - Prednisone taper was adjusted (see below) - You should restart Prednisone 5mg daily - Levofloxacin - Started Tiotropium inhaler You were discharged with improved breathing and blood sugar control. Should you develop chest pain, worsening shortness of breath, fevers, chills, nausea, vomiting, or any other symptom concerning to you, please call you primary care provider or go to the emergency room. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 36070], [Name12 (NameIs) 1046] Phone:[Telephone/Fax (1) 250] Date/Time:[2114-6-4] 12:00 Provider: [First Name11 (Name Pattern1) 2671] [Last Name (NamePattern4) 44538], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2114-6-12] 2:00 Provider: [Name10 (NameIs) 306] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 1387] Date/Time:[2114-6-12] 3:00 Completed by:[2114-6-2]	[ "305.60", "244.9", "491.21", "E932.0", "300.01", "338.21", "584.9", "276.1", "273.4", "530.81", "311", "276.2", "250.93", "V12.04", "070.70" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12916, 12922	5586, 8602	289, 296	13118, 13202	3689, 5400	14201, 14685	2858, 2944		10155, 12893		12943, 13097		8628, 10132			13226, 14178									2959, 3670																							229, 251						324, 1935								5414, 5563							1957, 2570	2586, 2842
16,200	124,381	48656	Discharge summary	report	Admission Date: [2114-9-28] Discharge Date: [2114-10-1] Service: MEDICINE Allergies: Lasix Attending:[First Name3 (LF) 99] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: (history obtained from daughter and chart) Ms. [Known lastname 32729] is a [Age over 90 ] year old female with COPD, restrictive lung disease [3-2] kyphoscoliosis, OSA, and diastolic CHF,(EF>55%), Afib on coumadin, multiple hospital admissions, most recently [2114-9-11] for diarrhea and LLE cellulitis, who was admitted from [Hospital1 ] with hypoxia and chest pain. Patient's diet was today advanced from liquids to ground consistency. It was then noted that her O2 saturation dropped from the baseline 90s to low 80s on 3L NC. Around 3pm she was noted to be more sleepy with low UOP (~50cc in AM shift). She was started on BiPAP and became more responsive. At the same time she also complained of some chest pain/pressure that per daughter already had improved before she was given nitro SL. She was also given solumedrol 125 IV and clorothiazide for low UOP. In terms of abx, patient was on CTX and azithro (unclear why azithro) but azithro was d/c'd today and patient was started on levo/flagyl for suspicion of aspiration PNA. A VBG at 8pm off BiPAP was 7.38/59/46. She had a (+) U/A with klebsiella and E.Coli from [9-12] and [9-14] and was being treated with abx for that in [Hospital1 ]. She was transferred to [Hospital1 18] ED for further management. . In the ED, VS 98.4, 73, 140/54, 16, 96% NRB. patient did not have any CP. Troponin 0.06, ASA was given and levofloxacin for (+) U/A. O2 Sats leveled off around 90% on 2L NS. . At baseline, she is a Co2 retainer with PaCo2 between 50-60, and baseline bicarb chronically between 35 and 40. She chronically lives with O2 sat at 88%. She also chronically complains of being SOB. . ROS: unable to obtain Past Medical History: 1. Restrictive lung dz [3-2] kyphoscoliosis (FEV1/FVC 113%pred) 2. COPD w/ CO2 retention (FEV1 0.86, bicarb approx 35, CO2 55) 3. Diastolic dysfunction EF > 55% 4. Paroxysmal atrial fibrillation 5. OSA: intolerant of BiPAP in past, uses nocturnal O2 0.5 L NC 6. HTN 7. spinal stenosis 8. Grave's disease: s/p ablation, now on Synthroid 9. TAH [3-2] fibroids 10. ASD, secundum type noted in [2108] 11. Hx of lacunar infarct 12. L eye CVA: residual visual field defect, [2101], on coumadin 13. L cataract surgery [21]. Right breast CA s/p radiation on [2084] Social History: Widow, 2 kids, lives w/ daughter, +tob 100 pk yr Family History: +ca, cva, 3 siblings. Physical Exam: VS 96.6, 135/46, 70, 22, 93% 2L NC and HighFlow Mask 10L FiO2 0.35 Gen sleepy but arousable, labored breathing HEENT dry MM, JV distended, mask on Chest: crackles b/l, wheezing throughout, poor air movement CV: irreg, no r/m/g Abd obese, S/ND, +BS Ext 3+ edema b/l Neuro easily arousable but sleepy Skin: dry, scaly Pertinent Results: CXR Large bilateral pleural effusions with associated atelectasis essentially unchanged from the prior examination. Basilar consolidation cannot be entirely excluded, although no acute interval change is apparent. . [2114-9-27] 10:55PM URINE RBC-[12-18]* WBC-21-50* BACTERIA-FEW YEAST-MOD EPI-0-2 [2114-9-27] 10:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2114-9-27] 10:55PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.015 [2114-9-27] 10:10PM GLUCOSE-130* UREA N-71* CREAT-2.0* SODIUM-140 POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-36* ANION GAP-12 [2114-9-27] 10:10PM WBC-11.8* RBC-3.11* HGB-9.0# HCT-29.2# MCV-94 MCH-28.9 MCHC-30.9* RDW-19.2* [2114-9-27] 10:10PM cTropnT-0.06* proBNP-9759* [2114-9-27] 10:10PM PT-20.8* PTT-27.9 INR(PT)-2.0* Brief Hospital Course: Patient was admitted for hypoxia and altered mental status in setting of multifactorial progressive underlying cardiovascular disease (COPD, restrictive disease due to kyphoskoliosis, OSA, CHF). Her condition continually worsened over her hospital course such that even on BiPAP patient would be hypercarbic. She became progressively agitated and confused. Given the very poor prognosis in terms of etiology for her respiratory status, her daughter agreed on [2114-9-30] to change the goals of care to 'comfort measures only'. Patient passed on [2114-10-1] at 2:30 AM. Daughter and attending were informed. Daughter declined post-mortem exam. Medications on Admission: Ethacrynic Acid 100 mg PO DAILY Chlorothiazide 250 mg PO DAILY Acetaminophen 650 mg PO Q6H:PRN Warfarin 2 mg PO QHS Senna 2 TAB PO BID Multivitamins 1 CAP PO DAILY Miconazole Powder 2% 1 Appl TP TID Ipratropium Bromide Neb 1 NEB IH Q6H Fluticasone-Salmeterol (250/50) 1 INH IH [Hospital1 ] Ferrous Sulfate 325 mg PO DAILY Docusate Sodium 100 mg PO BID Amiodarone 100 mg PO DAILY Levothyroxine Sodium 112 mcg PO DAILY CeftriaXONE 1 gm IV Q24H Discharge Disposition: Expired Discharge Diagnosis: cardiac arrest respiratory failure Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2114-10-1]	[ "427.31", "428.0", "403.90", "599.0", "244.1", "V10.3", "507.0", "745.5", "585.9", "428.32", "737.30", "327.23", "518.83", "V58.61", "496", "584.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5059, 5068	3910, 4562	219, 225	5147, 5153	3018, 3887	5205, 5240	2643, 2666				5089, 5126		4588, 5036			5177, 5182									2681, 2999																							172, 181						253, 1955															1977, 2560	2576, 2627
17,795	179,589	52772	Discharge summary	report	Admission Date: [2200-11-27] Discharge Date: [2201-2-10] Date of Birth: [2142-2-13] Sex: M Service: MEDICINE Allergies: Dofetilide / Lipitor / Haldol / Reglan Attending:[First Name3 (LF) 759] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: multiple ET intubation during 3 MICU admissions (now extubated) right IJ [2200-12-10] (removed) right PICC line placement [2201-1-5] (removed) NGT placement [2201-1-7] (removed) left PICC line placement [2201-1-27] (still in place) NGT placement [2201-1-30] (removed) 2 units of pRBC transfusion ([2201-1-31] and [2200-12-24]) 1 unit of plate transfusion ([2201-1-30]) History of Present Illness: The patient is a 58 year old male with severe cardiomyopathy (EF ~20%) who was seen in ED in [Month (only) ] and treated for a pneumonia. He now presents with progressive symptoms including sinus pain, cough, rhinorrhea, headache and mild shortness of breath. He describes his cough as productive of pink sputum. He denies any lower extremity edema. The patient first presented to the ED on [2200-11-5] and was evaluated in the emergency department and found to have a RML pneumonia. He was discharged with a Z-pack but this was later changed to levofloxacin given concern for a possible interaction with amiodarone. He completed a 7 day course of levofloxacin with great improvement in his symptoms. Approximately six days prior to this presentation, he began to have recurrence of his symptoms. He took three days of amoxicillin 500 mg, which he had left over from a previous dental procedure. This has made him feel somewhat better. On [11-24], he presented to his PCP. [Name10 (NameIs) ] that time a repeat CXR showed "probable partial resolution of a right-sided pneumonia." His symptoms continued to worsen over the next three days and his PCP ultimately advised him to come to the emergency department. . In the ED, vital signs were T 100.5, HR 69, BP 98/66, RR 20, O2 sat 97%. He received 500 mg levofloxacin and was admitted to the floor. Past Medical History: 1. Dilated cardiomyopathy of unclear etiology (EF=20 percent) 2. 3+ MR (s/p repair [8-29] at [Hospital1 112]) 3. AF (s/p maze procedure [8-29], AV paced, on coumadin and amiodarone) 4. COPD: PFT [5-30](FVC=2.86, FEV1=2.28, MMF=2.09, FEV1/FVC=80) 5. Hypercholesterolemia 6. AICD with pacer placement in [12-28] following an episode of NSVT 7. Polymorphic ventricular tachycardia [2-27] dofetilide therapy 8. CAD s/p IMI in [2189] LAD stent in [12-28] (patent on cath [8-29]), s/p SVG to OM1 9. Depression/anxiety Social History: He has a 20pk/yr smoking history but quit over 10yr ago. Denies any intravenous drug use or alcohol use. Lives in [Hospital1 392] w/ his girlfriend and has a 11yr old son who does not live with him. Does not work but used to work for a security company and a catering company. Family History: Noncontributory Physical Exam: VS - T 100.5, BP 106/69, HR 69, RR 20, O2 sat 93% on RA GEN - well appearing male, lying in bed in NAD, occastionally coughing HEENT - no LAD, sclera anicteric, no conjunctival palor CV - rrr, III-IV/VI systolic murmur, best heard at apex with radiation to axilla PULM - crackles at left base and right middle areas; good inspiratory effort ABD - soft, non-tender, non-distended EXT - warm, no edema Pertinent Results: Admission Labs: [2200-11-27] 02:07PM LACTATE-2.2* [2200-11-27] 02:00PM UREA N-13 CREAT-1.1 SODIUM-138 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 [2200-11-27] 02:00PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-2.0 [2200-11-27] 02:00PM WBC-13.0* RBC-4.41* HGB-14.3 HCT-45.4 MCV-103* MCH-32.5* MCHC-31.6 RDW-13.7 [2200-11-27] 02:00PM NEUTS-83.1* LYMPHS-9.5* MONOS-6.3 EOS-0.4 BASOS-0.8 [2200-11-27] 02:00PM PLT COUNT-161 [2200-11-27] 02:00PM PT-21.0* PTT-29.3 INR(PT)-2.0* MICU Admission Labs: [2200-11-30] 01:59PM BLOOD WBC-23.8# RBC-4.24 Hgb-14.4 Hct-44.0 MCV-104* MCH-34.0* MCHC-32.7 RDW-14.1 Plt Ct-147* [2200-11-30] 05:30AM BLOOD Neuts-76* Bands-2 Lymphs-9* Monos-5 Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0 [2200-12-2] 11:50AM BLOOD PT-53.5* PTT-42.9* INR(PT)-6.4* [2200-12-2] 11:50AM BLOOD Fibrino-746* D-Dimer-3362* [2200-11-30] 01:59PM BLOOD Glucose-138* UreaN-44* Creat-2.5* Na-134 K-5.4* Cl-97 HCO3-16* AnGap-26* [2200-11-30] 01:59PM BLOOD ALT-50* AST-110* LD(LDH)-848* CK(CPK)-49 AlkPhos-74 [2200-11-30] 05:30AM BLOOD proBNP-6548* [2200-12-1] 03:17PM BLOOD Cortsol-27.0* [2200-12-1] 05:29PM BLOOD Cortsol-36.9* [2200-12-2] 11:50AM BLOOD ANCA-NEGATIVE B [2200-11-30] 02:09PM BLOOD Lactate-10.9* K-5.3 [2200-11-30] 04:00PM BLOOD O2 Sat-74 . Discharge labs: [2201-2-10] 06:04AM BLOOD WBC-10.0 RBC-2.71* Hgb-9.2* Hct-29.7* MCV-110* MCH-33.9* MCHC-30.8* RDW-21.5* Plt Ct-67* [2201-2-10] 06:04AM BLOOD PT-11.4 PTT-26.5 INR(PT)-1.0 [2201-2-10] 06:04AM BLOOD Glucose-119* UreaN-36* Creat-0.3* Na-143 K-3.8 Cl-112* HCO3-25 AnGap-10 [2201-2-10] 06:04AM BLOOD ALT-75* AST-49* LD(LDH)-546* CK(CPK)-25* AlkPhos-325* TotBili-2.3* [2201-2-10] 06:04AM BLOOD Albumin-1.9* Calcium-7.9* Phos-3.0 Mg-2.1 Other Labs: [2200-12-2] 11:50AM BLOOD ESR-66* [2200-12-24] 03:36AM BLOOD Parst S-NEG [2201-1-3] 04:34AM BLOOD LAP-154* [2200-11-30] 01:59PM BLOOD CK-MB-3 cTropnT-0.05* [2200-11-30] 10:49PM BLOOD CK-MB-5 cTropnT-0.08* [2200-12-1] 04:23AM BLOOD CK-MB-NotDone cTropnT-0.08* [2200-12-22] 03:28PM BLOOD CK-MB-NotDone cTropnT-0.02* [2200-12-23] 02:45AM BLOOD CK-MB-NotDone cTropnT-0.11* [2201-1-24] 09:40PM BLOOD CK-MB-NotDone cTropnT-0.09* [2201-2-6] 02:54PM BLOOD CK-MB-NotDone cTropnT-0.18* [2201-2-7] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.13* [2201-2-7] 07:09AM BLOOD CK-MB-NotDone cTropnT-0.12* [2201-2-9] 06:36AM BLOOD CK-MB-7 cTropnT-0.06* [2201-2-9] 12:08PM BLOOD CK-MB-NotDone cTropnT-0.07* [2201-2-10] 06:04AM BLOOD cTropnT-0.08* [2201-1-20] 03:59AM BLOOD Triglyc-539* [2201-2-8] 08:26AM BLOOD Triglyc-278* HDL-17 CHOL/HD-12.7 LDLcalc-143* [2200-12-22] 03:28PM BLOOD T3-125 Free T4-GREATER TH [2200-12-23] 02:45AM BLOOD T4-22.2* calcTBG-0.31* TUptake-3.23* T4Index-71.7* [2200-12-24] 03:36AM BLOOD T4-20.2* T3-105 Free T4-6.2* [2200-12-25] 03:50AM BLOOD T4-20.8* T3-97 Free T4-7.3* [2200-12-26] 04:20AM BLOOD T4-20.4* T3-93 Free T4-6.1* [2200-12-27] 04:56AM BLOOD T4-18.5* T3-88 [2200-12-28] 02:57AM BLOOD T4-15.7* T3-82 [2200-12-29] 03:23AM BLOOD T4-13.5* T3-74* [2200-12-29] 10:31AM BLOOD T4-16.0* calcTBG-0.53* TUptake-1.89* T4Index-30.2* [2200-12-30] 05:15AM BLOOD T4-15.2* T3-69* [2201-1-6] 05:13AM BLOOD T4-19.3* T3-99 Free T4-6.2* [2201-1-7] 04:15PM BLOOD T4-GREATER TH T3-116 calcTBG-0.31* TUptake-3.23* [2201-1-9] 05:34AM BLOOD T4-24.6* T3-115 calcTBG-0.28* TUptake-3.57* T4Index-87.8* [2201-1-11] 04:30AM BLOOD T4-24.3* T3-113 calcTBG-0.33* TUptake-3.03* T4Index-73.6* [2201-1-13] 05:41AM BLOOD T4-18.4* T3-88 calcTBG-0.48* TUptake-2.08* T4Index-38.3* [2201-1-21] 03:08AM BLOOD T4-11.4 T3-47* calcTBG-0.72* TUptake-1.39* T4Index-15.8* [2201-2-3] 03:29AM BLOOD T4-7.9 T3-45* Free T4-1.7 . Microbiology: [2200-11-28] Urine Legionella - negative [2200-11-29] Blood cultures - NGTD [2200-11-30] Viral antigen panel - negative, cultures pending [2200-11-30] Urine culture - negative [2200-11-30] BAL - 4+ polys, gram stain negative, PCP neg, AFB neg, cultures negative [2200-12-1] Blood cultures, urine cultures - negative [2200-12-3] Blood cultures, urine cultures - negative [2200-12-3] Sputum cultures - 2+ yeast [2200-12-3] Stool - C. diff negative [2200-12-5] Blood, urine cultures - NGTD [2200-12-5] Sputum cultures - yeast [2200-12-7] Blood, urine cultures - NGTD [2200-12-8] Stool - C. diff negative [2200-12-9] Blood, urine cultures - NGTD . Imaging and studies: CXR ([2200-11-27]) Comparison is made with the prior chest x-ray of [11-24]. Since that time, there has been increase in density in the right mid zone. The heart remains enlarged. The costophrenic angles are sharp. These findings suggest [Month (only) 9140] of the right-sided pneumonia which probably lies in the apical segment of the right lower [Month (only) 3630]. . TTE [2200-12-1]: The left atrium is moderately dilated. No definite intracardiac shunt identified. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with severe global hypokinesis and septal dysynchrony. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened with mildly restrained leaflets. The annuloplasty ring is well seated but with increased gradient c/w mild functional mitral stenosis. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [2200-9-11], the severity of mitral regurgitation is lower (may be related to acoustic shadowing). The transmitral gradient has increased (previously 5mmHg mean) and the estimated mitral valve area is smaller (prior P1/2 time 95ms). Left ventricular systolic function is more depressed (global) -EF 20%. CXR [1-24]: [Month/Year (2) ] air space disease bilaterally, right greater than left. Complement of superimposed failure may be present but lack of distention of the pulmonary vessels and persistent sharp features of the costophrenic sulci suggest otherwise. . Thyroid U/s ([2200-12-11]) IMPRESSION: This is a normal EEG recording during stage II sleep. No epileptiform features or focal slowing were noted. However, only a very brief period of wakefulness was recorded, precluding a full evaluation for possible encephalopathy. If clinical suspicion for encephalopathy remains, a repeat study during wakefulness could be considered. . [Month/Day/Year ] ([2200-12-29]) Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with moderate regional systolic dysfunction with near akinesis of the inferior and inferolateral walls and mild hypokinesis of remaining segments. Right ventricular cavity size is normal with mild global free wall hypokinesis. There is abnormal septal motion/position. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. A mitral valve annuloplasty ring is present. There is a minimally increased gradient consistent with trivial mitral stenosis. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be quanitified.There is no pericardial [Month/Day/Year 17838]. . EEG ([2201-1-18]) IMPRESSION: This is a normal EEG recording during stage II sleep. No epileptiform features or focal slowing were noted. However, only a very brief period of wakefulness was recorded, precluding a full evaluation for possible encephalopathy. If clinical suspicion for encephalopathy remains, a repeat study during wakefulness could be considered. CT [1-22]: 1. Abnormal markedly distended urinary bladder with mild hydroureter and hydronephrosis bilaterally in the setting of well positioned Foley catheter. This likely is due to obstruction of the catheter system and flushing or replacement is recommended. No other cause for lower quadrant intraabdominal pain identified. 2. Nonspecific opacities within the right middle [Month/Year (2) 3630] and left lower [Last Name (LF) 3630], [First Name3 (LF) ] represent resolving pneumonia, however acute infectious process or chronic interstitial process (especially within the lower [First Name3 (LF) 3630]) cannot be excluded. Moderate right-sided pleural [First Name3 (LF) 17838] and compression atelectasis. 3. Cholelithiasis without evidence of acute cholecystitis. 4. Simple right renal cyst. 5. Mild amount of intraabdominal and pelvic free fluid. . Abd U/S ([2201-1-31]): RIGHT UPPER QUADRANT ULTRASOUND: Limited evaluation of the liver shows no evidence of biliary ductal dilatation. A gallstone is noted in the fundus of the gallbladder. The gallbladder wall is normal with no gallbladder distention or pericholecystic fluid. There is no extrahepatic biliary ductal dilatation with the common duct measuring 4 mm. IMPRESSION: Cholelithiasis, without evidence of biliary ductal obstruction or cholecystitis. . CXR ([2201-2-1]) The previously seen Dobbhoff tube in the right mainstem bronchus has been removed. There is a feeding tube with the distal tip beyond the pylorus. There is a left-sided AICD, unchanged. There are again noted diffuse airspace opacities bilaterally with relative sparing in the left upper lung zone. This may be secondary to underlying pulmonary edema versus multifocal pneumonia. There are streaky densities at the left base consistent with subsegmental atelectasis. There is a small right-sided pleural [Month/Day/Year 17838]. . CT abd ([2201-2-7]) IMPRESSION: 1. Persistent linear opacities at the left lung base. Interval change in configuration of opacities in the right middle [Month/Day/Year 3630] with an appearance of nodular density. Decrease in size of right-sided pleural [Month/Day/Year 17838] with persistent compression atelectasis. 2. Cholelithiasis without evidence of acute cholecystitis. 3. Multiple hypoattenuating lesions in both kidneys, most of which are too small to characterize. 4. Slightly increased amount of the pelvic ascites. 5. Resolution of abnormally distended urinary bladder and hydroureter. . CXR ([2201-2-8]) There has been interval removal of the feeding tube. The left AICD is unchanged. Sternal wires are unchanged. Again noted are diffuse interstitial infiltrates with more focal infiltrate in the left lower [Month/Day/Year 3630]. This left lower [Month/Day/Year 3630] infiltrate is slightly more confluent than on the film from the prior week. Brief Hospital Course: The patient is a 58 year old male with dilated cardiomyopathy who presents with cough, fevers and increased shortness of breath after a recent course of antibiotics for a pneumonia. Breif summary: [11-27] - [11-30]: admitted to the medicine service for pneumonia [11-30] - [1-4]: admitted to the MICU for respiratry failure, intubated until [12-31]. [1-4] - [1-13]: transferred to the floor, medicine [1-13] - [1-21]: readmitted to the MICU for repeat resp distress [1-21] - [1-25]: readmitted to the floor [1-25] - [2-3]: readmitted to the MICU with CHF excerbation [2-3]: transferred to the floor. 58 year old gentleman with atrial fibrillation, iCMP (EF of 20%), h/o VT on amiodarone, s/p pacemaker, CAD s/p CABG, COPD, who was initially admitted for pneumonia, but has had a complex hospital course included 3 MICU admissions, hypoxic respiratory failure secondary to pneumonia/CHF exacerbation, amiodarone-related thyrotoxicosis, ARF (resolved Cr peaked at 2.4, now resolved 0.4 today)leukocytosis, and thrombocytopenia, vocal cord paralysis. . the patient was originally admitted to medicine on [11-27] for pneumonia. On [11-30] the patient developed hypotension and hypoxic respiratory failure, was intubated, placed on triple pressors and transferred to MICU. He was on levaquin on admission, started on broad spectrum antibiotic course on MICU transfer which included azithromycin, ceftriaxone, and vancomycin. Pt also received flagyl course empirically for c. diff. MICU stay was prolonged and difficult. Pt was weaned off pressors by [12-8] but could not be extubated until [12-31] secondary to pneumonia and pulmonary edema related to decompensated cardiomyopathy that was difficult to manage in the setting of sepsis. The patient was also persistently febrile until [12-31]. No source could definitively be identified. Chest x-ray did reveal bilateral air space opacities. Numerous blood, urine and sputum cultures were not revealing of a source. BAL lavage was also unrevealing. DFA, viral cultures and legionella were negative. . The patients stay was further complicated by amiodarone related thyrotoxicosis, type II. Pt was started on steroids for this reason. Tapazole was briefly given but discontinued for secondary rise in LFT's and belief that this was type II. Thyrotoxicosis did not resolve. In addition, the pt had persistently elevated WBC--elevated LAP score pointed to leukemoid reaction. . The patient was transferred to the general medical floor on [1-4]. By that point his fevers had resolved and his respiratory status were satisfactory. Notably his mental status remained poor since his extubation. On the floor he was persistently delirious. His WBC remained elevated and he was intermittently tachycardic. His thyrotoxicosis did not resolve despite increased dosing of decadron. From [1-12] to [1-13] the pt developed diarrhea. On [1-13], the pt developed a fever to 103.9 and became tachycardic to the 140's. Vancomycin and zosyn was empirically started. It was also believed the mental status was somewhat worse. Laboratories revealed WBC of 24.5 from 21.6 and lactate of 2.6. Urinalysis and CXR was unrevealing. Pt was transferred to MICU given septic physiology. . While in the MICU patient improved. He had an NGT placed as he failed speech and swallow. In terms of thyrotoxicosis patient followed with endocrine, continued on steroids and Cholestyramine which was stopped on [1-21]. Patient was also noted to have thrombocytopenia so HIT Ab was sent which was negative. Antibiotics were stopped on [1-17]. Patient was called out to the floor on [1-21]. . Patient was maintained on 6L of shovel mask until [1-25], when he was noted to be more hypoxic. He pulled off his FM in the AM and O2 sats were 68% on RA transiently. His sats, which had been in the mid 90s over the past few days dropped to the low 90s on 10L mask. Pt had progressively [Month/Day (4) 9140] tachypnea and increasing O2 requirement on [1-25]. His ABG on a facemask was 7.55/30/49. He was placed on a 100% NRB. He was given 20 of IV lasix at 5 pm and put out 1 L in 2 hours. CXR done in the morning shows [Month/Day (4) 9140] bilateral airspace disease and possible component of pulmonary edema. He was again admitted to MICU for hypoxia and pulmonary edema on [1-25]. . While at the MICU for the 3rd time, he was treated for CHF exacerbation with IV lasix which he responded and his pulmonary status gradually improved; it was noted that he had melena on [2201-1-31] and drop in HCT with Hct nadired on [2201-1-29] at 23.6; GI was consulted, given pt HD stable and responded well to transfusion (1 unit during this MICU admission), EGD was held for now, and conservative management unless acute bleeding. Given his complicated hospital course, a family meeting was held on [2201-2-2] at which time pt was made DNR/DNI, no PEG placement, and he expressed wishs to be made comfortable; His defibrilator was turned off by EP per pt's request on [2201-2-3], and his pacer was left in place; Given his vocal cord paralysis, PEG has been recommended, however, pt currently refusing replacement of Dobhoff or feeding device, and prefered to eat by PO with understanding that po puts pt at very high risk for aspiration. he is being called to the floor on [2201-2-3] for further discussion of long term goal of his care. On the floor, he remained afebrile, and his SBP remained 80-100s, with transient drop of SBP to 68-72s and responded to fluid bolus IVNS 500cc; goals of care were readdress with the patient and his guardian (please see goals of care note by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 12879], and pt expressed wishes to give IV TPN, PT and reahab a try, but goals of care needs to be readdress if siutation arises that he needs to be transferred to the MICU or coming back to the hospital after being discharged to rehab. He was started on IV TPN on [2201-2-6] and PT started working with the patient over the weekend of [2201-2-7] to get patient ready for rehab placement. Some of the other issues not addressed above are listed below: Acute Renal Failure: On the morning of [2200-11-30] the patient's creatinine was noted to have increased from 1.0 to 2.5 and ultimately peaked at 3.0 with associated decreased urine output. His renal failure occured in the setting of increased NSAID use, hypotension and new onset peripheral eosinophilia at 8%. Urine electrolytes revealed a FENA of 1.2 % in the setting of lasix use. Urinalysis showed many WBCs but no eosinophils. Urine did not contain muddy brown casts. The differential diagnosis for his acute renal failure included both prerenal azotemia, acute tubular necrosis and acute interstitial nephritis. He received IV fluids and pressure support to maintain his renal perfusion. NSAIDS were immediately discontinued. Ceftriaxone was also discontinued given concern for AIN. His renal function quickly improved with return to baseline creatinine by MICU day 8. On floor, renal function remained NL, w/Cr 0.3-0.4. . Thryotoxicosis: The patient was found to have elevated T4 and T3 levels and undetectable TSH on the [11-21], three weeks into his hospital course. He was treated with Methamizol and Dexamethasone. Methamizole was subsequently discontinued because of LFT elevation. Dexamethasone was tapered. TFT were trending down. Endocrinology was following. As the patient is dependent on Amiodaron for prevention of VT/Vfib it was continued. If the patient has recurrent problems due to thyroid hyperactivity, radioablation of the thyroid has to be considered. T4/T3 levels continued to trend down on the floor, but not to the point that steroids could be tapered. pt needs to continued for 2-3 months on IV methylpredinosolone 40mg, then continued a slow taper after than by for the next month. He needs to have his Thyroid function test checked weekely after discharge; . Thrombocytopenia: Pt. with falling platelet count starting [1-9]. Reached nadir oof 23 on [2201-1-23], then plateaued. Unclear etiology, but possibilities include amiodarone, methamazole. HIT seems less likely given negative HIT antibody x2. As plt count continued to decline on floor, hematology was consulted; he received a total of 1 unit of platelets during this admission and currently on steroids for amiodorone induced thyrotoxicosis. His Plateletes remained stable in the 50,0000s at the time of discharge. . Dilated cardiomyopathy: [Date Range 461] was performed on [2200-12-1] and [12-31] revealed severe LV global hypokinesis with an ejection fraction of 20%. Given his intial hypotension his outpatient cardiac regimen was held. Once his blood pressure had stabilized off pressors he was restarted on his outpatient eplerenone, ace-inhibitor and beta blocker; He was found to be in thyroid storm which is likely partly repsonsible for his worsened cardiac function. However, his meds were d/c'ed except metoprolol given his low BP at baseline prior to discharge. . Mitral Regurgitation: The patient has known 3+ MR status post mitral valve repair in [2198]. Repeat [Year (4 digits) 113] on this admission revealed 1+ mitral regurgitation. It was felt that this issue was stable throughout this admission. . Atrial Fibrillation: The patient is status post maze procedure in [2198]. The patient is also status post AICD placement for NSVT and throughout this hospitalization he was noted to be in either an atrial or ventricularly paced rhythm. Given initial concern that amiodarone might be contributing to his [Year (4 digits) 9140] pulmonary function his amiodarone was held for the majority of his hospitalization, but was then reintroduced when his pulmonary process became more clearly pulmonary edema. He went into a run of VT/Vfib with very frequent shocks and was reloaded with amiodarone drip x 1 day and was transitioned to amiodarone 200daily. EP changed his pacer settings to shock for VT with rate>183 and for VF. When he was discovered to have thyrotoxicosis he was started on an esmolol drip which improved his ectopy. He was then transitioned back to oral beta blockers. On the floor, pt had HR in 70's-90's, and was in sinus rhythm on telemetry. During his 3rd MICU admissions, pt decided to deactivate his AICD, and we continue to hold off his amiodorone given his pulm toxicity. . Cardiac: The patient is status post inferior MI in [2189] and stent placement in [2197]. His EKG was unchanged during this admission. Cardiac enzymes were unremarkable on admission to the MICU, which was rechecked while he was called to the floor as pt had multiple chest pain complaints (ECGs were paced, CE unremarkable); He had two [Year (4 digits) 113] done during this admission which remained poor EF 20%; However, ASA were stopped due to thrombocytopenia, melena with Hct drop; After he was kept on beta blocker (although didn't get much due to aspiration and hypotensive episodes by either mouth or IV), and all other Cardiac meds were d/c'ed prior to discharge due to low BP; He was to follow up with cardiology to address whether his cardiac meds need to be restarted; Depression/anxiety: Was continued on lexapro, then this was stopped when he was not taking POs. Pt became very depressed and psych was consulted. we restarted him on lexapro on [2-3] ( 5mg qday x 1 week, then increase to 10mg qday after that); see goals of care/code status below. Nutrition: The patient required a short course of TPN during his MICU course and otherwise received tube feeds while intubated for his nutritional needs. On the floor, he was reevaluated by speech and swallow and found to be completely unable to swallow any fluids without aspiration. Initially, he was amenable to a PEG tube, but this was been delayed in setting of thrombocytopenia. However, on transfer to the floor on [2-3], he was interested in the Dauboff out and no PEG placed. He understands that he may aspirated and die by making this decision; intially on the floor he expressed no interested of TPN or PEG, but on [2201-2-6] agreed to IV TPN for nutritional support, he was made NPO, but agreed to give small amounts of apple sauce, ice chips, small amounts of water, and small amounts of pureed foods for comfort, but remained for full aspiration precautions. Goals of care/Code: Initially he was full Code. However, after the prolonged hospital course, he voiced sentiments of being CMO. A family meeting with the MICU team and his guardian decided goals of care. The paitent was changed to DNR/DNI after this meeting on [2-2]. In congruence with this decision, the ICD were inactivated on [2-3] and his Dauboff was removed. If situation arises (any fever, chill, chest pain, SOB, or any concerning symptoms), please contact patient's gaudian ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 108846] home [Telephone/Fax (1) 108847], cell [Telephone/Fax (1) 108848] work [Telephone/Fax (1) 108849]), goals of care needs to be readdressed at that point. Guardianship: [Name (NI) 108850] obtained this hospitalization after the long intubation period in [Month (only) ]. patient's gaudian ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 108846] home [Telephone/Fax (1) 108847], cell [Telephone/Fax (1) 108848] work [Telephone/Fax (1) 108849]), Medications on Admission: 1. Amiodarone 200 mg daily 2. Atrovent TID 3. ASA 81 mg daily 4. Beclomethasone (NASAL) 2 puffs each nostril [Hospital1 ] 5. Clonazepam 1 mg TID 6. Coumadin 3 mg--one to two tablet(s) by mouth as directed by [Company ] coumadin clinic 7. Eplerenon 25 mg daily 8. Lexapro 20 mg daily 9. Lisinoprol 5 mg daily 10. Lorazepam 1 mg daily PRN 11. Nasonex 50 mgc two sprays each nostril every day 12. Protonix 40mg daily 13. Senna 14. Toprol XL 25 mg 15. Triamcinolone 0.05 %--apply 2ml [Hospital1 ] 16. Zocor 10 mg daily Discharge Medications: 1. TPN Day 3 Central standard TPN 3 in 1 with fat based on 80kg weight, total TPN Volume [2194], Amino Acid(g/d)340, Dextrose(g/d) 120, Fat(g/d) 40, Kcal/day [2194]; with trace elements and standard vitamin added; with 50 meqNaAc; 20 meq NaPO4; 10 meq KAc; 40 meq KPO4; 10 meq MgSO4, 12 meq CaGluc, 20 units insulin added to the TPN 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): please swab around inside mouth with this solution - cannot take swish/swallow as he aspirates but may have thrush . 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for mouth hygiene: please swab around inside mouth with this solution - cannot take swish/swallow as he aspirates but may have thrush . 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. sliding scale insulin please continue sliding scale insulin and check FS qid while pt is on TPN 8. Pantoprazole 40 mg IV Q24H if unable to tolerate PO protonix 9. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for Nausea. 10. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q6H (every 6 hours): hold for SBP<90 and HR<55. 11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): hold for oversedation. 12. Methylprednisolone Sodium Succ 40 mg Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 2 months: after 2 months, please continue a slower taper for the next mongh, decrease the dosage by 10mg per week; Please also make sure that you check weekly thyroid function tests including (T4, free T4, and T3) . 13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed. 14. PICC line PICC line care per rehab protocol 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 16. Lorazepam 2 mg/mL Syringe Sig: 0.5 ml Injection Q4H (every 4 hours) as needed for anxiety. 17. Morphine 10 mg/mL Solution Sig: 0.5 ml Intravenous every 4-6 hours as needed for pain: hold for oversedation or RR<12. 18. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO once a day: full aspiration precaustions, please crush meds and give with apple sauce. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary diagnosis: Pneumonia Congestive heart failure (exacerbation) responded to lasix Vocal cord dysfunction due to intubation thyroid toxicosis from amiodorone (improved) depression hyponatremia resolved Thrombocytopenia (platelets in the 50,000 and stable) Melena (responded to pRBC transfusion, and Hct remained stable) ------- Secondary diagnosis: Dilated cardiomyopathy (EF 20%) 3+ Mitral regurgitation (s/p repair [8-29] at [Hospital1 112]) Atrial fibrillation (s/p maze procedure [8-29], AV paced, on coumadin and amiodarone) both coumadin and amiodorone were stopped during this admission and AICD deactivated) COPD PFT [5-30](FVC=2.86, FEV1=2.28, MMF=2.09, FEV1/FVC=80) Hyperlipidemia Coronary artery disease s/p IMI in [2189] LAD stent in [12-28] (patent on cath [8-29]), s/p SVG to OM1 Discharge Condition: afebrile, VSS (SBP baseline upper 80-90s), with full aspiration precautions Discharge Instructions: Full aspiration precautions: Pt should remain NPO, and only offer PO for comfort (apple sauce, ice chips, small amounts of water, and small amounts of pureed foods); Patient is aware and understand the risks of aspiration when taking POs, and he is willing to accept these risks for comfort. . There were entensive discussion during this prolonged hospitalization; Given multiple medical problems, see goals of care discussion notes from Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 12879] (attached); pt is DNR/ DNI, and expressing wishes to be comfort measure only at some point during his hospitalization, but now, he is willing to accept IV TPN and willing to work with PT; . If situation arises (any fever, chill, chest pain, SOB, or any concerning symptoms), please contact patient's gaudian ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 108846] home [Telephone/Fax (1) 108847], cell [Telephone/Fax (1) 108848] work [Telephone/Fax (1) 108849]), goals of care needs to be readdressed at that point. . Other instructions: 1. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. 2. Adhere to 2 gm sodium diet . Please take all your medications as prescribed. . Please follow up all of your appointments Followup Instructions: Please follow up with your PCP 1-2 weeks after discharge in addition to the following appointments: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2201-2-27] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2201-2-27] 3:40 Provider: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], [MD Number(3) 1240]:[Telephone/Fax (1) 3512] Date/Time:[2201-3-24] 1:00 You will also need to follow up with otolaryngology (Ear, Nose, & Throat) for further evaluation of your vocal cords and throat. Call [Telephone/Fax (1) 31733] to make an appointment. Tell them you were seen by the ENT resident while you were in the hospital and were told to schedule a follow-up appointment. Completed by:[2201-2-11]	[ "995.92", "288.60", "584.9", "276.1", "E942.0", "261", "242.91", "V53.32", "293.0", "008.45", "424.0", "412", "V58.65", "427.31", "425.4", "518.81", "707.03", "507.0", "428.0", "V45.82", "478.30", "V45.81", "496", "038.9", "287.31", "578.1", "486" ]	icd9cm	[ [ [] ] ]	[ "38.93", "03.31", "33.24", "99.15", "00.17", "99.05", "96.6", "96.72", "99.04", "96.04" ]	icd9pcs	[ [ [] ] ]	31311, 31382	14542, 28088	307, 710	32257, 32335	3455, 3455	33659, 34536	3002, 3019		28666, 31288		31403, 31403		28114, 28643			32359, 33636				4811, 5261					3034, 3436																							260, 269						738, 2115			31757, 32236		3991, 4795	31422, 31736									2137, 2686	2702, 2986				5273, 14519
28,536	149,435	51303	Discharge summary	report	Admission Date: [2131-5-3] Discharge Date: [2131-5-15] Date of Birth: [2087-11-8] Sex: M Service: NEUROSURGERY Allergies: Morphine Attending:[First Name3 (LF) 1835] Chief Complaint: Patient presents with a right-sided radiculopathy of L5-S1 that has been progressing over time. The patient has failed medical treatment. The patient has requested surgical exploration and decompression knowing the risks and benefits of a redo redo operation. Major Surgical or Invasive Procedure: L4-S1 lami and foraminotomies - repeat operation History of Present Illness: The patient presents with a right- sided radiculopathy of L5-S1 that is progressing over time. The patient has failed medical treatment. The patient has requested surgical exploration and decompression knowing the risks and benefits of a redo redo operation. Past Medical History: HTN Obesity Chronic Rhinitis Sleep Apnea(requiring CPAP) Social History: Lives alone in basement apartment Family History: non-contributory Physical Exam: A&O x 3 Sensation full throughout. Motor intact Incision clean, dry, intact Pertinent Results: CTA-Chest([5-7]): CT CHEST: Extensive pulmonary emboli are identified in the right and left pulmonary arteries extending into all lobar branches (saddle), branching into many segmental and subsegmental braches. The interventricular septum is somewhat flattened. The main pulmonary artery is prominent, measuring 3.6 cm (3:31), and is suggestive of pulmonary hypertension. The heart, aorta, and coronary arteries are otherwise unremarkable in appearance. Non- pathologically enlarged nodes are identified in the prevascular, AP window, and pretracheal locations. There is no supraclavicular or axillary lymphadenopathy. The lungs are clear, with no pleural effusion, consolidation, or nodular opacity. A right suprarenal hypodensity is incompletely imaged. Incidental note is made of DISH of the thoracic spine, primarily on the right side. ECG Study Date of [2131-5-7] 10:32:40 AM Sinus rhythm. Modest intraventricular conduction delay - may be in part right ventricular conduction delay Since previous tracing of [2131-4-11], no significant change. [2131-5-13] 05:50AM BLOOD WBC-7.4 RBC-3.97* Hgb-11.1* Hct-33.1* MCV-83 MCH-28.1 MCHC-33.7 RDW-13.8 Plt Ct-283 [2131-5-14] 06:10AM BLOOD PT-21.6* PTT-31.2 INR(PT)-2.0* [2131-5-13] 05:50AM BLOOD Plt Ct-283 [2131-5-13] 05:50AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-139 K-3.9 Cl-98 HCO3-33* AnGap-12 [2131-5-13] 05:50AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.1 Brief Hospital Course: The patient was admitted s/p an elective re-do laminectomy on [2131-5-4]. He was starting to mobilize and worked with PT on [5-7]. At that time he had a desaturation and was found to have bilateral pulmonary emboli. He was transferred to the SICU and started on a heparin drip. The following day he was transferred back to the step-down unti after a stable night. He continued to work with PT on a daily basis and they felt that he would not require rehab. The patient's PTT was monitored and the heparin drip was adjusted accordingly Q 6 hours. Coumadin was started on [2131-5-11] at a dose of 7.5 mg. His INR was monitored and it was 2.0 on [2131-5-13]. The heparin drip was then stopped. His is being discharged on 10mg daily on M,W, Fri; with instructions to take 7.5mg on Tues, Thurs, Sat, Sun. He was given instructions to follow up with his PCP for [Name9 (PRE) 444] of his Coumadin dosing and INR. Medications on Admission: 1. Astelin 137 mcg Aerosol, Spray Sig: One (1) Nasal daily (). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [Hospital1 ] (2 times a day). 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Astelin 137 mcg Aerosol, Spray Sig: One (1) Nasal daily (). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [Hospital1 ] (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Continue until you stop taking your pain medication. Disp:60 Tablet(s) Refills:2 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Continue until you stop taking you pain medication. Disp:60 Capsule(s) Refills:2 8. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: No driving while on narcotics. Disp:60 Tablet(s) Refills:0 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Warfarin 5 mg Tablet Sig: see below Tablet PO once a day: Take 10mg on Monday, Wednesday and Friday. Take 7.5mg on Tuesday, Thursday, Saturday, Sunday. Make Appt with PCP for [Name9 (PRE) ] of INR. Should have blood drawn in [2-6] days. Disp:25 Tablet(s) Refills:0 11. Outpatient Lab Work Please Draw INR weekly and fax to Patient's PCP for [Name9 (PRE) 444] of Coumadin(Warfarin) dosing. Patient to provide PCP fax info Discharge Disposition: Home Discharge Diagnosis: 1. s/p L4-S1 lami/foramiotomies (redo operation) 2. Massive bilateral pulmonary emboli Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound(s) clean and dry / No tub baths or pools for two weeks from your date of surgery ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit -Because of your pulmonary emboli, you are required to take an anticoagulant medication called Coumadin(Warfarin) for six months. This medication will periodically require blood testing to ensure a therapuetic level. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: Follow-up in Dr.[Name (NI) 9034] office for suture/staple removal in [9-18] days. Call [Telephone/Fax (1) 1669] to make an appointment. Follow-up with Dr. [Last Name (STitle) ] in 3 months with CT scan of the lumbosacral spine. Call the office to make an appointment. ------- Please call and make an appointment to be seen by your PCP upon hospital discharge for the ongoing managment of your Coumadin(warfarin) therapy. Completed by:[2131-5-15]	[ "V13.01", "722.52", "278.01", "415.11", "401.9", "327.23", "472.0" ]	icd9cm	[ [ [] ] ]	[ "03.02", "03.09", "93.90" ]	icd9pcs	[ [ [] ] ]	5376, 5382	2614, 3542	532, 583	5513, 5537	1149, 2591	7049, 7518	1019, 1037		3971, 5353		5403, 5492		3568, 3948			5561, 7026									1052, 1130																							233, 494						611, 871															893, 951	967, 1003
19,277	145,103	25705	Discharge summary	report	Admission Date: [2169-6-3] Discharge Date: [2169-6-19] Service: MEDICINE Allergies: Morphine / Codeine Attending:[First Name3 (LF) 2186] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Bronchoscopy intubation attempted post-pyloric dobhoff placement by IR (unsuccessful) PICC line placement History of Present Illness: Pt is an 85 y/o F with h/o CVA, CRI, asthma p/w respiratory failure. Pt seen by her son on am of admission coughing after taking pills, increased coughing "fit" after breakfast. Pt noted to be "wheezy" this am and given alb/ipratropium neb. Add'l neb given after breakfast for repeat wheezing. HR in 140s per son after 2nd neb. Pt noted to be getting more dyspneic and tachypneic. Epi 1:1000 solution given in neb form by son. Pt then became apneic with "thready" pulse. Son initiated CPR. 20-30 seconds to return of spontaneous breathing. EMS arrived and unable to intubate. BVM until arrival in ED. ED reports tachypnea (RR 30s), hypoxia (O2 sat 91% with 100%FiO2 on BVM). Intubated with some difficulty, gastric contents found in oral cavity on intubation. Given levofloxacin and flagyl in ED for presumed aspiration pna. BP and HR stable (SBP 130s, HR 90s) in ED. ROS (-) per family and caretaker. [Name (NI) ] CP, no f/c, no n/v/d. Past Medical History: -- asthma, allergy-induced during early summer months -- CVA x 3 with residual R sided deficits and expressive aphasia -- h/o Pneumococcal PNA x 3 in past (last 3yrs ago) -- CRI (bl cr 1.7-2.2) -- Paraesophageal hernia/GERD -- h/o DVT [2157] -- h/o GIB on coumadin Social History: lives with son (a physician), has 24hr care at home, no h/o tob or EtOH Family History: NC Physical Exam: VS:T 98 BP150/80 HR70s resp: 100%O2sat AC 450/16/peep 8/FiO2 50% Gen: elderly female, intubated, sedated, responds to noxious stimuli, moving L UE/LE HEENT: PERRL, Anicteric, poor dentition, sl dry MM Neck:no JVD, no bruits CV:II/VI hsm at apex, RRR Chest:bronchial BS, rhonchi at R base > L base Abd:sl distended, + BS, tympanitic Extr:1+ pitting LE, chronic stasis changes, 3 x 2 cm excoriation at R calf, R UE contracture Neuro: R LE clonus with crossover, upgoing babinski on R, L patella DTR [12-22]+ Rectal Pertinent Results: [2169-6-3] 03:09PM PLT COUNT-139* [2169-6-3] 03:09PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2169-6-3] 03:09PM NEUTS-89* BANDS-1 LYMPHS-5* MONOS-2 EOS-2 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [2169-6-3] 03:09PM WBC-12.1* RBC-3.38* HGB-8.7* HCT-27.5* MCV-81* MCH-25.7* MCHC-31.6 RDW-13.3 [2169-6-3] 03:27PM GLUCOSE-197* LACTATE-4.2* NA+-137 K+-5.4* CL--103 TCO2-20* [2169-6-3] 03:30PM PT-11.4 PTT-16.1* INR(PT)-0.9 [2169-6-3] 03:30PM CK-MB-7 cTropnT-0.09* [2169-6-3] 03:30PM CK(CPK)-155* [2169-6-3] 03:30PM GLUCOSE-180* UREA N-39* CREAT-1.6* SODIUM-136 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18 [2169-6-3] 05:13PM TYPE-ART PO2-467* PCO2-43 PH-7.36 TOTAL CO2-25 BASE XS--1 INTUBATED-INTUBATED [2169-6-3] 10:05PM RET AUT-1.1* [2169-6-3] 10:05PM PLT COUNT-127* [2169-6-3] 10:05PM WBC-16.8* RBC-3.44* HGB-9.0* HCT-27.8* MCV-81* MCH-26.2* MCHC-32.3 RDW-14.0 [2169-6-3] 10:05PM TSH-3.8 [2169-6-3] 10:05PM calTIBC-264 VIT B12-1188* FOLATE->20 HAPTOGLOB-87 FERRITIN-77 TRF-203 [2169-6-3] 10:05PM ALBUMIN-3.4 CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.9 IRON-65 [2169-6-3] 10:05PM CK-MB-10 MB INDX-4.5 cTropnT-0.10* [2169-6-3] 10:05PM ALT(SGPT)-22 AST(SGOT)-34 LD(LDH)-369* CK(CPK)-220* ALK PHOS-70 TOT BILI-0.2 Discharge : [2169-6-19] 02:53AM BLOOD WBC-8.6 RBC-4.11* Hgb-10.9* Hct-33.7* MCV-82 MCH-26.5* MCHC-32.4 RDW-16.5* Plt Ct-227 [2169-6-19] 02:53AM BLOOD Plt Ct-227 [2169-6-19] 02:53AM BLOOD ALT-26 AST-26 AlkPhos-76 TotBili-0.2 [2169-6-19] 02:53AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8 Studies: CXR [6-16]: A right PICC line remains in satisfactory position within the superior vena cava. The heart is mildly enlarged but stable. Pulmonary vascularity is within normal limits for technique. There is improving aeration at both lung bases with residual patchy opacity in the left retrocardiac region as well as residual small pleural effusions, left greater than right. IMPRESSION: 1) No evidence of pulmonary edema. 2) Improving aeration at the lung bases with residual atelectasis predominantly at the left lung base. [6-9] Echo: IMPRESSION:Preserved global biventricular systolic function. At least mild mitral regurgitation. Based on [2160] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [6-3] CT HEAD: FINDINGS: There is no intraparenchymal or extra-axial hemorrhage. There is no shift of normally midline structures, mass effect or hydrocephalus. There are large chronic-appearing infarcts involving the left frontal lobe and the left temporoparietal regions with an ACA and MCA distribution respectively. There is also extensive bilateral subcortical and periventricular white matter hypodensities consistent with chronic small vascular ischemic change. There is mild prominence of the ventricles and sulci consistent with age related involutional change. The visualized paranasal sinuses and osseous structures are unremarkable. IMPRESSION: 1. No intracranial hemorrhage or mass effect. 2. Multiple large chronic-appearing infarcts involving the left frontal and left temporoparietal regions. 3. Extensive chronic small vessel ischemic change and age involutional change. [2169-6-7] 6:20 pm BRONCHIAL WASHINGS GRAM STAIN (Final [2169-6-8]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2169-6-9]): OROPHARYNGEAL FLORA ABSENT. YEAST. ~6OOO/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 64078] ([2169-6-4]). LEGIONELLA CULTURE (Final [2169-6-17]): NO LEGIONELLA ISOLATED. VIRAL CULTURE (Preliminary): No Virus isolated so far. [2169-6-4] 12:42 am SPUTUM Site: ENDOTRACHEAL FINAL REPORT [2169-6-13] GRAM STAIN (Final [2169-6-4]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2169-6-6]): SPARSE GROWTH OROPHARYNGEAL FLORA. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. STAPH AUREUS COAG +. MODERATE GROWTH. YEAST. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 1 S PENICILLIN------------ =>0.5 R LEGIONELLA CULTURE (Final [2169-6-13]): NO LEGIONELLA ISOLATED. Brief Hospital Course: 1) Respiratory failure ?????? etiology presumed to be asthma exacerbation complicated by [Month/Day/Year 8974] pneumonia. Pt was intubated in ED, and given Levaquin and Flagyl for a presumed aspiration pneumonia. On arrival to the [Hospital Unit Name 153], Vancomycin was added to pt's abx regimen. Pt remained on mechanical ventilation, with good ventilation and oxygenation, but unable to extubate [12-21] copious secretions. A bronchoscopy was performed which showed minimal secretions, but some airway collapse with cough. A BAL was obtained. When sputum cx and BAL cx came back positive for [Name (NI) 8974], pt was changed to oxacillin. Extubation was attempted on HD #6, but failed [12-21] supraglottic edema. Pt was reintubated and started on IV steroids. Pt completed a 7 day course of oxacillin and was successfully extubated on HD #10. Pt was transferred to the floor on [6-15]. By [6-18], pt's respiratory status improved with nebs. CXR showed increased airation at bases. 2) coagulopathy - Early in hospitalization, pt had coag panel wnl. On HD #7, pt was noted to have bleeding into an infiltrated PIV site and an isolated elevated PTT. Pt had only been on prophylactic SQ heparin and heparin flushes for a PICC line placed during this hospitalization. Per nursing reports, samples were from peripheral venipuncture sites, and not drawn from lines with heparin. However, SQ heparin was empirically decreased to [Hospital1 ] and a thrombin time study was sent. When the thrombin time study was found to be markedly elevated, a followup reptilase study was sent. PTT levels were then inconsistently elevated on subsequent labs. The coagulopathy was presumed heparin-induced due to the inconsistent nature of the PTT elevation. However, without any intervention, the pt's PTT was normal at times. 3) HTN ?????? While intubated, pt's BP was well-controlled on propofol gtt and metoprolol. After extubation, Diovan was started for elevated BP and Metoprolol D/C'ed for bradycardia. However, pt then had 12 beats of SVT and Metoprolol was restarted. On transfer to floor, BP was well-controlled on metoprolol IV and hydralizine. Pt can be transitioned back to oral anti-HTN agents now that she can take POs. 4) Anemia ?????? Pt has chronic anemia of unknown etiology. Pt was on QD iron at home, and by report from son had a recent neg [Name (NI) ]. During hospitalization, hemolysis labs, iron studies, and stool guaiac were nl. Pt did receive 1U pRBCs on HD #3 for Hct of 24, but was otherwise stable. 5) h/o CVAs ?????? Pt has baseline expressive aphasia and R-sided upper motor neuron signs (hyperreflexia and sustained clonus) from prev CVAs. Pt did have a noncontrast head CT in ED which was negative for acute bleed or mass effect, but was consistent with chronic small vessel dz. She was continued on plavix QOD (home regimen) during hospitalization and asprin. 6) Cardiac enzyme leak ?????? Pt had small trop leak up to 0.10 on admission with non-specific T wave changes in lateral leads. Findings were attributed to demand ischemia [12-21] epinephrine administration during respiratory arrest. Pt did have a TTE during hospitalization which was essentially nl (EF > 55%). Pt was on B-blocker, statin, and plavix during hospitalization. 7) CRI ?????? By history from son, pt has a baseline Cr 1.7-2.2. However, during admission baseline was noted to be ~1.2. Pt did have mild ARF during hospitalization, presumed [12-21] lasix diuresis. 8) Osteoporosis - Pt is on home regimen of vit D, calcium, and premarin which were all held during hospitalization. Please restart these medications at your discretion. 9) FEN ?????? Following intubation, multiple attempts were made for bedside NG tube placement. However, were unsuccessful due to pt's hiatal hernia. An NG tube was eventually placed by IR under radiographic guidance (a technically difficult 2-hour procedure), but was subsequently lost during pt positioning. Pt was kept NPO following extubation [12-21] risk of aspiration. Speech and swallow eval was requested, but deamed inappropriate as pt was not able handle secretions. Replacement of NG by IR was attempted, but unsuccessful after a long procedure. Speech and swallow evaluation was requested again and pt was deemed to be able to take POs with a modified diet. She was discharged to rehab facility with a soft solid PO diet order. 10) Access ?????? A R PICC line was placed by the IV nurse [First Name (Titles) ] [Last Name (Titles) 25422]n for IV abx. She will be d/c'd with the PICC line and this can be removed if it is not needed for blood draws or nutrition on discharge to [Hospital1 ]. 11) Prophylaxis ?????? Pt was given a PPI for DVT prophylaxis, and SQ heparin for DVT prophylasix 12) Code ?????? full 13) [Name (NI) ] - Pt was discharged to [Hospital3 ] facility once she was cleared by speech and swallow and her respiratory status was stable. 14) Comm ?????? son [Name (NI) ]. [Last Name (STitle) ] Ofc [Telephone/Fax (1) 62715]; Cell [Telephone/Fax (1) 64079]; Home [Telephone/Fax (1) 64080] or [Telephone/Fax (1) 64081]; [Doctor First Name ] (caretaker) 978-492-05 Medications on Admission: singular 10 qd [Doctor First Name 130] 180 [Hospital1 ] duonebs [Hospital1 ]:prn ASA 81 qd plavix 37.5mg daily lipitor 40 qd ditropan 15 qhs paxil 25 qam provigil 200 provera 3.125 premarin 0.3 avapro 150/300 qd Folic Vit E Ferrous Sulf Calcium/Vit D Actonel 35 qwk Xanax prn Vicodin prn Discharge Medications: 1. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO twice a day. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Four (4) mls PO DAILY (Daily). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every 6-8 hours as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every 6-8 hours as needed. 11. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week. 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 15. Plavix 75 mg Tablet Sig: 0.5 Tablet PO once a day. 16. Paxil 10 mg Tablet Sig: 2.5 tablets PO qam. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Dx: hypoxic respiratory failure aspiration pneumonia asthma exaccerbation hypertension chronic anemia Hyperchloremic metabolic acidosis Secondary Dx: asthma HTN chronic renal insufficiency GERD History of CVAs osteoporosis Discharge Condition: stable, afebrile, breathing room air Discharge Instructions: If you experience fever, chills, shortness of breath, chest pain, or other concerning symptoms, please call your doctor or come to the ED for evaluation. 1. Please take all medications as directed 2. Please attend all follow-up appointments. Followup Instructions: Please follow-up with your PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 18734] within [11-20] weeks after discharge. Please call [Telephone/Fax (1) 18735] to schedule an appointment. Completed by:[2169-6-19]	[ "584.9", "401.9", "493.92", "733.00", "285.9", "276.2", "518.81", "507.0", "482.41" ]	icd9cm	[ [ [] ] ]	[ "96.72", "33.24", "96.04", "99.15", "38.93", "96.6" ]	icd9pcs	[ [ [] ] ]	14502, 14572	7711, 12933	245, 353	14848, 14886	2290, 4878	15178, 15457	1731, 1735		13284, 14479		14593, 14827		12959, 13261			14910, 15155									1750, 2271																							186, 207						381, 1333		4887, 7688													1355, 1626	1642, 1715
28,530	161,493	34264	Discharge summary	report	Admission Date: [2152-5-22] Discharge Date: [2152-5-29] Date of Birth: [2094-11-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 4886] is a 57 yo man recently discharged from [Hospital1 18] following a prolonged hospital stay during which he developed perforated bowel [1-22] metastatic lung cancer. He initially presented to an OSH with worsening back pain and was eventually diagnosed with ? cauda equina syndrome from metastatic lung CA. While on the table for spinal fusion surgery, he became hypotensive, and his abdomen was noted to be rigid. An upright CXR demonstrated free air under the diaphragm and he underwent emergent laparotomy and right hemicolectomy and ileostomy. Attempts at weaning him from the ventilator were unsuccessful, and he underwent trach and G-tube placement. Of note, he was diagnosed with a lung abscess during his stay. Thoracic surgery was consulted and felt his prognosis was too poor for any surgical intervention to have a meaningful effect on his survival. His abdominal fluid grew out Pseudomonas and E. coli. Multiple sputum cultures grew out MSSA, and one grew out yeast and another grew out E. coli. He was discharged to rehab on vancomycin, pip-tazo, metronidazole, ciprofloxacin and fluconazole. He was transferred back to the [Hospital1 18] from rehab for fever. He was afebrile on transfer to the rehab facility but by the night of [2152-5-19] he spiked to 103.3. He was seen by the infectious disease consultant on [2152-5-20] at which time ceftriaxone/flagl and the prior antibiotics were stopped. Per the ID note, it was unclear based on the available records to him if the pulmonary cavitary lesion was an abscess. His vent settings for the 3 days prior to transfer were CPAP/PS 10/5 50%. He has an 8-0 portex tracheostomy. In the ED, his initial vital signs were 99.9 [Numeric Identifier 78882]/66 10 100%. A CXR was done as well as CT torso (with contrast). He received vancomycin/zosyn as well as dilaudid and toradol for pain. He received 4L normal saline. On arrival to the MICU, he denied shortness of breath, worsening secretions, chest pain, dysuria, or change in ostomy output. He has a small amount of pain in his abdomen in the right lower quadrant. Past Medical History: Probable metastatic lung ca (9mm lesion RUL) h/o low back pain hepatitis C h/o ETOH Social History: Smokes [12-22] pack cigarettes per day. drinks ETOH heavily, [1-23] beers per day and sometimes [12-22] pint of vodka per day Family History: Mother with lung ca Physical Exam: VS: 99.4 105 103/70 16 100% vent: CPAP/PS 10/5 50% GEN: thin, cachetic male in NAD HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM, Neck supple, trach in place, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, NT, ND, + BS, no HSM. large vertical ex-lap scar healing by secondary intent EXT: muscle wasting. warm, dry, +2 distal pulses BL, no femoral bruits. midline on left A/C NEURO: alert & orientedx3 no R/L neglect, CN II-XII grossly intact, 5/5 strength throughout upper extremity. [2-23] plantar/dorsiflex bilat. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: [2152-5-22] 03:19PM WBC-25.5# RBC-3.79# HGB-10.5# HCT-33.0# MCV-87 MCH-27.8 MCHC-31.9 RDW-15.8* [2152-5-22] 03:19PM NEUTS-86.5* LYMPHS-7.8* MONOS-5.5 EOS-0.1 BASOS-0.1 [2152-5-22] 03:19PM PLT COUNT-961# [2152-5-22] 03:19PM GLUCOSE-126 UREA N-25* CREAT-1.2 SODIUM-133 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-20* ANION GAP-15 [2152-5-22] 03:20PM LACTATE-1.5 [2152-5-22] 04:30PM URINE RBC-0 WBC-[2-23] BACTERIA-FEW YEAST-FEW EPI-0 [2152-5-22] 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2152-5-22] 04:30PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2152-5-22] 03:19PM ALT(SGPT)-8 AST(SGOT)-14 ALK PHOS-101 TOT BILI-0.7 . [2152-5-23] 5:13 am SPUTUM Source: Endotracheal. FINAL REPORT [2152-5-26] GRAM STAIN (Final [2152-5-23]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2152-5-26]): SPARSE GROWTH OROPHARYNGEAL FLORA. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA \| TRIMETHOPRIM/SULFA---- <=1 S . [2152-5-24] 3:56 pm URINE Source: Catheter. FINAL REPORT [2152-5-25] URINE CULTURE (Final [2152-5-25]): YEAST. 10,000-100,000 ORGANISMS/ML. . [2152-5-22] CT Torso: IMPRESSION: 1. Very limited evaluation for intra-abdominal abscess, questionable focus of fluid collection in the right paracolic gutter, smaller, when compared to [5-4] study. 2. Slight decrease in size of cavitated right upper lobe lesion. 3. Interval worsening of centrilobular ground-glass nodules throughout both lung fields, consistent with multifocal infection. 4. Lytic L5 vertebral lesions with pathologic compression fracture. 5. Increase in conspicuity of hypodense hepatic parenchymal lesions Brief Hospital Course: Mr. [Known lastname 4886] is a 57yo male with history of metastatic NSCLC c/b cord compression c/b bowel perforation s/p hemicolectomy and pulmonary abscess presenting with fevers and leukocytosis. 1)Fever: Likely related to pulmonary abcess vs. possible fluid collection in the abdomen (right paracolic). He was initially started on Vancomycin and Zosyn for broad spectrum coverage. After several family meetings the decision was made not to proceed with any further agressive work-up given his overall prognosis. His antibiotic regimen was changed to Levaquin and Flagyl. He was also started on Bactrim for his sputum cultures (stenotrophomonas). He continued to spike fevers which was not surprising in the setting of his underlying abcess. He will be discharged to complete 14 days of levofloxacin/flagyl/bactrim. 2)Respiratory failure: Patient was initially placed on CPAP + PS but was then weaned to trach mask which he has been able to tolerate well and is oxygenating appropriately. He will be transferred on trach collar FiO2 0.35. He should use PMV at least once daily as tolerated. 3)Lung cancer: No further treatment indicated given the advanced stage. 4)Depression: On day of discharge, he was started on low dose citalopram. He should be monitored on this and dose can be uptitrated upon discharge. 5)FEN: Continued on G tube feedings. He was evaluated by speech and swallow who felt that with 1:1 supervision, he can consume pureed diet for pleasure. He should be sitting upright and if evidence of aspiration, PO food should be dicontinued. 6)Access: Midline. 7)Prophylaxis: Heparin SQ for DVT prophylaxis. 8)Code: DNR (confirmed with patient and family). Medications on Admission: Heparin 5,000 SC tid Acetaminophen 650mg q4hrs prn Oxycodone 5-10 mg q4hrs prn Metoprolol Tartrate 50 tid ceftriaxone 1g q24 (start [2152-5-20]) flagyl 500 mg q8 (start [2152-5-13]) Lorazepam 1 mg q4hrs Insulin (regular insulin) lansoprazole 30 mg daily chlorhexidine 15mL [Hospital1 ] promote with fiber goal 50cc/hr Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 3. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed. 4. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 14 days. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 14 days. 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Metastatic Lung CA Perforated Bowel s/p partial colectomy [4-/2152] Right paracolic fluid collection Right lung loculated abscess L5 metastatic lesion with cord compression Discharge Condition: Fair; comfort as goal. Discharge Instructions: Please continue to take your antibiotics as prescribed. . Please note that we have started you on a medication to help your mood, citalopram. . Please inform staff at rehab if you are having fevers, chills, increasing pain or any other symptoms that are uncomfortable that concern you.	[ "311", "070.70", "162.9", "513.0", "305.1", "567.22", "518.81", "V58.67", "V44.2", "305.00" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	8510, 8525	5825, 7517	323, 329	8746, 8771	3540, 5802		2768, 2789		7898, 8487		8546, 8725		7543, 7875			8795, 9083									2804, 3521																							277, 285						357, 2488															2510, 2596	2612, 2752
54,470	163,095	40293	Discharge summary	report	Admission Date: [2196-11-9] Discharge Date: [2196-11-12] Date of Birth: [2114-10-13] Sex: F Service: MEDICINE Allergies: Percocet / Codeine / Morphine Attending:[First Name3 (LF) 7333] Chief Complaint: Dyspnea, diaphoresis Major Surgical or Invasive Procedure: Cardiac catheterization S/P colectomy, cholecystectomy and hernia repair at [Hospital3 ] on [2196-11-3]. Dr. [Last Name (STitle) 7871] was her surgeon. History of Present Illness: At outside hospital, an 83 y.o. with no prior cardiac history, except for DOE, which may have been pulmonary in nature, underwent elective laparoscopy for a colon mass on [2196-11-3] at NEBH. The patient also had lysis of adhesions, right colectomy, and cholecystectomy, along with abdominal hernia repair with fascia release and mesh placement. She was initially sent to ICU, and then called out to telemetry floor. On [11-8] afternoon, she complained of difficulty in breathing and diaphoresis. She also states that she had some tightness in her chest. The patient had EKG changes with T wave depressions and ST depressions and was then sent back to ICU. Her first troponin at 3pm yesterday cam back at 0.84. She also had some transient hypotension last eve down to 80/40, which responded to 250 mL bolus NS x 2, 11pm trop 0.68, 5am today down to 0.47. She again had some transient systolic bp down to 80's and received an additional 250 NS this am. They have been holding her lopressor. She continues with significant T wave depressions, but no further shortness of breath or diaphoresis. Lung sounds are diminished with occasional audible wheezes, slight white sputum, few crackles this am which cleared with cough, cxr negative. Large abdominal dressing and 2 JP drains along with abdominal binder, mepitel dressing to right chest, perhaps secondary to open sore of unclear etiology. . Following her transfer to [Hospital1 18], the patient underwent a cardiac catheterization. She was then transferred to the CCU floor. She currently denies any shortness of breath, diaphoresis, chest pain or discomfort. Past Medical History: 1. CARDIAC RISK FACTORS: None 2. CARDIAC HISTORY: None -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Colon cancer 29/10 pos PPD with negative CXR PNA [9-2] UTI Severe COPD/ashtma Migraines Anxiety Depression s/p hernia repair, hysterectomy, and knee arthroscopy. (Vitals at NEBH: 95/52, 88 SR, rr 19-23, open face mask at 40% with 95% O2 sat (mouth breather). Social History: -Tobacco history: Distant (40 years ago) -ETOH: Distant (40 years ago) Family History: The patient's mother and sister had "weak hearts." The patient has one sister and one granddaughter with Marfan syndrome. Physical Exam: Admission Exam: VS: BP 126/60 HR 80 RR 20 O2 sat 96% GENERAL: Obese, pleasant woman in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple, no LAD. CARDIAC: S1, S2, no murmurs auscultated. LUNGS: No accessory muscle use. CTAB to anterior auscultation. ABDOMEN: Soft, protuberant, bandaged. EXTREMITIES: No edema. No femoral bruit at right groin insertion site. PULSES: radial/pedal pulses 2+ Discharge exam: Gen: remembers she was confused overnight. Sitting up in chair eating breakfast HEENT: supple, no JVD CV: RRR, no M/R/G RESP: crackles bibasilar ABD: well approximated staples running midline from xyphoid to groin. No swelling, drainage or signs of infection. Wrap around support bandage at upper end of staples. 2 JP drains near stapled area, one drain has no fluid, the other has about 100cc of serosanguinous drng and have emptied approx 400 cc in last 24 hours. No sig pain around incision area. Good BS and appetite, pt has had BM. EXTR: minimal edema. Extremeties: right groin with no hematoma or sig ecchymosis. Skin: skin tear over central clavicle, drsg [Name5 (PTitle) 88400]. Pertinent Results: Admission labs: [2196-11-9] 02:20PM TYPE-ART PO2-82* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-0 [2196-11-9] 02:20PM HGB-10.7* calcHCT-32 O2 SAT-95 [2196-11-9] 05:20PM WBC-7.0 RBC-4.08* HGB-11.5* HCT-35.0* MCV-86 MCH-28.1 MCHC-32.8 RDW-14.6 [2196-11-9] 05:20PM PLT COUNT-296 [2196-11-9] 05:20PM CALCIUM-7.8* PHOSPHATE-2.9 MAGNESIUM-1.7 [2196-11-9] 05:20PM GLUCOSE-126* UREA N-7 CREAT-0.4 SODIUM-143 POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-28 ANION GAP-11 . Discharge labs: [2196-11-12] 05:25AM BLOOD WBC-9.8 RBC-3.60* Hgb-10.6* Hct-31.7* MCV-88 MCH-29.5 MCHC-33.5 RDW-15.1 Plt Ct-397 [2196-11-12] 05:25AM BLOOD Glucose-113* UreaN-7 Creat-0.4 Na-140 K-3.9 Cl-104 HCO3-30 AnGap-10 [2196-11-10] 06:30AM BLOOD CK(CPK)-61 [2196-11-10] 06:30AM BLOOD CK-MB-6 [2196-11-11] 12:36PM BLOOD Mg-2.0 [2196-11-10] 06:30AM BLOOD Triglyc-139 HDL-36 CHOL/HD-3.2 LDLcalc-52 . Echocardiogram [11-11]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears depressed (ejection fraction 30 percent) secondary to hypokinesis of the midventricular segments and akinesis of the apex. The basal segments are hyperdynamic. Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The ascending aorta is mildly dilated. 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. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CARDIAC CATH: [2196-11-9] Left ventriculography: 1+ mitral regurgitation, LVEF=40%, extensive area of anteroapical and inferoapical akinesis LMCA: LAD: 30% mid LCx: no significant disease RCA: 40% mid Most consistent with Takotsubo syndrome. Brief Hospital Course: # CORONARIES: Cardiac catheterization did not show significant coronary artery disease. Venogram during catheterization showed characteristic apical ballooning, consistent with Takotsubo cardiomyopathy. EF 40%. 30% occlusion of LAD mid and 40% of RCA mid. The patient was originally treated with a low-dose beta blocker. Given the possibility of coronary vasospasm, however, the patient was switched to verapamil therapy. The patient was also started on low-dose ACE inhibitor therapy (lisinopril 5 mg PO daily), given her ejection fraction. Because of presence of some coronary disease, the patient was started on aspirin (81mg PO daily). . # PUMP: Found to have likely Takotsubo cardiomyopathy with LVEF=40%, areas of hypokinesis. Started on verapamil, lisinopril, ASA therapies. Patient was generally euvolemic by exam during her hospitalization. . # ASTHMA/COPD: The patient consistently had expiratory wheezing on exam. The patient was provided nebulizer treatments with ipratropium and albuterol. The patient was encouraged to follow up with PCP outpatient regarding daily inhaler treatment, as she was thought to have poorly controlled COPD that would benefit from therapy. . # DEPRESSION: Continued Lexapro home dose. . # ABDOMINAL WOUND CARE: s/p colectomy, cholecystectomy, lysis adhesion, hernia repair. Surgery was consulted--they think the patient can have her staples removed 7-10 days after her operation (Day 10=[2196-11-13]). We are trying to get patient an appointment with Surgery as outpatient to have staples removed and also to examine JP drains for removal. The patient's right JP drain still produced more than 30 mL per day on discharge; the left JP drain did not. Medications on Admission: Home: Lexapro 20mg daily Meds on Transfer from OSH: Folate 1mg daily Lopressor 25mg [Hospital1 ] (on hold b/c low bp (80/40)) Lovenox 70mg 9:30am today Protonix 40mg ASA 325mg last eve Plavix 600mg am Albuterol nebs Discharge Medications: 1. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 3. verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours): As needed for difficulty breathing. Disp:120 nebulizer treatment Refills:2 6. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed for dyspnea. Disp:120 nebulizer treatment Refills:2 Discharge Disposition: Extended Care Facility: [Hospital 66] Rehab Discharge Diagnosis: Takotsubo cardiomyopathy Colon cancer s/p colectomy Chronic obstructive pulmonary disease Asthma Depression 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 49817], It was a pleasure caring for you at [Hospital1 ] hospital. You were treated for a condition known as Takotsubo syndrome. This is a problem in your heart that acts like a heart attack. However, the arteries in your heart are not blocked in the way that heart attack arteries usually are. In order to help with this condition, we have started you on two medications: lisinopril and verapamil. You also had some plaque in your arteries, so we recommend that you take one baby aspirin per day. We also think that your breathing problems are not being treated fully right now. You should follow up with your primary care provider in order to determine which combination of medications would best control your symptoms of difficulty in breathing. START taking verapamil three times a day. START taking a baby aspirin (81 mg) once a day. START taking lisinopril once a day. Continue taking your Lexapro. You can have breathing treatments every six hours if you are short of breath. Followup Instructions: We are working to schedule the following appointments for you. You should call these doctors, however, to confirm the appointments. Surgery Appointment: to be scheduled for [11-14], [11-15] or [11-16] for wound assessment and JP drain removal. With: [Name6 (MD) 7870] [Name8 (MD) 7871], MD Where: [Hospital6 2910], [Apartment Address(1) 88401], [Location (un) 86] MA. Phone: [Telephone/Fax (1) 54970] . Please schedule an appointment with your primary care doctor after you get out of rehabilitation . Asked for cardiology f/u with Dr. [Last Name (STitle) 4920] (not [Doctor First Name ]) from [Hospital1 ].	[ "414.01", "429.83", "346.90", "518.0", "493.20", "153.9", "V45.72", "300.4" ]	icd9cm	[ [ [] ] ]	[ "88.56", "88.53", "37.23" ]	icd9pcs	[ [ [] ] ]	8688, 8738	5920, 7162	313, 479	8890, 8890	3963, 3963	10112, 10776	2667, 2790		7891, 8665		8759, 8869		7645, 7868			9073, 10089				4464, 5897					2805, 3235				2203, 2266			3251, 3944																253, 275					7175, 7619	507, 2131					3979, 4448				8905, 9049			2297, 2562			2153, 2183	2578, 2651
3,632	143,957	1482	Discharge summary	report	Admission Date: [2167-12-3] Discharge Date: [2167-12-24] Date of Birth: [2099-10-3] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: Fall Major Surgical or Invasive Procedure: ICP monitor (bolt) placed [12-5], converted to drain [12-6], removed [12-17]. PEG, percutaneous trach [12-14] performed at bedside. History of Present Illness: 68yo M h/o DM2, UC, pancreatitis, gout, EtOH, OA, portal HTN, melanoma who fell down the stairs at his home and hit his head on the concrete floor. He was found unconscious by his son. BIB EMS where had GCS 3 at the scene, awake and following commands. Past Medical History: Ulcerative Colitis- dx'ed in [2161]. Treated with Prednisone and Mecaptopur. Type II DM- takes 40-90 units of Lantus depending on glucose levels. EtOH abuse Pancreatitis Nephrolithiasis- [2152] Gout- last flare in [2141]. Osteoarthritis- arthroscopy in [2163] for medial meniscal tear; unsecessful. Social History: retired, drinks 3-4 drinks/day (cognac and vodka), no IV drug use, smoke 35 pack year hx Family History: mother with recurrent kidney stones Physical Exam: T 98.9, HR 100, BP 220/108, O2 sat 100%. agitated, GCS 8. pupils sluggish 3mm BL. posterior occiput lac 4cm spine: no step-off. CTAB RRR soft, NT, ND. fast neg. reducible ventral hernia rectal: normal tone, guaiac positive. pelvis stable. R ankle lac 3cm. LLL abrasion. Pertinent Results: [2167-12-2] 11:30PM BLOOD WBC-6.2 RBC-3.10* Hgb-12.2* Hct-34.2* MCV-110* MCH-39.3* MCHC-35.7* RDW-15.8* Plt Ct-369 [2167-12-2] 11:30PM BLOOD Plt Ct-369 [2167-12-2] 11:30PM BLOOD PT-12.7 PTT-21.4* INR(PT)-1.0 [2167-12-3] 06:00AM BLOOD Glucose-176* UreaN-18 Creat-0.5 Na-141 K-3.3 Cl-104 HCO3-24 AnGap-16 [2167-12-3] 06:00AM BLOOD ALT-25 AST-28 AlkPhos-47 Amylase-79 TotBili-0.6 [2167-12-3] 06:00AM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.8 Mg-1.5* [2167-12-6] 02:18AM BLOOD TSH-0.78 [2167-12-2] 11:30PM BLOOD ASA-NEG Ethanol-133* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2167-12-2] 11:57PM BLOOD Glucose-133* Lactate-3.6* Na-141 K-3.5 Cl-104 calHCO3-21 [2167-12-2] 11:30PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2167-12-2] 11:30PM URINE RBC-[10-30]* WBC-0-2 Bacteri-NONE Yeast-NONE Epi-<1 RenalEp-0-2 [2167-12-2] 11:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: 68yo M bib EMS to [Hospital1 18] trauma bay. Given thorough evaluation in trauma bay by trauma and ED staff. Was emergently intubated for airway protection secondary to agitation. Head CT revealed R EDH, SDH, and SAH with intraparenchymal bleed. Pt admitted to Trauma-SICU. Neurosurgery consult obtained with rec for SBP control, dilantin, and hourly neuro checks. Ortho consult obtained for multiple fx's; no acute surgical issue present. Pt had L cordis placed on HD 1. Given banana bag, CIWA protocol for h/o EtOH abuse; EtOh level 133, other tox negative. Given stress dose steroid with taper to home dose equivalent, and Kefzol. Hct dropped to 20 and pt given 2U PRBCs, subsequently stabilized to high-20's. Begun on TF via NGT. Repeat Head CT stable. Resumed on home meds for cardiac and IBD. Vent weaning initiated but limited by patient agitation. [Initials (NamePattern4) ] [Last Name (NamePattern4) 8745] bolt was placed on HD 4 for pt cont to not follow commands and become agitated. The following day the ICP rose to 30 and the bolt was changed to a drain by neurosurgery. Pt spiked a fever to 101 on HD 5, pancultures were negative. A neurology consult was obtained. MRI confirmed the initial Head CT findings, and a repeat Head CT showed no changes. An EEG on HD 6 showed diffused marked and severe encephalopathy and pt begun on depakote. Pt continue to spike fever to 101.4, repeat cultures were again negative, as was CDiff. On HD 9 LENIs were obtained for persistent fever of unknown origin, but were negative. On HD 12 the had a tracheostomy and PEG tube inserted. The pt remained stable until HD 14 when the ICP monitor was removed. On HD 15 a CTA of the chest was obtained for persistent tachypnea showing bilateral small PEs. Neurosurgery requested no anticoagulation or IVC filter be used unless the emboli were immediately life threatening. On HD 16 a culture of the pt's A-line tip grew out MRSA, and Vancomycin was started. On HD 17 ([2167-12-20]) the pt was transferred to the floor. He continuted to do well on the floor with occaisional episodes of agitation. On [2167-12-22] a behavioral neurology consult was obtained and the pt was started on Seroquel and Trazodone with excellent improvement of agitiation. He remained stable until discharge on [2167-12-24]. Medications on Admission: COdeine Folate MVI Bextra Mesalamine Prednisone Moxepril Mercaptopurine Asachol Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO QD (). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mesalamine 500 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 7. Peppermint Spirit Spirit Sig: 1-2 drops PO PRN (as needed). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4-6H (every 4 to 6 hours) as needed. 11. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for agitation. 13. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed for sleep aid. 14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q4-6H (every 4 to 6 hours) as needed. 15. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 18. Insulin Regular Human 150 unit/1.5 mL Syringe Sig: One (1) units Injection four times a day: see attached sliding scale. 19. Vancomycin HCl 1250 mg IV Q12H 20. Magnesium Sulfate 2 gm / 100 ml D5W IV ONCE Duration: 1 Doses Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: R EDH, R SDH, R SAH. intraparenchymal bleed. R rib fx x2. R clavicular head fx L glenoid fx. Discharge Condition: stable Discharge Instructions: Continue all medications as in hospital. Followup Instructions: Follow-up with Neurosurgery in 2 weeks [Telephone/Fax (1) 1669]. cd Follow-up with orthopedics in 2 weeks at ([Telephone/Fax (1) 8746]. Follow-up wtih trauma in 2 weeks ([Telephone/Fax (1) 376].	[ "995.92", "E879.8", "274.9", "715.90", "276.1", "305.00", "810.03", "250.00", "851.80", "V09.0", "572.3", "038.11", "807.03", "V10.82", "458.9", "V13.01", "811.03", "891.0", "E880.9", "556.9", "518.81", "873.0", "782.1", "415.19", "996.62", "348.30" ]	icd9cm	[ [ [] ] ]	[ "96.72", "43.11", "38.93", "99.15", "01.18", "38.7", "99.04", "31.1", "33.21", "02.2", "33.24", "38.91", "86.59", "96.04" ]	icd9pcs	[ [ [] ] ]	6825, 6904	2601, 4948	320, 470	7041, 7049	1556, 2578	7138, 7348	1214, 1251		5078, 6802		6925, 7020		4974, 5055			7073, 7115									1266, 1537																							276, 282						498, 753															775, 1092	1108, 1198
32,746	101,739	44040+58675	Discharge summary	report+addendum	Admission Date: [2189-11-14] Discharge Date: [2189-11-20] Service: MEDICINE Allergies: Sulfasalazine / Percocet Attending:[First Name3 (LF) 5119] Chief Complaint: Dyspnea, cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is an 84 yo M with PMH of CVA w/residual weakness, CAD s/p stent, h/o COPD, h/o aspiration PNA and chronic pleural effusion/LLL collapse presenting with worsened dyspnea and cough over two weeks. He reports that symptoms started two weeks ago with increased dyspnea and a "head cold" and progressed to a productive cough. He denies any fevers, does endorse 8 pound weight gain and some increased leg edema. He has also been using his nebulizer treatments more frequently as well increased from QHS to TID. . Of note he was recently admitted from [Date range (1) 94557] and treated with course of Vanc/Zosyn for HAP/aspiration pneumonia. In addition, his wife was recently admitted with GPR bacteremia with growth of Corynebacterium Diptheria on [3-27] blood culture bottles with concern from ID consult of infection rather than contamination. . VS on arrival to the ED T99.4 BP 138/86 HR 84 RR 16 97% on 4L NC. He had a CXR which showed stable LLL effusion with stable LLL consolidation. He was given levofloxacin and flagyl to treat aspiration pneumonia. While in the ED he had acute episode of tachycardia, likely Afib with rate in the 140's-150's with associated drop in blood pressure to 101/37. He was given 500ml NS and diltiazem 10mg IV x2, with improvement in HR to the 120's. He was admitted to the ICU [1-24] concern for persistent tachycardia with borderline blood pressure. Past Medical History: 1. Type 2 DM 2. Ulcerative colitis s/p ileostomy and colectomy 3. Hypertension 4. CAD s/p stent (90's) 5. s/p CVA X3 (94, 95, 96) 6. Prostate ca s/p XRT on Hormone therapy 7. Paget's disease 8. GERD 9. Esophageal ulcer and stricture 10. Venous stasis 11. Anxiety 12. Bladder Cancer secondary to prostate ca therapy 13. Macular Degeneration 14. Pulmonary Embolism [2170] 15. Anemia 16. Hyperlipidemia 17. Hearing Loss 18. Melanoma Social History: Patient lives at [Hospital ] [Hospital ] Nursing Home. Wife was in the ICU. No smoking, EtoH or IVDU. Has local sons. Family History: NC Physical Exam: ADMISSION PHYSICAL: VS: T98.3 HR 132 BP 149/64 RR 24 95% 3L NC Gen: alert, resting comfortably in NAD HEENT: NC AT, dry mucous membranes CV: irregularly irregular Lungs: breath sounds diminished at bases L> R, scattered ronchi, no wheezing Abd: distended, nontender, ileostomy, no rebound or guarding, normoactive bowel sounds Ext: 1+ pitting edema in RLE, trace LE edeam LLE, DP's palpable bilaterally Pertinent Results: Admission Labs: WBC-10.9 RBC-3.58* Hgb-10.2* Hct-30.7* MCV-86 MCH-28.4 MCHC-33.2 RDW-15.3 Plt Ct-295 Neuts-88.7* Lymphs-5.5* Monos-4.1 Eos-1.4 Baso-0.3 PT-12.5 PTT-23.8 INR(PT)-1.0 Glucose-248* UreaN-34* Creat-2.1* Na-135 K-5.3* Cl-93* HCO3-30 AnGap-17 Calcium-8.9 Phos-3.2 Mg-1.3* Lactate-2.6* . Labs on discharge: WBC-10.6 RBC-3.17* Hgb-8.7* Hct-27.1* MCV-86 MCH-27.6 MCHC-32.2 RDW-14.4 Plt Ct-316 BLOOD Glucose-202* UreaN-36* Creat-1.9* Na-137 K-3.9 Cl-95* HCO3-35* AnGap-11 BLOOD Calcium-9.2 Phos-3.1 Mg-1.9 . Studies: [2189-11-14] CXR - CONCLUSION: 1. Stable left basal effusion and left lower lobe consolidation. 2. Atelectasis at the right lung base. 3. Increased density and trabeculation in the right humerus is unchanged and most likely related to Paget's disease. Brief Hospital Course: 84 yo M with PMH of CVA w/residual weakness, CAD s/p stent, h/o COPD, h/o aspiration PNA and chronic pleural effusion/LLL collapse presenting with worsened dyspnea and cough over two weeks, with new Afib w/RVR in the ED. MICU Course: Mr. [Known lastname ] was admitted to the MICU with worsening and cough for 2 weeks in the setting of Afib with RVR. His SOB was in the setting of new onset afib and an 8lb weight gain and it was believed to due to afib. He was started on PO Diltiazem 15mg PO QID but he had converted back to sinus rhythm by the time he arrived in the ICU. He was continued on low dose Diltiazem for control of his afib. His amlodipine was stopped due to borderline hypotension in the setting of afib. He was continued on his home COPD regimen of Spiriva and Atrovent and also treated with Albuterol. He is being discharged on albuterol PRN. Sputum and blood cultures were obtained and were negative. Urine legionella was ordered and was negative. He was given an insulin sliding scale for his diabetes. His blood pressure stayed in the 120s-130s/50s and heart rate remained in the 70s throughout his MICU stay. . # GI Bleed: The patient was transferred to the floor. He had been started on a heparin drip and coumadin because of his A fib. He began to pass blood and maroon stool through his ostomy, and thus his heparin and coumadin was stopped. His HCT nadired at 25.9 and gradually increased without blood transfusion to 27.1. His HCT on admission was 30.7. The maroon stool resolved and the patient was passing only brown stool and no blood for the last 3 days prior to discharge. The goals of care were discussed with patient and he did not want aggressive care and he did not want a colonoscopy to investigate the source of the bleeding. . #Dyspnea/cough: The patient's dyspnea and cough were likely due to his COPD exacerbation in conjunction with his chronic lung disease. He has known pleural effusion and long standing emphysema. His atrial fibrillation likely exacerbated his dyspnea by causing some mild pulmonary edema. The patient has CHF and had an 8 lb weight gain before admission suggesting an element of heart failure. He was treated for a COPD exacerbation with prednisone 60mg x 3 days. He was given spiriva, atrovent, and albuterol PRN and was discharged on these medications. The patient is at high risk for aspiration and understands the risk of aspiration but has decided to eat a regular diet. His oxygen saturation was 99% on 2L at the time of discharge. Please use humidified oxygen as pt requests this for comfort given that pt has very dry throat. . # Afib w/RVR - He presented in A fib with RVR in the ED. He was placed on diltiazem. He was in NSR in the unit and has been since. He should be continued on the diltiazem. His amlodipine was stopped. . # CKD - The patient renal function slightly worsened while in the hospital with a creatinine of 2.1 from a baseline of 1.9. He was given 1L of NS given that this was thought to be prerenal. His creatinine returned to his baseline of 1.9 prior to discharge. The patient was continued on metolazone. . # Type 2 DM - The patient had several days of high blood sugars, at times greater than 500, in the setting of being on prednisone. His NPH was increased during this time. He was discharged on his home regimen of NPH. His glipizide was held while in the hospital and restarted on discharge. . # Hypertension - The patient has been normotensive since admission. He was on amlodipine as an out patient and is now on diltiazem. . # Skin Ulcer - The patient has a stage II cocyx ulcer which should be cared for as follows: clean with wound cleanser and pat dry. Use no sting barrier to wipe peri wound tissue and let dry. Then apply wound gel and cover with Allevyn foam dressing which should be changed q 3 days. The patient should be turned q2hrs and as needed. He should also be getting up out of bed to his chair. Sitting time should be limited to 1 hr at a time with a 4 inch foam cushion. He also has skin tears between his thumb and first finger bilaterally which should be cared for as follows: on hands bilaterally between thumbs and first finger has skin tears. Apply aquaphor and 4 x 4 to cover. This should be changed daily. Medications on Admission: Amlodipine 5 mg Tablet PO DAILY Multivitamin One (1) Tablet PO DAILY (Daily) Acetaminophen 1000mg QHS Omeprazole 20 mg PO DAILY Clopidogrel 75 mg Tablet PO DAILY Simvastatin 20 mg PO DAILY Bicalutamide 50 mg PO DAILY Tiotropium Bromide 18 mcg One (1) Cap Inhalation DAILY Ditropan 10mg daily FerrouSul 325mg daily Glipizide 5 mg [Hospital1 ] Ocuvite zaroxyln 2.5mg daily Wellbutrin 37.5mg [Hospital1 ] Atrovent nebs TID NPH 8 unis SC QAM Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO at bedtime. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Ditropan XL 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Disp:30 Tab,Sust Rel Osmotic Push 24hr(s) Refills:2 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Ocuvite Tablet Sig: One (1) Tablet PO once a day. 11. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 12. Bupropion 75 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Other 8 units sc qAM 14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 15. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) cap Inhalation three times a day. 16. humalog sliding scale pls resume prior scale Finger sticks [Hospital1 ] <60 give [Location (un) 2452] juice or [12-24] amp of D50 and call physician 60-249 do nothing 251-300 4 units 301-350 6 units 351-400 8 units >400 give 10 units and call physician 17. Diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day): hold for HR<60 or SBP<100. 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation q4hrs as needed for shortness of breath or wheezing. 19. Procrit 10,000 unit/mL Solution Sig: One (1) dose Injection every 2 weeks. 20. Dextromethorphan Poly Complex 30 mg/5 mL Suspension, Sust.Release 12 hr Sig: One (1) dose PO every six (6) hours as needed for cough. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: Primary diagnosis: A fib COPD exacerbation GI bleed . Secondary diagnosis: DM Ulcerative colitis s/p ileostomy and colectomy HTN CAD s/p stent CVA x3 Prostate cancer Bladder cancer Paget disease GERD Esophageal ulcer and stricture Venous stasis Anxiety Macular degeneration Pulmonary embolism Anemia Hyperlipidemia Hearing loss Melanoma Discharge Condition: Stable. Oxygen at 2 liters which is his baseline. Slightly decreased BS at bases of his lungs with some crackles. Cough. Afebrile. Discharge Instructions: You were admitted to the intensive care unit with Atrial fibrillation. This lead to some difficulty breathing. You were also found to have a COPD exacerbation which was treated with prednisone. You now are only requiring your baseline amount of oxygen of 2L. Being on the prednisone caused your blood sugars to be high but they have greatly improved. Because of your A fib you were started on a blood thinner which caused you to bleed into your ostomy bag. You decided that you did not want anything invasive done by gastroenterology. Your anticoagulation was stopped and you understand the risks of not being anticoagulated. Please return to the hospital if you develop blood in your ostomy, worsening shortness of breath, or any other new concerning symptom. Followup Instructions: Please follow up with a physician at your nursing facility. [First Name7 (NamePattern1) 1569] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 5122] Completed by:[2189-11-20] Name: [Known lastname ],[Known firstname ] Unit No: [Numeric Identifier 14949] Admission Date: [2189-11-14] Discharge Date: [2189-11-20] Date of Birth: [2105-4-8] Sex: M Service: MEDICINE Allergies: Sulfasalazine / Percocet Attending:[First Name3 (LF) 954] Addendum: Pls note under medications: Other should read- NPH 8 units sc qAm Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital 345] Nursing Home - [Location (un) ] [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 955] Completed by:[2189-11-20]	[ "530.3", "V12.51", "362.50", "428.0", "V10.51", "E934.2", "250.02", "V15.3", "459.81", "882.0", "V46.2", "438.89", "V10.46", "414.01", "530.20", "491.21", "V44.3", "403.90", "272.4", "788.30", "585.3", "V58.67", "530.81", "300.4", "511.9", "707.03", "427.31", "389.9", "556.9", "707.22", "V10.82", "E942.9", "731.0", "729.89", "280.0", "465.9", "V45.82", "578.1", "458.29" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12419, 12683	3588, 7860	250, 256	10786, 10922	2783, 2783	11738, 12396	2339, 2344		8356, 10288		10426, 10426		7886, 8333			10946, 11715									2359, 2764																							195, 212				3099, 3565		284, 1721			10501, 10765		2799, 3080	10445, 10480									1743, 2179	2195, 2323
4,329	190,063	45171	Discharge summary	report	Admission Date: [2141-9-28] Discharge Date: [2140-10-3] Service: CCU CHIEF COMPLAINT: Status post left internal carotid artery angioplasty and stenting. HISTORY OF PRESENT ILLNESS: This is an 80-year-old woman with a history of diabetes, coronary artery disease, carotid until three months ago, when she developed word-finding difficulty. Her carotid Doppler on [2140-9-28] showed 80% to 99% stenosis of left carotid artery, and 70% to 79% stenosis of the right carotid artery. Otherwise, she denied any focal deficits, including weakness, numbness, diplopia, dysphasia, field cuts, or gait difficulty. She is known to have stocking-glove numbness and hypesthesia secondary to diabetic She was admitted on [2140-9-28] for a left internal carotid artery angioplasty and stenting. Her creatinine on admission was 2.3. She was prehydrated with 0.5% normal saline and was given Mucormyst. She went for left internal carotid artery angioplasty and stenting on [2140-9-29], the date of transfer to CCU, without any complications. She was on dopamine drip initially due to carotid procedure which induced bradycardia and no hypotension. She was transferred to CCU for close monitoring. PAST MEDICAL HISTORY: 1. Carotid disease: Left internal carotid and right carotid artery stenosis. For details, see carotid Doppler. 2. Coronary artery disease: Status post CABG in [2133], status post PTCA of LIMA in [2136]. 3. Chronic anemia: Iron deficiency. 4. Small ASD by echo in [2133]. 5. History of TIA and CVA in [2133]. Aspirin and Plavix since. 6. Post-stroke seizure in [2133]. 7. Diabetes with peripheral neuropathy, retinopathy and nephropathy. HbA1C in [2139-10-15] was 7.4. 8. Chronic renal insufficiency, creatinine ranging from 1.6 to 2.0. 9. Cervical spondylosis, C4-C5, C5-C6, T8-T9, L5-S1. 10. Left chronic lumbosacral radiculopathy. 11. Hypertension. 12. Hypercholesterolemia. 13. Status post bilateral cataract surgery. 14. Status post left upper extremity fracture repair. MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Plavix 75 mg q.d. 3. Lipitor 10 mg q.d. 4. Glyburide 10 mg b.i.d. 5. Imdur 30 mg b.i.d. 6. Neurontin 300 mg b.i.d. 7. Zyprexa 2.5 mg q.h.s. 8. Atenolol 25 mg q.d. 9. Iron sulfate 325 mg q.d. 10. Depakote 250 mg q.h.s. 11. Lasix 20 mg b.i.d. 12. Calcium 600 mg b.i.d. 13. Tylenol p.r.n. ALLERGIES: No known drug allergies. FAMILY HISTORY: Negative for CVA. Father passed away in car accident. Mother passed away from colon cancer. SOCIAL HISTORY: No tobacco or alcohol. Lives with husband at home. Ambulates with cane for a short distance, wheelchair for a long distance. PHYSICAL EXAMINATION ON ADMISSION TO CCU: Temperature 96.2??????, heart rate 85, blood pressure 116/44, O2 sat 91% to 93% on room air, 96% to 100% with 4 liters by nasal cannula. General: Lying in bed in no acute distress. Head and neck: Normocephalic, atraumatic. Oropharynx clear. Soft left carotid bruit. Cardiovascular: Normal S1 and S2. S3 present. Lungs are clear to auscultation bilaterally anteriorly. Abdomen soft, obese, nondistended, nontender. Extremities: No pitting edema. Bilateral distal pulses. Right groin has small ecchymosis, no bruit, slightly tender. Neuro: Awake, alert and oriented. Cranial nerves II - XII grossly intact. Sensory decreased in bilateral lower extremities. Strength 4+ to [4-17] bilaterally. Nonfocal exam. LABORATORY: White count of 8.8, hematocrit 27.7 which is down from 31.1 pre-procedure, platelets 242, sodium 136, potassium 4.4, chloride 101, BUN 87, creatinine 1.7, glucose 189, calcium 11.3, mag 2.4, phos 4.6. She had a head MRI without contrast on [2140-9-28], no acute infarct, advanced chronic microvascular ischemic changes involving deep central white matter, 70% stenosis precavernous and cavernous portion of the left internal carotid artery, less than 30% stenosis of the mid-basilar artery. Significant carotid stenosis by Doppler. Left carotid 90% to 99%. HOSPITAL COURSE: The patient remained stable during the hospital stay. She was off dopamine soon in CCU. She was transfused with 2 units of packed red blood cells for a hematocrit of 24.6 post-procedure and her hematocrit has remained stable since. She was restarted on all her home medications on hospital day #2. She was scheduled for discharge the next day. However, on hospital day #3, she was found to have a soft bruit at her right groin site. An ultrasound revealed a 2.6 cm pseudoaneurysm just superior and medial to the puncture site. Therefore, she stayed in the hospital awaiting IR to perform ultrasound-guided thrombin injection. After physical therapy evaluation, rehab was recommended, given the patient's poor functional status. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Rehab facility. DISCHARGE DIAGNOSES: 1. Carotid disease, status post left internal carotid artery stent. 2. Right femoral pseudoaneurysm, status post thrombin injection. 3. Coronary artery disease. 4. Diabetes. 5. Hypercholesterolemia. 6. Chronic renal insufficiency. DISCHARGE MEDICATIONS: 1. Furosemide 20 mg b.i.d. 2. Atenolol 25 mg q.d. 3. Imdur 30 mg b.i.d. 4. Olanzapine 2.5 mg q.d. 5. Lipitor 10 mg q.d. 6. Glyburide 10 mg b.i.d. 7. Calcium carbonate 500 mg b.i.d. 8. Potassium acetate 2 tablets t.i.d. 9. Iron sulfate 325 mg q.d. 10. Depakote 250 mg q.h.s. 11. Neurontin 300 mg t.i.d. 12. Plavix 75 mg q.d. 13. Aspirin 325 mg q.d. 14. Sublingual nitroglycerin p.r.n. Her most labs on discharge show a white count 6.3, crit 31.6, platelets 174, sodium 143, potassium 4.8, chloride 106, bicarb 28, BUN 71, creatinine 1.9, glucose 84, calcium 11.6, mag 2.3, phos 3.7. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. [MD Number(1) 5211] Dictated By:[Name8 (MD) 96551] MEDQUIST36 D: [2140-10-2] 14:14 T: [2140-10-2] 14:13 JOB#: [Job Number ]	[ "250.40", "403.90", "433.10", "428.0", "V45.81", "285.9", "V45.82", "998.2", "333.82" ]	icd9cm	[ [ [] ] ]	[ "99.29", "39.90", "88.41", "39.50" ]	icd9pcs	[ [ [] ] ]				4809, 4854			2447, 2542	4875, 5113	5136, 5989					4050, 4787																																		104, 172						201, 1221															1243, 2430	2558, 4033
50,429	133,298	39568	Discharge summary	report	Admission Date: [2156-10-4] Discharge Date: [2156-10-10] Date of Birth: [2077-6-24] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: s/p NSTEMI in [2156-5-8], for surgical evaluation Major Surgical or Invasive Procedure: coronary artery bypass graft x2 History of Present Illness: 79 year old man s/p NSTEMI in setting of acute gallstone pancreatitis. Cardiac catheterization at that time revealed 2 vessel coroanary artery disease with 60-90% LAD and D2 80% and 90% l-PDA. Past Medical History: -Coronary artery disease -Hypertension -History of TIA Dyslipidemia -Gallstone pancreatitis s/p ERCP-lap chole -Urosepsis(complication of lap chole) -Obesity -Benign Prostatic Hypertrophy-urinary retention -Gout -Rib fractures-s/p fall Prostate CA for TURP in near future Past Surgical History: ERCP-Laproscopic Cholecystectomy [5-/2156] Social History: Race: caucasian Last Dental Exam: Lives with:son (widowed) Occupation: retired civil engineer Tobacco: no ETOH: 4 drinks/day Recreational Drugs: no Family History: Family History: non contributory Physical Exam: Physical Exam Pulse: 61 Resp: O2 sat: 95%-RA B/P Right: Left: 134/72 Height: 5'7" Weight: 199 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs crackles bilaterally [] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]obese Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact Pertinent Results: [2156-10-9] CHEST RADIOGRAPH INDICATION: Left pneumothorax, left effusion, left rib fracture, assessment for interval change. COMPARISON: [2156-10-6]. FINDINGS: As compared to the previous radiograph, there is no more evidence of a left-sided pneumothorax. Unchanged displaced left rib fractures with local pleural thickening and moderate pleural effusion. Basal left atelectasis and retrocardiac atelectasis. No newly appeared focal parenchymal opacities. Moderate cardiomegaly without evidence of pulmonary edema. Unchanged alignment of sternal wires, unchanged right jugular catheter. labs [2156-10-10] INR 2.9 HCT 30 BUN/Creat 18/0.8 K 4.1 Brief Hospital Course: 79 year old man s/p NSTEMI in setting of acute gallstone pancreatitis. Cardiac catheterization at that time revealed 2 vessel coroanary artery disease with 60-90% LAD and D2 80% and 90% l-PDA. Mr. [Known lastname 1637] was admitted and taken to the operating room on [2156-10-4] for Coronary artery bypass grafting x2-left internal mammary artery graft to left anterior descending and reversed saphenous vein graft to the left- sided posterior descending artery. Post operatively he was admiited to the ICU intubated and sedated. Within 24 hours he awoke neurologically intact and was weaned from the ventilator and extubated. He was begun on betablockers, statins and diuresed toward his pre-operative weight. His chest tubes and pacing wires were removed per protocol. He was transferred fromt he ICU to the step down unit. Mr. [Known lastname 1637] developed post operative atrial fibrillation and was started on amiodarone and coumadin therapy. He converted to Sinus rhythm and has remained in sinus rhythm. He was evaluated by physical therapy for strength and conditioning. On POD# 4 Mr. [Known lastname 1637] reported seeing flashes of color which he had noticed 2 days prior but felt the episodes were decreasing in frequency. He was examined and evaluated by opthalology and no occular pathology was found. Occular symptoms had completely resolved on POD#6. He was cleared for discharge to rehab on POD#6 by Dr. [Last Name (STitle) ]. Mr. [Known lastname 1637] was discharged to [Location (un) 582] in [Location (un) 620]. [Telephone/Fax (1) 63378]. Medications on Admission: Atenolol 50", Diovan 160', Lasix 20 QOD, Aggrenox 25/200", Allopurinol 300', Flonase, Amibien prn *preop for TURP(prostate ca) after CABG, has a foley in place w/leg bag-leave in Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Warfarin 1 mg Tablet Sig: Dose as directed Tablet PO DAILY (Daily): NO coumadin on [2156-10-10] INR 2.9. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 13. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: 2 tabs daily for 7 days then 1 tab daily ongoing. 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day): while on lasix. 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: until lower extremity edema resolves. Discharge Disposition: Extended Care Facility: [Location (un) 582] at [Location (un) 620] Discharge Diagnosis: CABG x2(LIMA-LAD, SVG-LPDA) Coronary artery disease, Hypertension, Hx TIA's, Dyslipidemia, Gallstone pancreatitis s/p ERCP-lap chole, Urosepsis(complication of lap chole), Obesity, Benign Prostatic Hypertrophy-urinary retention, Gout, Rib fractures-s/p fall, Prostate CA for TURP in near future, ERCP-Laproscopic Cholecystectomy [5-/2156] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait and walker Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 2+ right> left 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: the cardiac surgical office will contact you with dates and times of your follow up appointments with you Surgeon and Cardiologist. Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] [Telephone/Fax (1) 28262] in [4-12] weeks Please follow up with your urologist regarding scheduling your prostatectomy. Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2-2.5 First draw monday [2156-10-11] Completed by:[2156-10-11**]	[ "997.1", "E878.2", "E849.7", "285.1", "278.00", "401.9", "414.01", "600.00", "272.4", "185", "427.31" ]	icd9cm	[ [ [] ] ]	[ "36.11", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]	5798, 5875	2377, 3974	376, 410	6263, 6503	1691, 2354	7343, 8004	1198, 1216		4211, 5775		5896, 6242		4000, 4188			6527, 7320								951, 1000	1231, 1672																							283, 338						438, 633															656, 928	1016, 1166
4,390	100,795	46620	Discharge summary	report	Admission Date: [2117-10-27] Discharge Date: [2117-11-4] Date of Birth: [2053-2-7] Sex: F Service: MEDICINE Allergies: Flagyl Attending:[First Name3 (LF) 633] Chief Complaint: LLQ pain Major Surgical or Invasive Procedure: Placement of a left ureteral stent History of Present Illness: 64 yo F w/ PMH of CHF, IDDM, hypothyroidism, ventricular arrythmia with ICD who is admitted to the [Hospital Unit Name 153] with GNR bacteremia s/p cystoscopy and stent placement for nephrolithiasis with difficulty extubating. Pt presented to the ED the day prior to transfer with left flank pain, nausea and vomiting. KUB and CT abdomen showed 8-mm stone within the proximal left ureter resulting in mild hydronephrosis. When she was in the ED she got a dose of ceftriaxone and a dose of ampicillin. She was admitted to urology where they were planning to do an elective stent placement. However overnight she developed low grade fevers to 100.8 and her blood cultures grew out GNR and her procedure was moved up to be emergent. She had a stent placed in her left ureter, and she received 700ml fluids total in the OR plus 125cc in the PACU. Post operatively she remained hypotensive (to unclear BPs) on 0.3 of phenylepherine which was weaned off in the PACU. In the PACU when they tried to wean down to extubate, on CPAP she was only pulling in tidal volumes in the 100s. She received Vanc and Cefepime in the PACU. Blood sugars were apparently elevated before to unclear levels, got 10u subcu regular noonish. Only value recorded is 220s. Reportedly good UOP while in PACU. She is transferred to the [Hospital Unit Name 153] for management of her blood pressure and respiratory status. On arrival to the MICU, patient's VS. 99.8 133/69 92 100% on CMV with TV 500, RR 15, FiO2 40% Review of systems: Unable to obtain [3-11] intubation Past Medical History: Diabetes CHF Depression Diverticulitis Hypothyroidism Spinal stenosis ARthritis Obesity Ventricular Arrhythmia PVD Neuropathic pain Hx hematuria Social History: The patient lives with her daughter. She previously worked as a social worker. She does not smoke or drink alcohol. She has remote cocaine use (quit [2099]) and alcohol use, 45 pack year tobacco hx, quit in [2099]. Family History: No family history of recurrent skin infections. No family history of premature coronary artery disease or sudden death. Father had kidney stones. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 99.8 133/69 92 100% on CMV with TV 500, RR 15, FiO2 40% General: NAD, appears comfortable, AAOx3 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, difficult to assess JVD d/t body habitus CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Dimished breath sounds at bases bilaterally anteriorly Abdomen: soft, tender at lower quadrants, maximally on LLQ, non-distended, no organomegaly, no rebound or guarding. Hypoactive bowel sounds. Ext: Trace edema in feet b/l. Warm, well perfused, 2+ pulses, no clubbing, cyanosis Pertinent Results: KUB [2117-10-27]: IMPRESSION: 8-mm stone within the proximal left ureter resulting in mild hydronephrosis. CT abd: IMPRESSION: 7-mm proximal ureteral stone at the level of the L3 vertebral body; upstream left hydroureteronephrosis with delayed excretion of contrast in the dilated left collecting system and proximal ureter. No definite contrast seen in the left ureter distal to the level of the renal stone. CXR [2117-10-28]: As compared to the previous radiograph, the patient has been intubated. The tip of the endotracheal tube projects 3 cm above the carina. A left pectoral pacemaker is in unchanged position. In the interval, lung volumes have substantially decreased, there are signs indicative of mild-to-moderate pulmonary edema and atelectasis at both lung bases. No evidence of pneumonia. Short-term followup with chest radiographs is required. . ECHO: The left atrium is elongated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. Compared with the prior study (images reviewed) of [2115-11-8], the right ventricle appears dilated and hypokinetic and there is evidence of pressure/volume overload of the left ventricle. Findings are suggestive of acute right heart strain - probably from pulmonary embolism although right ventricular ischemia is also possible. . CTA chest: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Mild pulmonary edema and bilateral atelectasis, right greater than left. 3. Incompletely imaged left kidney showing a 6-mm stone and start of the double J-stent but also small foci of air in the kidney of unclear significance. . microbiology: [2117-10-29] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2117-10-29] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2117-10-28] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2117-10-28] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2117-10-28] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2117-10-28] URINE URINE CULTURE-FINAL INPATIENT [2117-10-27] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI} EMERGENCY [Hospital1 ] URINE CULTURE (Final [2117-10-29]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [2117-10-27] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL FINAL REPORT [2117-10-30] Blood Culture, Routine (Final [2117-10-30]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [2117-10-31] 08:10AM BLOOD WBC-5.7 RBC-4.12* Hgb-12.4 Hct-38.8 MCV-94 MCH-30.2 MCHC-32.0 RDW-13.6 Plt Ct-150 [2117-10-30] 08:15AM BLOOD WBC-5.9 RBC-3.86* Hgb-12.1 Hct-36.6 MCV-95 MCH-31.3 MCHC-33.1 RDW-13.6 Plt Ct-134* [2117-10-29] 07:18PM BLOOD Hct-37.1 [2117-10-29] 02:44AM BLOOD WBC-8.6 RBC-3.93* Hgb-12.3 Hct-37.1 MCV-94 MCH-31.3 MCHC-33.2 RDW-13.8 Plt Ct-122* [2117-10-28] 12:15PM BLOOD WBC-11.9* RBC-3.95* Hgb-12.4 Hct-37.4 MCV-95 MCH-31.3 MCHC-33.0 RDW-14.7 Plt Ct-144* [2117-10-28] 07:10AM BLOOD WBC-12.4# RBC-3.83 Hgb-11.9* Hct-36.2 MCV-95 MCH-31.1 MCHC-32.9 RDW-13.7 Plt Ct-140* [2117-10-27] 11:53AM BLOOD WBC-8.2 RBC-4.57 Hgb-14.3 Hct-43.0 MCV-94 MCH-31.3 MCHC-33.3 RDW-13.4 Plt Ct-210 [2117-10-30] 08:15AM BLOOD Neuts-57 Bands-0 Lymphs-30 Monos-11 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [2117-10-29] 02:44AM BLOOD Neuts-71.9* Lymphs-18.4 Monos-7.9 Eos-1.6 Baso-0.3 [2117-10-31] 08:10AM BLOOD Plt Ct-150 [2117-10-30] 08:15AM BLOOD Plt Smr-LOW Plt Ct-134* [2117-10-30] 08:15AM BLOOD PT-13.5* PTT-37.1* INR(PT)-1.3* [2117-10-29] 06:11PM BLOOD PT-14.5* PTT-40.8* INR(PT)-1.4* [2117-10-29] 02:44AM BLOOD Plt Ct-122* [2117-10-29] 02:44AM BLOOD PT-17.1* PTT-31.8 INR(PT)-1.6* [2117-10-28] 12:15PM BLOOD Plt Ct-144* [2117-10-28] 07:10AM BLOOD Plt Ct-140* [2117-10-27] 11:53AM BLOOD Plt Ct-210 [2117-10-27] 11:53AM BLOOD PT-13.3* PTT-33.5 INR(PT)-1.2* [2117-10-29] 06:11PM BLOOD Fibrino-597* [2117-11-3] 03:00PM BLOOD Glucose-169* UreaN-14 Creat-0.7 Na-138 K-4.4 Cl-94* HCO3-36* AnGap-12 [2117-11-3] 07:00AM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-141 K-4.1 Cl-95* HCO3-44* AnGap-6* [2117-11-2] 06:40AM BLOOD Glucose-186* UreaN-12 Creat-0.9 Na-140 K-4.5 Cl-94* HCO3-46* AnGap-5* [2117-11-1] 06:30AM BLOOD Glucose-143* UreaN-14 Creat-0.8 Na-140 K-4.3 Cl-95* HCO3-40* AnGap-9 [2117-10-30] 08:15AM BLOOD Glucose-235* UreaN-14 Creat-0.7 Na-136 K-4.5 Cl-98 HCO3-33* AnGap-10 [2117-10-29] 02:44AM BLOOD Glucose-215* UreaN-13 Creat-0.7 Na-136 K-4.1 Cl-100 HCO3-29 AnGap-11 [2117-10-28] 12:15PM BLOOD Glucose-229* UreaN-19 Creat-1.0 Na-136 K-4.1 Cl-97 HCO3-29 AnGap-14 [2117-10-28] 07:10AM BLOOD Glucose-241* UreaN-17 Creat-1.0 Na-137 K-4.3 Cl-99 HCO3-30 AnGap-12 [2117-10-27] 11:53AM BLOOD Glucose-231* UreaN-14 Creat-0.9 Na-140 K-4.3 Cl-100 HCO3-34* AnGap-10 [2117-11-3] 03:36PM BLOOD CK(CPK)-176 [2117-10-27] 11:53AM BLOOD ALT-42* AST-48* AlkPhos-132* TotBili-0.5 [2117-10-27] 11:53AM BLOOD Lipase-20 [2117-11-3] 03:36PM BLOOD CK-MB-2 cTropnT-<0.01 [2117-11-3] 07:00AM BLOOD cTropnT-<0.01 [2117-11-3] 03:00PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.3 [2117-10-29] 06:11PM BLOOD Hapto-223* [2117-10-29] 02:44AM BLOOD %HbA1c-9.7* eAG-232* [2117-11-2] 06:40AM BLOOD TSH-3.3 [2117-11-2] 06:40AM BLOOD Cortsol-16.9 [2117-11-1] 03:40PM BLOOD Type-ART Temp-37 pO2-84* pCO2-67* pH-7.39 calTCO2-42* Base XS-11 Intubat-NOT INTUBA Brief Hospital Course: 64 yo F w/ complex PMH including systolic CHF, DM2, s/p ICD, hypothyroidism, OSA who was taken to the OR urgently for septic nephrolithiasis with Ecoli bacteremia who developed post-op hypotension transiently requiring pressors and failure to extubate. . #E.coli urosepsis with obstructive uropathy/nephrolithiasis and hydronephrosis- Imaging revealed nephrolithiasis and hydronephrosis. Bcx and UCX revealed Ecoli. Pt was taken to the OR for uretral stent placement on [2117-10-28].[Name (NI) ], pt was hypotensive and there was a failure to extubate and pt was admitted to the ICU. Upon admission to the ICU, she was no longer hypotensive and HR was within normal limits. Vancomycin and cefepime were initially continued. Pt improved and was transferred to the medical floor on [2117-10-29]. Her antibiotics were weaned to IV ceftriaxone given susceptibility pattern. Plan is to continue IV antibiotics through [2117-11-11]. Picc line was placed. Pt will be following up in urology clinic on [2117-11-17] for further evaluation and discussion on further treatment of nephrolithiasis and hydronephrosis. Of note, pt still with bloody tinged urine. Pt will be discharged with the foley catheter in place. Would plan for voiding trial and foley removal as soon as urine becomes more clear. #Respiratory failure/hypoxia/hypercarbia- Patient was intubated for the procedure and likely failed initial weaning because it was initiated when she was still too sedated. She had successful SBT on admission to the ICU and was extubated within two hours of admission. However, while on the medical floor, pt was noted to have asymptomatic hypoxemia, often requiring 1-2L NC. Pulmonary was consulted and felt as though pt likely has obesity hypoventilation and OSA. CPAP initiated. Pt will be discharged with oxygen NC and CPAP with instructions to follow up in pulmonary clinic. Of note, pt's echo revealed RV dilation with moderate global free wall hypokinesis. RV pressure overload noted. Echo suggesting RV strain. However, CTA of the chest was performed on the same day and was negative for PE, showing some mild pulmonary edema. In addition, EKG performed and similar to prior. Cardiac enzymes were negative. Some atelectasis noted, but no sign of PNA. . #systolic heart failure-Diuretics, BB, and [Last Name (un) ] initially held in ICU due to sepsis. Lasix, spironolactone and BB Restarted. Plan to restart [Last Name (un) ] upon discharge. TTE revealed evidence of pressure overload and CTA revealed some pulmonary edema. Pt was continued on her home dose of lasix 20mg daily and given an additional dose of 20mg IV lasix on [2117-11-3] given CTA findings. No evidence for ischemia. CTA without PE. ECHO suggested acute RV strain, however, EKG did not reveal ischemia, cardiac enzymes were negative. . #DM: On U500 at home, has not been seen at [Last Name (un) ] in over 1 yr. Blood sugars here had have been in 200s. [Last Name (un) ] was consulted. Per their final recommendations: lantus 45units, 15units of standing premeal humalog with humalog sliding scale. Pt will need to follow up with [Last Name (un) ] upon discharge from rehab or during rehab. . #H/o Ventricular Arrhythmia: ICD in place . #hypothyroidism-continued home levothyroxine 200mcg qday . #Depression: continue home meds Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR. 1. BuPROPion (Sustained Release) 300 mg PO QAM 2. Citalopram 40 mg PO DAILY 3. Fluocinonide 0.05% Ointment 1 Appl TP [Hospital1 ] Apply to legs and feet twice a day, avoid use on face, unerarms, and groin. 4. Furosemide 20 mg PO DAILY As needed for SOB or swelling. 5. Gabapentin 600 mg PO DAILY 6. Levothyroxine Sodium 200 mcg PO DAILY 7. Metoprolol Succinate XL 200 mg PO DAILY Please hold for SBP <100 or HR <50. 8. Nystatin-Triamcinolone Ointment 1 Appl TP [Hospital1 ]:PRN Rash 9. Simvastatin 40 mg PO DAILY 10. Spironolactone 25 mg PO DAILY Please hold for SBP <100. 11. traZODONE 50 mg PO HS:PRN Insomnia Please hold for oversedation 12. Valsartan 40 mg PO DAILY 13. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 300 mg PO QAM 3. Citalopram 40 mg PO DAILY 4. Furosemide 20 mg PO DAILY As needed for SOB or swelling. 5. Levothyroxine Sodium 200 mcg PO DAILY 6. Metoprolol Succinate XL 200 mg PO DAILY Please hold for SBP <100 or HR <50. 7. Simvastatin 40 mg PO DAILY 8. Spironolactone 25 mg PO DAILY Please hold for SBP <100. 9. Gabapentin 100 mg PO DAILY 10. CeftriaXONE 2 gm IV Q24H please prepare in normal saline (no dextrose) given very high blood sugars 11. Docusate Sodium 100 mg PO BID please hold for loose stools 12. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain hold for sedation 13. Senna 1 TAB PO DAILY please hold for loose stools 14. Fluticasone Propionate NASAL 2 SPRY NU DAILY 15. Nystatin-Triamcinolone Ointment 1 Appl TP [Hospital1 ]:PRN Rash 16. Fluocinonide 0.05% Ointment 1 Appl TP [Hospital1 ] Apply to legs and feet twice a day, avoid use on face, unerarms, and groin. 17. Polyethylene Glycol 17 g PO DAILY 18. Valsartan 40 mg PO DAILY THis medication was held during admission. PLease restart [11-5] and monitor creatinine 19. Glargine 45 Units Breakfast Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 15 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Obstructive nephrolithiasis of the left ureter with gram negative septicemia resulting from this and associated bacterial urinary tract infection. . Hypoxemia metabolic acidosis hypercarbia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for evaluation of a severe kidney infection causing sepsis. You were found to have a kidney stone and blockage in your kidney due to your kidney stone. You symptoms improved with urinary drainage and antibiotics. . You were noted to have low oxygen levels. For this, you were evaluated by the lung doctors who are recommending that you have an outpatient sleep study and lung function testing. See below. Followup Instructions: Department: SURGICAL SPECIALTIES When: WEDNESDAY [2117-11-17] at 10:30 AM With: UROLOGY UNIT [Telephone/Fax (1) 164] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital3 249] [Hospital1 ]/EAST Address: [Location (un) ], E/CC-6, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2010] Department: PULMONARY FUNCTION LAB When: MONDAY [2117-11-29] at 3:40 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: MONDAY [2117-11-29] at 4:00 PM With: DR. [Last Name (STitle) ]/DR. [Last Name (STitle) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: RADIOLOGY When: WEDNESDAY [2117-12-15] at 10:20 AM With: RADIOLOGY [Telephone/Fax (1) 590] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PODIATRY When: THURSDAY [2118-1-13] at 10:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM [Telephone/Fax (1) 543] Building: Ba [Hospital Unit Name 723] ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "327.23", "428.0", "278.00", "278.03", "401.1", "995.91", "V49.86", "428.22", "V43.65", "287.5", "244.9", "250.62", "427.1", "591", "V15.82", "250.52", "443.9", "V58.67", "362.01", "276.4", "592.1", "518.0", "V85.37", "518.81", "599.0", "V45.02", "038.42", "311", "357.2", "714.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "59.8", "38.97", "87.74", "38.93", "57.32" ]	icd9pcs	[ [ [] ] ]	16735, 16805	11225, 14569	276, 313	17039, 17039	3119, 11202	17669, 19390	2333, 2480		15446, 16712		16826, 17018		14595, 15423			17222, 17646									2495, 3100																		1864, 1905					227, 238						341, 1844									17054, 17198						1927, 2074	2090, 2317
30,314	181,929	32478	Discharge summary	report	Admission Date: [2175-9-29] Discharge Date: [2175-10-10] Service: MEDICINE Allergies: Cephalosporins / Macrodantin / Sulfa (Sulfonamides) / Penicillins Attending:[First Name3 (LF) 1162] Chief Complaint: Syncope after Dialysis Major Surgical or Invasive Procedure: new tunneled catheter placement History of Present Illness: Ms. [Known lastname 22437] is a 84 year-old female with a history of diabetes and ESRD on dialysis who presented with syncope post-dialysis. Patient reported that she was at dialysis and completed her session but does not remember any further details. She denied head trauma or prior episodes of syncope as well as fevers, chills, rigors, chest pain or shortness of breath. She was transferred to [Hospital1 18] where her blood pressures were in the 90s systolic. Labs showed an elevated alk phos, troponin I of 0.07 with a CK of 23. WBC was 15.6 with 84% neutrophils. INR of 4.6 Given ativan 0.5mg IV, dilaudid 0.5mg IV and 250cc of NS. In the ED, noted to be 101.0 rectally. BPs were noted to be as low as 88/41. One liter of NS was given with improvement to the 90s and low 100s. Given levaquin 750mg IV and vancomycin 1gram IV; for pain, given 1mg IV morphine. . Upon arriving to to the ICU patient complained of back pain. She denied any nausea/vomiting, chest pains, or shortness of breath. Past Medical History: 1. End-stage renal disease, dialysis T, Th, Sat 2. Diabetes mellitus 3. Hypertension 4. s/p hip fracture with surgical repair ([2172]); currently bed-bound 5. G-tube feeds x6 months 6. s/p colostomy for perforated bowel, thought to be secondary to diverticulitis 7. Chronic foley 8. Seizure disorder, in the setting of renal failure. No recent seizures. 9. Back pain 10. Bed sore Social History: Lives with husband and son. Bed-bound since hip fracture. Has health aid assistance at home. Family History: Non-Contributory Physical Exam: vitals - T96.8, HR 67, BP 113/46, RR 20, 100% on 2 liters. gen - Awake and alert. Oriented to person, "[Hospital3 ]" and "[2176-8-30]". Occasionally grimaces with pain. heent - Anicteric. No palor. cv - Regular. Distant heart sounds. pulm - Clear anteriorly. abd - Soft. G-tube and colostomy in place. Non-tender. ext - Warm. Trace to 1+ edema. Pertinent Results: [2175-9-28] 11:40PM WBC-11.7* RBC-3.75* HGB-10.3* HCT-33.4* MCV-89 MCH-27.5 MCHC-30.8* RDW-17.1* [2175-9-28] 11:40PM ALT(SGPT)-38 AST(SGOT)-34 CK(CPK)-15* ALK PHOS-625* AMYLASE-31 TOT BILI-0.4 [2175-9-28] 11:40PM GLUCOSE-149* UREA N-49* CREAT-1.6* SODIUM-139 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15 [2175-9-29] 06:10AM cTropnT-0.18* [2175-9-29] 06:10AM CK(CPK)-15* [2175-9-29] 12:53PM WBC-14.3* RBC-3.63* HGB-9.7* HCT-32.4* MCV-89 MCH-26.6* MCHC-29.8* RDW-16.1* [2175-9-29] 12:53PM ALBUMIN-2.5* CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-2.1 [2175-9-29] 12:53PM GLUCOSE-88 UREA N-61* CREAT-2.0* SODIUM-130* POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-24 ANION GAP-16 [2175-9-29] 12:53PM ALT(SGPT)-42* AST(SGOT)-43* ALK PHOS-580* TOT BILI-0.4 Urine cx: URINE CULTURE (Final [2175-10-3]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. PREDOMINATING ORGANISM. INTERPRET RESULTS WITH CAUTION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S IMIPENEM-------------- <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S WOUND CULTURE (Final [2175-10-8]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). [Female First Name (un) ] ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE GROWTH. STAPH AUREUS COAG +. SPARSE 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 PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S Brief Hospital Course: 1. Syncope: Likely in the setting of low BP after dialysis. Pt was persistently hypotensive early in hospitalization. She was found to have both a pseudomonas UTI and an infected dialysis line, either or both of which could have caused sepsis leading to hypotension. Her anti-hypertensives were initially held and her beta blocker has been added back to her regimen as of discharge. She will need to follow up with her PCP regarding [Name9 (PRE) 35455] titration of her meds. 2. Sepsis: Pt with fevers and hypotension early in hospital course. Found to have pseudomonas UTI and also infected dialysis line with [Female First Name (un) ] and MRSA cultured from drained exuded from insertion site. Sensitivities listed above. She is to receive a total 14 day course of both meropenem and vancomycin to be administered after HD with her last dose on [10-17]. The patient's prior HD cath was removed and a new line was placed 48 hour later by our interventional radiology group. Subsequent cultures have been NGTD. 3. ESRD: Dialysis T/Th/Sat, last dialysis at [Hospital1 18] was on [10-10]. 4. Pseudomonas UTI: Sensitive to Meropenem which was used given penicillin and cephalosporin allergies, and resistance of organism to quinolones. She will receive meropenem for 14 days. 5. Diabetes: Lantus regimen from home caused marked hypoglycemia, her most recent Lantus dose is 8 units at bed time with a RISS. Her BG on this regimen and with her tube feeds has been well controlled. 6. Seizure d/o: Continued Keppra. 7. Anticoagulation: On warfarin for DVT treatment, this has been held until below therapuetic level so that new dialysis line could be placed. This will need to be restarted on discharge with close follow up. 8. Hemodialysis line infection: [Female First Name (un) 564] and MSSA cx'd from discharge exuding from insertion site. Line pulled from RIG on [2175-10-7] and new tunnelled line placed by IR on [10-9]. ---Code: DNR/DNI Medications on Admission: 1. Ambien 5mg daily 2. Sucralfate 1gram QID 3. Vitamin C 500mg [Hospital1 ] 4. Keppra 500mg [Hospital1 ] 5. Lantus 24 units daily 6. Hydroxyzine 25mg [Hospital1 ] PRN 7. Hydralazine 10mg Q8H PRN 8. Nystatin [Hospital1 ] 9. Triamcinolone topical 10. Tylenol 650mg Q4H 11. Metoprolol 50mg [Hospital1 ] 12. Procel oral powder [Hospital1 ] 13. Omeprazole 20mg [Hospital1 ] 14. Remeron 15mg daily 15. Renax daily 16. Oxycodone 5mg Q4H PRN 17. Warfarin 1.5mg QHS Discharge Medications: 1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:30 Adhesive Patch, Medicated(s) Refills:2 6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous after hemodialysis: Last dose to be given on [10-17]. 8. Vancomycin 1000 mg IV AT HEMODIALYSIS 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 11. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 13. RENAX 35-2.5-70-20 unit-mg-mcg-mg Tablet Sig: One (1) Tablet PO once a day. 14. Lantus 100 unit/mL Solution Sig: One (1) Subcutaneous at bedtime: 8 units SC qhs. 15. med Continue with regular insulin sliding scale and checking BG qAC, qHS. Please see attached sheet for sliding scale. 16. Insulin Syringe 0.3 mL 28 x 1 Syringe Sig: One (1) Miscellaneous four times a day. Disp:30 1 box Refills:6 17. Lancets Regular Misc Sig: One (1) Miscellaneous four times a day. Disp:60 1 box Refills:2 18. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day: Per sliding scale. Disp:1 1 bottle Refills:6 19. Warfarin to be restarted by PCP as outpatient. Discharge Disposition: Home With Service Facility: [Hospital3 3765] Home Care Discharge Diagnosis: UTI hypotension ESRD on HD dialysis line infection Discharge Condition: stable Discharge Instructions: You were admitted with hypotension and found to have low blood glucose and a urinary tract infection. Later in the hospital it was seen that your dialysis line was infected and so it was removed and a new line placed. You should call your PCP or return to the ER if you develop fevers, chills, nausea, vomiting or any new symptoms. You should continue your tube feeds at the previous rate. Patient has 24 hour established care already. Followup Instructions: You will need to follow up with Dr. [Last Name (STitle) 9063] from nephrology at [Telephone/Fax (1) 75785] ([Hospital3 3765]) as well as your PCP, [Name10 (NameIs) ] [Last Name (STitle) ] in [Location (un) 11269] at [Telephone/Fax (1) 33980]. Please make an appointment for next week. You will also need to continue antibiotics with hemodialysis (Th,Th,Sat) to receive a total 14 day course. Your last dose of antibiotics should be administered on [10-17]. You will need to have your INR drawn on [10-11] with results sent to your PCP.	[ "E879.1", "996.62", "250.02", "038.9", "599.0", "511.9", "403.91", "E849.9", "707.03", "345.90", "276.1", "041.7", "263.9", "585.6", "995.91" ]	icd9cm	[ [ [] ] ]	[ "96.6", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	9404, 9465	5104, 7099	297, 331	9560, 9569	2312, 5081	10056, 10635	1905, 1923		7634, 9381		9486, 9539		7125, 7611			9593, 10033									1938, 2293																							235, 259						359, 1371															1393, 1779	1795, 1889
67,527	169,907	36304	Discharge summary	report	Admission Date: [2154-4-8] Discharge Date: [2154-5-1] Date of Birth: [2070-4-17] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Neosporin / Ampicillin / Tobrex Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Off-Pump Coronary Artery Bypass Graft x 2 (Saphenous vein graft to left anterior descending, Saphenous vein graft to posterior descending artery) History of Present Illness: 83 year old female with history of coronary artery disease CAD status post PCI and stents to RCA in [2145] and PTCA to LAD [2138] who initially presented to outside hospital for dyspnea on exertion. Now transferred to [Hospital1 18] for high risk PCI with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] vs bypass surgery with Dr. [Last Name (STitle) ]. Pt presented to her outpatient cardiologist for progressively worsening shortness of breath, orthopnea, and PND. Can ambulate ~15 yards before having to stop due to dyspnea. Also using more pillows (2 at baseline) to sleep at night. For these symptoms, she underwent an Adenosine test with an anterolateral perfusion defect and EF of 85%. She underwent cardiac catherization on [2154-4-5] that showed ostial LM 80%, ostial RCA 70%, mild AS and left subclavian occlusion. Past Medical History: Coronary Artery Disease status post PCI and stents to RCA in [2145] and PTCA to LAD [2138] Hypertension Hypercholesterolemia Aortic Stenosis Diabetes Mellitus Carotid stenosis status post right carotid endarterectomy Chronic kidney disease Left subclavian steal syndrome Gastroesophageal reflux disease Glaucoma Sleep apnea Reactive airway disease Past surgical history: Tonsillectomy, Left ankle repair, Right carpal tunnel release, Total abdominal hysterectomy, Laser eye surgery Social History: Non-smoker Lives alone Three children Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mother and father died from cancer. Brother passed away from GI bleed and PUD and another with liver cirrhosis. One sister passed away [2-4] cancer, another sister passed as a child. Physical Exam: VS: 97.9 168/63 72 20 97% on RA GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL (left cornea is irregular in shape), EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 3/6 systolic murmur heard throughout the precordium and radiating to bilateral carotids. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, quite distended but apparently baseline. No tenderness of palpation. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. Right groin: No bruits. Bandage c/d/i. No hematoma. Not tender. PULSES: Right: DP 2+ PT 1+ Left: DP 2+ PT 1+ Pertinent Results: [4-10] Carotid U/S: 1. No significant right ICA stenosis. 2. Left ICA occlusion. 3. Subclavian steal, brachial artery interrogation on the left also indicates a significant stenosis involving the left subclavian artery. [4-11] Chest CT: 1. Signs of mild volume overload. 2. Questionable signs of anemia. 3. Severe aortic, aortic valvular, mitral annulus and coronary artery calcifications. 4. Minimal cylindrical bronchiectasis. [4-16] Echo: TEE during off pump CABG. A patent foramen ovale is present. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is 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. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.7cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is mild-moderate valvular mitral stenosis (area~1.5cm2). Mild (1+) mitral regurgitation is seen. [4-19] Headt CT: Low-attenuation area is identified on the right parietal region, likely consistent with a chronic ischemic event. There is no evidence of acute intracranial hemorrhage. Dense atherosclerotic calcifications are visualized in the carotid siphon more prominent on the right and possibly producing stenosis of the right internal carotid, please correlate clinically, there is also atherosclerotic calcifications identified on the right vertebral artery. Multiple punctate dermal calcifications, possibly related with vascular atherosclerotic disease. If there is no clinical contraindication, correlation with MRI and MRA is recommended or CTA of the head and neck. [2154-4-25] 05:20AM BLOOD WBC-8.3 RBC-3.31* Hgb-9.7* Hct-29.3* MCV-89 MCH-29.4 MCHC-33.1 RDW-13.8 Plt Ct-344 [2154-4-25] 10:10AM BLOOD UreaN-57* Creat-2.0* K-3.8 [2154-4-10] 09:00AM BLOOD ALT-12 AST-20 LD(LDH)-219 AlkPhos-128* TotBili-0.5 Brief Hospital Course: Mrs. [Known lastname 82252] was transferred to [Hospital3 ] for surgery or high-risk PCI. Upon admission she was medically managed and required extensive work-up prior to any intervention. Appropriate work-up took several days and she was eventually brought to the operating room on [4-16] where she underwent an off-pump coronary artery bypass graft x 2, Saphenous vein grafted to left anterior descending artery and saphenous vein graft to the posterior descending artery. She tolerated this procedure well and was transferred to the surgical intensive care unit in critical but stable condition. She was extubated and weaned from her pressors. She complained of left arm pain and was seen by both neurology and vascular. Neurology work up found little on exam to explain her complaint. In reviewing the carotid and subclavian duplex, Vascular felt mrs[Last Name (un) 82253] symptoms to be consistent with her known history of left subclavian steal syndrome. Vascular suggested that she may benefit from an outpatient evaluation for a subclavian stent. The renal service was consulted for acute renal failure with a creatinine rise up to 3.6, which subsequently slowly improved with increased renal perfusion. Rapid atrial fibrillation was treated medically, and her rhythm converted to sinus. Chest tubes and epicardial wires were removed per protocol. She was placed on ciprofloxacin for a urinary tract infection. By post-operative day nine she was transferred to the surgical step-down floor for further monitoring and progression. She was seen in consultation by the physical therapy service for strength and mobility. By post-operative day #15 she was ready for discharge to rehab. All follow up appointments were advised. Medications on Admission: Home meds: [Last Name (un) ] 81 mg daily, Humalog 75/25 20 units at breakfast, 20 units at supper, Lipitor 80 mg daily, Lisinopril 40 mg daily, Metoprolol 50 [Hospital1 ] Meds on transfer: Amlodipine 5mg [Last Name (LF) ], [First Name3 (LF) ] 325 mg [First Name3 (LF) ], Lipitor 80 mg [First Name3 (LF) ], Humalog 75/25 22 units QAM, 16 units QPM, Lopressor 50 [Hospital1 ], Tylenol PRN, Colace PRN, Morphine PRN, SL Nitro PRN, Zofran PRN 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension Sig: One (1) Subcutaneous twice a day: 20 units of Humalog 75/25 at breakfast and dinner. Disp:qs Refills:2 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 11. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 12. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection ACHS per Sliding scale. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: Coronary Artery Disease Hypertension Hypercholesterolemia Aortic Stenosis Diabetes Mellitus Carotid stenosis status post right carotid endarterectomy Chronic kidney disease Left subclavian steal syndrome Gastroesophageal reflux disease Glaucoma Sleep apnea Reactive airway disease Past surgical history: Tonsillectomy, Left ankle repair, Right carpal tunnel release, Total abdominal hysterectomy, Laser eye surgery Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) ] (cardiac surgery) in 4 weeks ([Telephone/Fax (1) 170]). Dr. [Last Name (STitle) 29070] (cardiology) in [2-5] weeks. Dr. [Last Name (STitle) ] (PCP) in [1-4] weeks. Dr. [Last Name (STitle) ] (vascular) in [2-5] weeks ([Telephone/Fax (1) 1241]). Please check Creatnine [5-2] and call results to NP/PA on [Hospital Ward Name 121] 6 #[Telephone/Fax (1) ] Completed by:[2154-5-1**]	[ "530.81", "729.5", "V58.67", "585.9", "414.2", "424.1", "435.2", "250.00", "997.5", "E878.2", "403.90", "272.0", "599.0", "780.57", "414.01", "V45.82", "041.4", "584.9", "447.1", "518.89", "365.9" ]	icd9cm	[ [ [] ] ]	[ "36.12", "38.93" ]	icd9pcs	[ [ [] ] ]	9003, 9033	5431, 7187	370, 517	9491, 9497	3172, 5408	10008, 10464	1997, 2299		7704, 8980		9054, 9335		7213, 7392			9521, 9985								9358, 9470	2314, 3153																							311, 332						545, 1413															1435, 1791	1942, 1981		7410, 7681
75,929	162,276	44924	Discharge summary	report	Admission Date: [2160-6-4] Discharge Date: [2160-6-9] Date of Birth: [2099-3-24] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3227] Chief Complaint: seizure Major Surgical or Invasive Procedure: [2160-6-6]: Right Frontal Craniotomy History of Present Illness: Pt is 61 y/o M with htn and hypercholesterolemia who presents after having seizure today. Pt states that he had finished working on a truck at work today when he passed out shortly after. EMS was called and pt was unarousable and had witnessed seizure in the field. Pt was given ativan and was not intubated. In the ambulance, pt did become awake and combative and had nausea and vomiting. Upon arrival to OSH, pt's mental status did improve and clear up. Pt had CT scan and MRI at OSH which showed large right frontal mass. Pt was given decadron and transferred to [Hospital1 18] for further management. Pt currently denies headaches, vision changes, dizziness, or focal weakness. No fevers, chills, chest pain, shortness of breath, cough, abd pain, or dysuria. No easy bruising. Past Medical History: PMH: htn hypercholesterolemia PSH: hernia surgery ankle surgery Social History: Works in excavating business. No tobacco, occasional EtOH. Family History: non-contributory Physical Exam: Exam upon discharge: Oriented x 3. PERRL, EOMs intact. Face symmetric, tongue midline. No drift. Full strength and sensation throughout. Sutures in place - incision clean, dry, intact. Pertinent Results: MRI/MRI Brain [2160-6-4]: IMPRESSION: 1. Right frontal meningioma with mass effect, leftward shift of the normally midline structures, and surrounding vasogenic edema. Presence of slow diffusion indicates likelihood of an atypical meningioma. The mass is in close contiguity with the superior sagittal sinus without definite signs of invasion. 2. No acute infarction. CT Head [2160-6-6]: Postoperative changes noted in the right frontal lobe status post resection of right frontal extra-axial mass with residual air, fluid, and small amount of high density material likely representing blood products in the resection cavity. Additionally, a tiny focus of hyperdense material along the intra hemispheric falx adjacent to the resection cavity most likely represents a small amount of subdural blood. MRI Brain [2160-6-7]: IMPRESSION: Incomplete study. Linear right parafalcine extra-axial contrast enhancement could be reactive in the immediate postoperative setting, but residual tumor is difficult to exclude. A repeated, complete study is recommended, when feasible. Brief Hospital Course: The patient was admitted to the hospital after having a seizure and a right frontal brain mass was discovered on MR imaging. He was given antiseizure medication, was placed on steroids and monitored with Q4 hour neuro checks. The patient was taken to the OR by Dr. [First Name (STitle) ] on [2160-6-6] for a right craniotomy for tumor resection. The procedure when well and there were no complications. The patient remained neurologically non-focal post-operatively. He was observed in the ICU overnight with continuous IVF at 125cc/hr to minimize the risk of sinus thrombosus. The patient was ambulating on his own, voiding without difficulty, and eating well. The patient was discharged to home on [2160-6-9]. Medications on Admission: lisinopril 40 mg daily omeprazole 20 mg daily rosuvastatin 20 mg daily ibuprofen prn Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Rosuvastatin 20 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). Disp:60 Capsule(s) Refills:2 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: No driving while on this medication. Disp:50 Tablet(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 8. Dexamethasone 1 mg Tablet Sig: Four (4) Tablet PO Q8H (every 8 hours) for 6 doses: On [6-11] take 3mg TID x 6 doses. On [6-13] take 2mg TID x 6 doses. On [6-15] take 1mg TID x 6 doses. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Right Frontal Mass Discharge Condition: Neurologically Stable Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone). -An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? 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. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: ??????You have an appointment in the Brain [Hospital 341] Clinic on [2160-6-30] at 11:30. 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. -Follow-up with plastic surgery for your left thumb if the weakness continues. Call [Telephone/Fax (1) 3009] to schedule an appointment. Completed by:[2160-6-9]	[ "348.5", "401.9", "729.89", "225.2", "780.39", "272.0" ]	icd9cm	[ [ [] ] ]	[ "01.51" ]	icd9pcs	[ [ [] ] ]	4557, 4563	2723, 3449	325, 368	4626, 4648	1614, 2700	10130, 10712	1376, 1394		3585, 4534		4584, 4605		3475, 3562			4798, 4819									1409, 1409																					8300, 10107		278, 287					4831, 8273	396, 1193									4663, 4774						1215, 1282	1298, 1360			1430, 1595
77,947	172,390	36134	Discharge summary	report	Admission Date: [2113-8-22] Discharge Date: [2113-8-26] Date of Birth: [2049-9-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 896] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 4587] is a 63 year-old male with hx of COPD on 2 L, CAD, hx of PE on coumadin, and DM who returned to the ED after a recent discharge with dsypnea and weight gain. He was recently hospitalized due to dyspnea from [8-17] to [8-18] which was thought to be multifactorial and had been discharged back to rehab. During his last admission he was treated with his outpatient COPD medications and lasix for diuresis. . Since discharge, he has continued to gain weight (296.9 lbs on [8-19] -> 308.3 lbs on [8-22]), despite increased lasix dosing of 40 mg po daily. He admits to stable orthopnea, PND, and lower extremity swelling. He does admit to a brief (1 minute) episode of chest pain this afternoon while eating lunch which did not radiate. He admits to a non-productive cough and recent chills, but denies fevers. He states his dyspnea started today, but his story is not entirely reproducible upon multiple questionings. . In the ED, initial vs were: T 99.4 P 94 BP 142/86 R 24 98% O2 sat. CXR was without infiltrate. Labs revealed bicarb of 45 and an ABG was significant for a pCO2 of 115. He was started on BiPAP. He was treated with nebs, prednisone 60 mg po, and 500 mg po azithromycin due to concern for COPD exacerbation. . Currently denies shortness of breath, chest pain, or tiredness. . Review of systems: (+) Per HPI (-) 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: -Diabetes mellitus Type II -CAD s/p CABG -RA -COPD on 2L home O2 -possibly decreased systolic function on last TTE (poor image quality) -Depression -Bipolar Disorder -Schizophrenia -HTN -PVD -Hx of PE in [2110] on coumadin -Recurrent hyperkalemia -Glaucoma Social History: He lives in an [Hospital3 ] home. Not currently working. Quit smoking recently. Drinks a pack of beer per month. Family History: His father died of heart disease. His mother had cancer. Physical Exam: Vitals: T: 98 BP: 124/91 P: 88 R: 39 O2: 95% on 4L General: Elderly male sitting in bed, alert, oriented to person, place, and time. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVD to the angle of the jaw, no LAD. Lungs: Purse-lipped [Hospital3 4605], able to talke in full sentences, but gets short of breath with any movement. Decreased breath sounds throughout, scattered slight inspiratory wheezes, occasional expiratory crackles. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft NTND. GU: no foley Ext: warm, well perfused, 2+ pulses. Venous stasis changes present bilaterally. Left extremity with hyperkeratosis and some weeping present along the shin. Pertinent Results: Labs on admission: [2113-8-22] 11:11PM TYPE-ART TEMP-36.9 PO2-62* PCO2-84* PH-7.41 TOTAL CO2-55* BASE XS-23 [2113-8-22] 11:11PM LACTATE-1.2 [2113-8-22] 11:11PM freeCa-1.14 [2113-8-22] 10:48PM GLUCOSE-136* UREA N-34* CREAT-1.8* SODIUM-144 POTASSIUM-5.9* CHLORIDE-94* TOTAL CO2-46* ANION GAP-10 [2113-8-22] 10:48PM CK(CPK)-103 [2113-8-22] 10:48PM CK-MB-2 cTropnT-0.03* [2113-8-22] 10:48PM MAGNESIUM-1.9 [2113-8-22] 04:00PM TYPE-ART PO2-79* PCO2-115* PH-7.31* TOTAL CO2-61* BASE XS-24 [2113-8-22] 02:52PM GLUCOSE-116* UREA N-33* CREAT-1.8* SODIUM-141 POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-45* ANION GAP-8 [2113-8-22] 02:52PM estGFR-Using this [2113-8-22] 02:52PM CK(CPK)-91 [2113-8-22] 02:52PM cTropnT-0.03* [2113-8-22] 02:52PM proBNP-1883* [2113-8-22] 02:52PM WBC-5.2 RBC-2.87* HGB-8.3* HCT-27.2* MCV-95 MCH-29.0 MCHC-30.6* RDW-15.8* [2113-8-22] 02:52PM NEUTS-69.9 LYMPHS-17.7* MONOS-9.4 EOS-2.7 BASOS-0.2 [2113-8-22] 02:52PM PLT COUNT-256 [2113-8-22] 02:52PM PT-19.5* PTT-28.5 INR(PT)-1.8* [2113-8-23] 04:09AM BLOOD WBC-5.4 RBC-2.85* Hgb-8.2* Hct-27.5* MCV-97 MCH-28.9 MCHC-29.9* RDW-15.3 Plt Ct-263 [2113-8-23] 04:09AM BLOOD Plt Ct-263 [2113-8-23] 04:09AM BLOOD PT-19.8* PTT-30.1 INR(PT)-1.8* [2113-8-23] 04:22PM BLOOD Glucose-105* UreaN-34* Creat-1.8* Na-146* K-3.9 Cl-93* HCO3-49* AnGap-8 [2113-8-23] 04:09AM BLOOD CK(CPK)-101 [2113-8-23] 04:09AM BLOOD CK-MB-2 cTropnT-0.03* [2113-8-23] 04:22PM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8 [2113-8-23] 05:50PM BLOOD Type-ART pO2-80* pCO2-84* pH-7.42 calTCO2-56* Base XS-24 [2113-8-22] 02:52PM BLOOD proBNP-1883* . Imaging: [8-22] CXR: 1. Unchanged cardiomegaly and mild heart failure. 2. Persistent left hemidiaphragmatic elevation, resulting in atelectasis with a small effusion. . [8-23] Echo: The left atrium is elongated. There is symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function appears grossly preserved (LVEF>55%). The right ventricular cavity appears dilated with depressed free wall contractility. The aortic valve is not well seen. The continuous wave Doppler flow velocity measurement across the aortic valve is consistent with mild aortic valve stenosis (valve area 1.2-1.9cm2). Tricuspid regurgitation is present but cannot be quantified. There appears to be at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Right ventricle appears dilated and hypocontractile. Pulmonary hypertension is present. . [8-24] CXR: FINDINGS: IMPRESSION: 1. Interval improvement of bilateral diffuse opacities. 2. Minor left lower lobe atelectasis, unchanged. 3. Chronic elevation of the left hemidiaphragm. Brief Hospital Course: This is a 63 year-old male with COPD on 2L NC, CAD, hx of PE on coumadin, and DM who returned to the ED after a recent admission for SOB with dyspnea consistent with CHF exacerbation, and with clinical improvement after diuresis. # CHF decompensation: The patient was initially admitted to the [Hospital Unit Name 153] secondary to concern for hypercarbic respiratory failure. The patient's work-up in the [Hospital Unit Name 153] pointed to the diagnosis of CHF decompensation. The patient's CXR showed no consolidation but did show some evidence of pulmonary edema. The patient's EKG was baseline, and his cardiac biomarkers were negative x 3. The etiology of this patient's decompensation was thought to be insufficient diuresis on home furosemide potentially exacerbated by dietary indiscretion. A subsequent TTE corroborated the diagnosis. Additionally, the patient clinically improved with IV lasix diuresis. He was transitioned to his home PO dose of lasix at discharge, and his weight had decreased. # Pulmonary Hypertension/COPD/OSA: The patient's respiratory status at baseline was compromised due to a history of COPD, OSA and pulmonary hypertension, and he was on 2L of oxygen at his rehab facility. The patient was initially treated for a COPD exacerbation with steroids and antibiotics, but these interventions were stopped when his acute dyspnea was felt to be secondary to CHF decompensation and his symptoms improved with diuresis. The patient was also started on a biPAP for his OSA with setting of [10-10], and the patient reported subjective improvements in his symptoms. The patient was also continued on his home COPD medications. # HTN: The patient was continued on his home doses of amlodipine and metoprolol. #. DM Type 2: The patient was continued on SSI. #. History of PE: The patient's admission INR was subtherapeutic at 1.8. His warfarin dose was increased during this hospitalization from 5 to 7.5mg daily and his coags were followed. His INR should continue to be monitored periodically. #. RA: The patient was continued on his home dose of hydroxychloroquine. #. Schizophrenia/Bipolar disorder/Depression: The patient was continued on his home doses of divalproex, oxcarbazepine, and risperidone. #. CKD: The patient's creatinine was 1.8 on admission. His creatinine remained stable at his baseline of 1.6-1.9. #. Hyperkalemia: The patient has a history of hyperkalemia. His admission K was 5.9. His potassium subsequently normalized with Kayexalate and Lasix diuresis and was normal at discharge. # BPH: The patient was continued on tamsulosin. Medications on Admission: 1. Duonebs 2. Alendronate 70 mg weekly (sunday) 3. Amlodipine 5 mg po daily 4. Aspirin 81 mg po daily 5. Calcitriol 0.25 mcg Capsule po daily 6. Calcium Carbonate-Vit D3-Min 600-400 mg-unit One Tablet [Hospital1 ] 7. Divalproex 500 mg Tablet, Delayed Release (E.C.) [Hospital1 ] 8. Docusate Sodium 100 mg Capsule po bid 9. Fluticasone 110 mcg inhalation [Hospital1 ] 10. Furosemide 20 mg po daily (was increased to 40 mg daily recently) 11. Hydroxychloroquine 400 mg po bid 12. Insulin Lispro 100 unit/mL Solution 13. Lactulose 15 ML by mouth daily 14. Metoprolol Tartrate 25 mg po bid 15. Oxcarbazepine 300 mg po bid 16. Ranitidine HCl 150 mg Tablet po bid 17. Risperidone 3 mg po qhs 18. Sennosides [Senna] 8.6 mg Tablet 2 Tablets by mouth qhs prn 19. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr po qhs 20. Tiotropium Bromide 18 mcg Capsule daily 21. Warfarin 5 mg po daily Discharge Medications: 1. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 9. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: Please take every Sunday. 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO qhs:PRN as needed for Constipation. 15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation twice a day. 16. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 17. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 18. Calcium 600 + Minerals 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. 20. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: per sliding scale. 21. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO twice a day. 22. Risperdal 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 23. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 24. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary: CHF exacerbation Secondary: Pulmonary hypertension, OSA, hypertension, DM, Rheumatoid arthritis, chronic kidney disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for difficulty [Location (un) 4605]. The cause of your difficulty [Location (un) 4605] was thought to be due to an exacerbation of your congestive heart failure. You were treated with diuretic medications, and your symptoms improved. You also have pulmonary hypertension, COPD, and obstructive sleep apnea which contributes to your difficulty [Location (un) 4605]. You were started on a CPAP while you were admitted. You should continue to use the CPAP nightly at home. . The following changes were made to your home medication regimen: -You were started on ammonium lactate 12% solution. This should be rubbed (deeply) into your lower extremities twice per day. -Your home furosemide dose was increased to 40mg twice daily -Your warfarin dose was also increased to 7.5mg daily and your INR will need to be followed. . You should take all of your medications as precribed, and keep all of your follow-up appointments. Followup Instructions: You have the following appointments scheduled: Department: WEST [Hospital 2002] CLINIC When: MONDAY [2113-8-28] at 11:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 435] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: WEST [Hospital 2002] CLINIC When: TUESDAY [2113-8-29] at 2:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 435] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: VASCULAR SURGERY When: THURSDAY [2113-8-31] at 1:30 PM With: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2113-8-26]	[ "278.8", "416.2", "416.8", "428.0", "V58.61", "327.23", "296.50", "295.90", "250.02", "278.00", "428.33", "585.3", "518.84", "600.00", "491.21", "276.7", "V45.81", "714.0", "403.10", "414.00", "518.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11783, 11853	6121, 8728	322, 328	12026, 12026	3190, 3195	13192, 14283	2369, 2429		9670, 11760		11874, 12005		8754, 9647			12204, 13169									2444, 3171																		1721, 1933					275, 284						356, 1702								3210, 6098	12041, 12180						1955, 2217	2233, 2353
23,802	125,209	17484	Discharge summary	report	Admission Date: [2190-8-27] Discharge Date: [2190-9-1] Date of Birth: [2149-10-9] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: shortness of breath, airway stenosis Major Surgical or Invasive Procedure: bronchoscopy and partial stent removal History of Present Illness: 40F with history of airway amyloidosis, s/p multiple bronchoscopies and stents. She has stenosis of left main stem stent. She is admitted for repeat bronchoscopy and stent revision/removal attempt. on ROS, denies chest pain/SOB/orthopnea/abd pain/dsyuria/changes in BM Past Medical History: 1. airway amyloidosis: Outpatient pulmonologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital6 ] and interventionalist Dr. [First Name (STitle) ] [Name (STitle) ] at [Hospital1 18]. Social History: lives in [Doctor First Name 5256]; former surgical floor nurse; lives with her husband and two children; occasional etoh; no smoking ever; no IVDA; sexually active with husband. [Name (NI) ] to [Location (un) 86] exclusively for her pulmonary care. Family History: Father with [Name2 (NI) 2320] Physical Exam: gen: slightly obese female in NAD, extremely pleasant, speak in complete sentences without SOB HEENT: anicteric, no conjunctival pallor, oral mucosa moist, neck supple, trach with collar in place, clean chest: rhonshi and stridor diffusely over all lung field cv: RRR, S1/S2 nml, no m/r/g, no pedal edema, no carotid bruit abd: +BS, slightly obese but s/nt/nd ext: no c/c/e neuro:A/O x 3, [Last Name (LF) 3899], [First Name3 (LF) 13775], moves all 4 extremities Pertinent Results: [2190-9-1] 05:58AM BLOOD WBC-9.5 RBC-3.30* Hgb-8.4* Hct-26.2* MCV-80* MCH-25.3* MCHC-31.9 RDW-13.3 Plt Ct-328 [2190-8-27] 04:49PM BLOOD Neuts-86.6* Bands-0 Lymphs-10.9* Monos-1.4* Eos-0.8 Baso-0.2 [2190-8-27] 04:49PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [2190-9-1] 05:58AM BLOOD Plt Ct-328 [2190-9-1] 05:58AM BLOOD Glucose-81 UreaN-8 Creat-0.8 Na-141 K-3.9 Cl-107 HCO3-25 AnGap-13 [2190-8-31] 04:00PM BLOOD CK(CPK)-66 [2190-8-31] 05:27AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2190-8-30] 06:10PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2190-8-31] 05:27AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.9 Brief Hospital Course: 1. Airway Amyloidosis Mrs. [Known lastname 48831] had stents in trachea and left main stem for this condition and admitted this time for removal of left main stem stent due to stenosis of stent. First bronchoscopy on this admission on [2190-8-27] revealed proximal trachea was within normal limits and tracheal stent with a mild amount of granulation.The right mainstem was within normal limits. The proximal left mainstem was approximately [5-18] mm in diameter. However, the distal left mainstem was nearly completely obstructed by granulation tissue. Some of this was removed with forceps. Most of the stent was completely epithelialized.Serial balloon dilations were performed. She was treated with mitomycin application today and admitted to the MICU for overnight observation s/p this procedure. Second bronchoscopy on [2190-8-31] was performed to remove the second, more imbedded, distal stent.During the procedure, the patient had an episode of hypotension with bradycardia, probably related to the frequent necessary episodes of apnea, even though her saturations always stayed at 98 to 100 percent. She was given atropine with good pressure response but there was ST elevation on her ECG. Procedure was thus terminated. She developed severe headache post-procedure, thought to be related to episode of hypercarbia. There was no focal neurological findings and CT head was negative for intracranial bleed or stroke. She was supported with morphine and it resolved spontaneously. She was ruled out for MI by 3 sets of negative enzymes. She was discharged because the repeat bronchoscpoy will not be performed until [2190-9-4] due to scheduling issues on the IP Service. She is staying in a hotel in [Location (un) 86] with her mother & will return on [2190-9-3]. Medications on Admission: 1. nexium 40mg po qd 2. prednisone taper down to 10mg po qd until tomorrow, f/b 5mg po qd Discharge Medications: 1. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for cough. Disp:30 Tablet(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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 7 doses. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. airway amyloidosis Discharge Condition: stable Discharge Instructions: please return to the hospital if you experience difficulty in breathing, fever, or if there are any concerns at all. Please return to the hospital on friday night [9-3] in order for you to have the repeat bronchoscopy done on Saturday [9-4]. Followup Instructions: 1. please return to the hospital on Friday night [2190-9-3] so that you could have repeat bronchoscopy on Saturday [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2190-9-3]	[ "E878.8", "V44.0", "996.59", "427.89", "997.1", "458.29", "519.1", "517.8", "277.3" ]	icd9cm	[ [ [] ] ]	[ "33.91", "32.01", "98.15" ]	icd9pcs	[ [ [] ] ]	5087, 5093	2473, 4278	345, 385	5159, 5167	1779, 2450	5465, 5735	1237, 1273		4418, 5064		5114, 5138		4304, 4395			5191, 5442									1288, 1760																							269, 307						413, 684															706, 943	959, 1221
8,743	154,684	4315	Discharge summary	report	Admission Date: [2133-1-7] Discharge Date: [2133-1-9] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3507] Chief Complaint: Lower GI Bleeding Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] F c ? hx diverticulosis, hiatal hernia (from previous d/c summary) who presented to ED after health-assistant noticed pt. unusually fatigued, taking less PO, and a large amount of dark blood with clots while moving patient in morning. Blood described as not bright with foul smell. Pt. without complaints at this time; no abdominal pain, light headedness, anal pain, vaginal discomfort. Assistant offered history that similar episode occurred in past after pt. tried to manually disimpact herself which she does daily. Last disimpaction 2 days prior. In [Name (NI) ], pt. hemodynamically stable c BP 150/90, HR 110, 98.9, sat 92% RA c HCT 28.1 (down from baseline 36-38) Guiaic + and GYN exam only remarkable for 2 cm vertical abrasion on posterior vagina not bleeding. GI saw pt. and felt that she likely had GIB [2-6] hemorrhoids or diverticulosis or AVM; felt that colonoscopy/flex sig. not indicated. As per d/w HCP, goal was to keep pt. comfortable and transfuse as needed. Past Medical History: HTN spinal stenosis Osteoarthritis Diverticulosis Hiatal hernia Increased cholesterol Atrial Fibrillation Dementia Social History: Lives at [Hospital3 537] in [Hospital3 ]. Widowed. No EtOH, smoking, or drugs. Patient has her cousins involved: [Name (NI) 6339] and [First Name8 (NamePattern2) ] [Name (NI) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 18678]; [Name (NI) 553] [Known lastname 18679] - Granddaughter [Telephone/Fax (1) 18680]. Family History: NC Physical Exam: VS- 96.0, 123/108, 78, 98%, 24 GEN- elderly female in NAD HEENT- no elevation of JVP, dry mucous membranes, + tenting over sternal skin LUNGS- + crackles b/l HEART- irregular irregular, S1, S2, + [2-10] SM at apex ABD- soft, ND, NT, BS+ EXT- wwp, no edema. scattered pressure ulcers over shins. NEURO- moving all extremities, can name objects. difficulty with orientation (1 - name) Pertinent Results: [2133-1-7] 11:53PM BLOOD calTIBC-263 VitB12-652 Folate-10.6 Ferritn-85 TRF-202 [2133-1-7] 11:53PM BLOOD Iron-245 [2133-1-9] 05:55AM BLOOD Glucose-126* UreaN-41* Creat-1.2* Na-145 K-3.5 Cl-107 HCO3-23 AnGap-19 [2133-1-7] 11:00AM BLOOD WBC-7.1 RBC-3.02# Hgb-9.6 Hct-28.1# MCV-93 MCH-31.8 MCHC-34.2 RDW-14.9 Plt Ct-244 [2133-1-8] 02:17PM BLOOD WBC-9.1 RBC-3.94 Hgb-12.1 Hct-35.4* MCV-90 MCH-30.7 MCHC-34.2 RDW-15.1 Plt Ct-225 [2133-1-9] 05:55AM BLOOD WBC-7.3 RBC-3.90* Hgb-12.1 Hct-35.0* MCV-90 MCH-31.0 MCHC-34.6 RDW-15.4 Plt Ct-214 Brief Hospital Course: #Lower GI bleeding, NOS; likely secondary to manual disimpaction: seen by GI and OB/GYN teams who felt bleeding was clearly GI. GI team consulted and felt etiology of bleed was likely hemmrhoidal vs diverticulae vs trauma from self disimpaction. GI team felt given advanced age and stable HCT (after transfusion of 1U of PRBC), that flex sigmoidoscopy would not be indicated given the patients advanced age. Morever, the patient was completely asx. The patient should be given senna, colace daily and would benefit from enemas. She should not be allowed to mannually self disimpact herself. Of note, ASA decreased to 81 mg on d/c. . #2 cm Vaginal abrasion: noted on GYN exam. Felt to be secondary to trauma from ED speculum exam. SW consulted; did not find any evidence to support sexual abuse. . #Afib: kept on BB. Of note, ASA decreased as above. Medications on Admission: Same (except full dose ASA) Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 5. Calcium 500 500 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Haldol please resume previous dose .75 qhs prn 7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Fleet Enema 19-7 g/118mL Enema Sig: One (1) Rectal once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: 1. Lower GI bleeding, NOS; likely secondary to manual disimpaction 2. 2 cm Vaginal abrasion Secondary Diagnoses: 1. Diverticulosis 2. Hypertension 3. Hiatal hernia 4. Increased cholesterol 5. Atrial Fibrillation 6. Dementia Discharge Condition: stable Discharge Instructions: Please contact Dr. [Last Name (STitle) 141] should you have any additional blood in your stools, black stools, abdominal pain, or any other complaints. DO NOT PUT YOUR FINGER IN YOUR ANUS in attempts to remove stool. . The patient can be given enemas prn for constipation. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 143], MD Phone:[Telephone/Fax (1) 142] Date/Time:[2133-4-16] 9:15	[ "562.10", "578.9", "427.31", "911.0", "272.0", "403.90", "294.8", "285.1", "585.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4649, 4720	2859, 3718	278, 285	4991, 5000	2275, 2836	5327, 5480	1847, 1851		3796, 4626		4741, 4836		3744, 3773			5024, 5304									1866, 2256			4857, 4970																				221, 240						313, 1320															1342, 1459	1475, 1831
20,499	176,552	7422	Discharge summary	report	Admission Date: [2103-1-21] Discharge Date: [2103-2-2] Service: MEDICINE Allergies: Codeine Attending:[Doctor Last Name 10493] Chief Complaint: SBO, Pneumonia, Renal failure Major Surgical or Invasive Procedure: NG Tube History of Present Illness: HPI: 87yo F with h/o DM and [Hospital ] transferred from OSH in [Location (un) 27238] with pneumonia, SBO, new onset Afib, in MICU for Afib with RVR and hypotension which has now resolved. . Patient initially presented to OSH [2103-1-17] with complaint of abdominal pain and vomiting. She was diagnosed with a UTI, pneumonia, and small bowel obstruction as well as acute renal failure, atria fibrillation, and acute MI. She was being managed medically with NGT to suction, not anticoagulated, and antibiotics prior to transfer to [Hospital1 18] [2103-1-20]. . Upon arrival to [Hospital1 18] ED T 99.3 HR 94 BP 130/65 RR 20 99%3Lnc. She was admitted to the medical floor where she went into Afib/RVR with HR 150s, BP 90s/p. she was treated initially with metoprolol 5mg iv with transient improvement. She then received 17.5mg iv diltiazem. The patient then converted to a sinus rhythm with stable blood pressures. She was continued on the heparin drip and ready for transfer to floor. . Past Medical History: * DM type II * Hypertension * Anxiety/depression * DJD * h/o arrhythmia * recurrent UTIs; last hospitalization [12-23] * OA s/p right hip replacement * CKD (baseline creatinine not known) . Social History: Social hx: - lives in [Location ], widow, has 24hr home aide - nonsmoker - no EtOH . Family History: Family hx: not elicited . Physical Exam: PE: T 98.2 HR 92 BP 166/68 RR 16 98%2L via NC I/O 24 hours 2.9/1.4; since midnight 3.1/1.9 Gen: NAD, pleasant, A&Ox2 (date) HEENT: PERRL, anicteric, Moist mucous membranes, NGT in place CV: RRR, no murmurs Resp: crackles lef base, o/w CTA Abd: Abd: +BS, soft, nontendner, minimal distension Ext: no edema, 2+ DPs Neuro: not oriented, MAEW Pertinent Results: [2103-1-21] 08:18PM PT-16.3* PTT-150* INR(PT)-1.5* [2103-1-21] 07:42PM GLUCOSE-205* UREA N-74* CREAT-1.3* SODIUM-148* POTASSIUM-4.0 CHLORIDE-116* TOTAL CO2-19* ANION GAP-17 [2103-1-21] 07:42PM CALCIUM-8.6 PHOSPHATE-2.2* MAGNESIUM-2.8* [2103-1-21] 07:42PM WBC-13.0* RBC-3.44* HGB-10.4* HCT-29.6* MCV-86 MCH-30.1 MCHC-35.1* RDW-13.9 [2103-1-21] 07:42PM PLT COUNT-275 [2103-1-21] 02:53PM PTT-55.8* [2103-1-21] 01:15PM TYPE-ART PO2-145* PCO2-26* PH-7.48* TOTAL CO2-20* BASE XS--1 [2103-1-21] 01:08PM GLUCOSE-126* UREA N-85* CREAT-1.6* SODIUM-154* POTASSIUM-2.9* CHLORIDE-119* TOTAL CO2-20* ANION GAP-18 [2103-1-21] 01:08PM CK(CPK)-154* [2103-1-21] 01:08PM CK-MB-5 cTropnT-0.03* [2103-1-21] 01:08PM CALCIUM-9.1 PHOSPHATE-1.9* MAGNESIUM-3.1* IRON-49 [2103-1-21] 01:08PM calTIBC-200* FERRITIN-515* TRF-154* [2103-1-21] 01:08PM calTIBC-200* FERRITIN-515* TRF-154* [2103-1-21] 01:08PM WBC-14.4* RBC-3.08* HGB-9.1* HCT-26.6* MCV-87 MCH-29.7 MCHC-34.3 RDW-13.8 [2103-1-21] 01:08PM PLT COUNT-386 [2103-1-21] 01:08PM RET AUT-1.4 [2103-1-21] 10:21AM URINE HOURS-RANDOM UREA N-1207 CREAT-54 SODIUM-LESS THAN [2103-1-21] 10:21AM URINE OSMOLAL-587 [2103-1-21] 10:21AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2103-1-21] 10:21AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 [2103-1-21] 08:07AM TYPE-[Last Name (un) ] COMMENTS-GREEN [2103-1-21] 08:07AM LACTATE-1.6 [2103-1-21] 07:50AM GLUCOSE-419* UREA N-92* CREAT-1.8* SODIUM-151* POTASSIUM-3.4 CHLORIDE-116* TOTAL CO2-20* ANION GAP-18 [2103-1-20] 05:00PM CK-MB-4 cTropnT-0.04* [2103-1-20] 05:00PM CK(CPK)-204* [2103-1-20] 05:00PM estGFR-Using this [2103-1-20] 05:00PM GLUCOSE-381* UREA N-91* CREAT-2.0* SODIUM-147* POTASSIUM-5.8* CHLORIDE-111* TOTAL CO2-17* ANION GAP-25* [2103-1-20] 05:18PM GLUCOSE-336* NA+-149* K+-5.8* CL--120* [2103-1-20] 06:41PM LACTATE-2.2* [2103-1-20] 09:15PM PLT COUNT-357 [2103-1-20] 09:15PM NEUTS-84.1* BANDS-0 LYMPHS-8.8* MONOS-6.5 EOS-0.1 BASOS-0.4 [2103-1-20] 09:15PM WBC-13.2* RBC-4.03* HGB-11.8* HCT-34.5* MCV-86 MCH-29.2 MCHC-34.1 RDW-13.7 [2103-1-21] 01:13AM K+-3.6 [2103-1-21] 01:15AM CK-MB-4 cTropnT-0.03* [2103-1-21] 01:15AM CK(CPK)-118 [2103-1-21] 01:15AM GLUCOSE-294* UREA N-96* CREAT-1.9* SODIUM-152* CHLORIDE-118* TOTAL CO2-20* [2103-1-21] 07:27AM URINE GRANULAR-0-2 [2103-1-21] 07:27AM URINE GRANULAR-0-2 [2103-1-21] 07:27AM URINE RBC-0-2 WBC-[5-27]* BACTERIA-MOD YEAST-NONE EPI-0-2 [2103-1-21] 07:27AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2103-1-21] 07:27AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 [2103-1-21] 07:30AM PLT COUNT-284 [2103-1-21] 07:30AM WBC-13.2* RBC-3.85* HGB-11.3* HCT-33.6* MCV-87 MCH-29.3 MCHC-33.6 RDW-13.9 Echo: The left atrium is mildly dilated. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. 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 leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The left ventricular inflow pattern suggests impaired relaxation. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Also noted is a left pleural effusion. . * KUB: Note is made of nasogastric tube coursing down below the left hemidiaphragm terminating in the left mid quadrant probably in the stomach. The gastric gas is somewhat distended. There are two loops of dilated small bowel measuring up to 4 cm in the left lower quadrant. However, colon and rectal gas is identified. . * Abd CT [2103-1-21]: 1. Dilated loops of small bowel with a transition point seen in the right abdomen, with decompressed small bowel seen distal to the transition point to the teminal ileum. Stool and gas seen throughout the colon. Findings suggest early small bowel obstruction. 2. Small left pleural effusion with associated atelectasis and consolidation, concerning for left lower lobe pneumonia. 3. Low attenuation left adrenal nodule, incompletely characterized on this non-contrast study. 4. Diverticulosis. . Brief Hospital Course: A/P: 87yoW with h/o DM and [Hospital ] transferred from OSH with Afib/RVR, UTI, Pneumonia, SBO and GI bleed. . # Afib/RVR: Per PCP patient had Afib on arrival to the OSH 5 days ago and has a h/o "arrhythmia." with no known CAD. Afib likely occured in setting of acute infection and SBO with dehydration. Converted to NSR since transfer to MICU and currently hemodynamically stable. The patient was started on IV metoprolol and then converted to po metoprolol after the NG tube was removed. Pt was initially started on aspirin but had to be discontinued due to her GI bleed. . # Pneumonia: A Retrocardiac/LLL opacity on CXR. She received a 7 day course of levaquin. The patient's oxygen saturation was stable and the patient had no respiratory distress while in house. . # UTI: The patient had a postive UA. She was initially treated with levaquin however cultures gew out E coli that was not sensitive to that antibiotic. The coverage was changed to ceftriaxone and her elevated WBC count resolved. . # SBO: No prior abdominal surgeries. By CT SBO appears in distal ileum, ?Meckel's vs volvulus since the patient had not had any previous abdominal surgeries making adhesions a less-likely cause. Surgery was consulted and involved in the patients care. An NG tube was placed in the emergency department and copious amounts of brown fluid was removed. The NG tube was in place for 8 days. Bowel sounds returned and the pt began to pass flatus and have small bowel movements. The NG tube was removed and the patient was able to tolearte a diet. . # GI bleed: While hospitalized the patient had 2 episodes of maroon colored, guaiac positive stools. GI was consulted and scoped agreed to do a colonoscopy once the SBO resolved. She underwent a colonoscopy which revealed multiple diverticuli but no active bleeding and noted that the terminal ileum was patent. The GI service suggested a small bowel follow through study as an outpatient if the family and primary care provider were interested in further investigating the cause of the SBO. . # Acute Renal Failure: Pt had a Cr of 2 on admission. After gentle hydration the Cr returned to [Location 213]. Her ARF was likely due to dehydration and her UTI. . # Hypernatremia: Likely hypovolemic due to SBO obsrtuction. She was hydrated with D5W to replace her free water loss. The hypernatremia resolved once the SBO resolved and the pt had normal sodium levels throughout her hospital stay. . # Hyperglycemia: Patient has a h/o type 2 diabetes. Her diabetes was difficult to manage because of her nutritional status and receiving IV D5W. She was begun on a sliding scale of regular insulin and a small dose of lantus. The lantus was slowly increased over her hospital stay. Once her NG tube was removed an the patient was started on a regular diet, her diabetes was better controlled. . # Vaginal discharge: The patient was noted to have copious amounts of yellow vaginal discharge. She had a pessary in place. OB/GYN was consulted. The patient receieve a dose of diflucan for treatment of possible yeast infection. The pessary was removed. The discharge was cultured but was negative for bacterial growth and yeast. The pessary was left out and will need to be replaced as an outpatient. Medications on Admission: norvasc 10mg MVI Klonopin 0.5mg PO TID ASA 81mg PO daily Vitamin B12 Vitamin E Vitamin C lantus 22 units hs mandelamine 400mg po daily protonix 40mg po daily ambien CR 10mg daily detrol LA 4mg daily flaxseed oil tab 1000mg daily remeron 30mg daily Discharge Disposition: Home With Service Facility: Private Care Discharge Diagnosis: Small Bowel Obstruction Pneumonia Atrial fibrillation resolved Urinary Tract Infection Hypernatremia Diabetes Vaginal discharge Discharge Condition: Vitals stable, Afebrile Followup Instructions: Follow up with your primary care provider in one week. Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007] has already spoken to him while you were in the hospital. He is aware of your current medical issues. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491] MD, [MD Number(3) 10495]	[ "300.00", "V58.67", "560.9", "403.90", "276.3", "276.0", "250.00", "599.0", "V43.64", "427.31", "715.95", "276.52", "276.2", "562.12", "486", "584.9", "623.5", "585.9", "311" ]	icd9cm	[ [ [] ] ]	[ "96.07", "45.23" ]	icd9pcs	[ [ [] ] ]	10232, 10275	6654, 9934	245, 254	10447, 10473	2048, 6631	10496, 10860	1639, 1666				10296, 10426		9960, 10209												1681, 2029																							176, 207						282, 1299															1321, 1516	1532, 1623
30,336	132,280	32627	Discharge summary	report	Admission Date: [2200-10-3] Discharge Date: [2200-10-15] Date of Birth: [2135-10-29] Sex: F Service: MEDICINE Allergies: Bactrim / Percocet / Dilaudid Attending:[First Name3 (LF) 3556] Chief Complaint: Altered mental status ? seizure, hyponatremia Major Surgical or Invasive Procedure: Right IJ central line placement Arterial line placement History of Present Illness: Ms. [Known lastname ] is a 64 yo female with with MS, quadriplegia, chronic indwelling foley, on 3L O2 at night, trasnferred from [Location (un) ] to our ED after being found minimally responsive this am by PCA with blood in mouth and ? seizure. Per daughter, pt has had symptoms of confusion, foul smelling urine, and decreased PO intake last 7-8 days which was similar to her usual UTIs but she did not receive antibiotics until day prior to transfer when daughter gave her one dose of amoxicillin. . At [Name (NI) ], pt found to have Na 117 and positive UA. She was oriented x 3, but somnolent. Head CT negative for acute process and CXR reportedly normal. Given 1g CTX for positive UA and 1mg narcan for lethargy. Labs significant for trop 0.15, WBC>20. ABG 7.22/95/295 on NRB at OSH. . In our ED, initial vs were: 96.5 76 126/43 20 100%RA. Labs significant for ABG 7.36/47/200, Na 119, WBC 16.7 Trop 0.09. UA positive. Received 3L NS for BP 80s/40s and overall dry appearance. Code status confirmed as DNR/DNI. VS prior to transfer: 114/54 76 22 100%2L. On the floor, she is somnolent but arousable and interactive. . Review of systems: Unable to fully obtain but per patient and daughter as below. (+) 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 arthralgias or myalgias. Denies rashes or skin changes. . Social History: Lives alone with PCA 20 hours per day, daughter lives nearby. Quit tobacco 20 years prior Family History: No FH recurrent infections, MS, DM. Physical Exam: General: Somnolent but arousable, oriented to self, daughter, not place or date, no acute distress HEENT: Sclera anicteric, MM very dry, oropharynx clear, tongue bite with dried blood Neck: supple, unable to appreciate JVP, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi CV: Distant. Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Baclofen pump LLQ GU: foley draining yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, trace edema Pertinent Results: [2200-10-9] 11:10AM BLOOD WBC-11.4* RBC-3.57* Hgb-11.5* Hct-34.3* MCV-96 MCH-32.1* MCHC-33.5 RDW-13.6 Plt Ct-318 [2200-10-8] 09:30AM BLOOD WBC-13.7* RBC-3.35* Hgb-10.5* Hct-30.7* MCV-92 MCH-31.3 MCHC-34.2 RDW-13.3 Plt Ct-281 [2200-10-7] 05:30AM BLOOD WBC-18.5* RBC-3.15* Hgb-9.8* Hct-29.8* MCV-95 MCH-31.3 MCHC-33.1 RDW-13.4 Plt Ct-288 [2200-10-6] 05:30AM BLOOD WBC-15.7* RBC-3.06* Hgb-9.5* Hct-28.8* MCV-94 MCH-31.0 MCHC-33.0 RDW-13.3 Plt Ct-229 [2200-10-5] 02:10AM BLOOD WBC-28.2* RBC-3.30* Hgb-10.5* Hct-30.5* MCV-93 MCH-32.0 MCHC-34.5 RDW-13.4 Plt Ct-175 [2200-10-4] 04:27AM BLOOD WBC-19.9* RBC-3.31* Hgb-10.6* Hct-31.1* MCV-94 MCH-32.1* MCHC-34.1 RDW-13.0 Plt Ct-207 [2200-10-3] 07:42PM BLOOD WBC-15.5* RBC-3.11* Hgb-9.8* Hct-29.4* MCV-94 MCH-31.6 MCHC-33.5 RDW-13.1 Plt Ct-167 [2200-10-3] 02:37PM BLOOD WBC-16.7# RBC-3.49 Hgb-11.2* Hct-32.9* MCV-94 MCH-32.0 MCHC-34.0 RDW-13.0 Plt Ct-209# [2200-10-3] 07:42PM BLOOD PT-11.5 PTT-27.3 INR(PT)-1.0 [2200-10-3] 02:37PM BLOOD PT-11.3 PTT-28.5 INR(PT)-0.9 [2200-10-10] 08:35AM BLOOD Glucose-84 UreaN-8 Na-133 K-4.1 Cl-94* HCO3-29 AnGap-14 [2200-10-9] 11:10AM BLOOD Glucose-98 UreaN-7 Creat-0.2* Na-129* K-4.8 Cl-92* HCO3-25 AnGap-17 [2200-10-8] 09:30AM BLOOD Glucose-94 UreaN-6 Creat-0.2* Na-127* K-4.8 Cl-88* HCO3-28 AnGap-16 [2200-10-7] 03:50PM BLOOD Glucose-81 UreaN-6 Creat-0.1* Na-129* K-4.5 Cl-89* HCO3-26 AnGap-19 [2200-10-7] 05:30AM BLOOD Glucose-85 UreaN-7 Creat-0.1* Na-125* K-4.2 Cl-85* HCO3-29 AnGap-15 [2200-10-6] 11:00PM BLOOD UreaN-7 Creat-0.2* Na-125* K-4.3 Cl-86* HCO3-28 AnGap-15 [2200-10-6] 11:10AM BLOOD Glucose-131* UreaN-6 Creat-0.1* Na-131* K-3.5 Cl-90* HCO3-33* AnGap-12 [2200-10-6] 05:30AM BLOOD Glucose-74 UreaN-5* Creat-0.1* Na-133 K-3.5 Cl-91* HCO3-32 AnGap-14 [2200-10-5] 04:11PM BLOOD Glucose-83 UreaN-6 Creat-0.1* Na-129* K-3.6 Cl-90* HCO3-28 AnGap-15 [2200-10-5] 02:10AM BLOOD Glucose-87 UreaN-6 Creat-0.2* Na-127* K-4.0 Cl-88* HCO3-25 AnGap-18 [2200-10-4] 05:27PM BLOOD Glucose-86 UreaN-6 Creat-0.1* Na-126* K-4.1 Cl-91* HCO3-26 AnGap-13 [2200-10-4] 04:27AM BLOOD Glucose-91 UreaN-7 Creat-0.1* Na-125* K-3.5 Cl-86* HCO3-27 AnGap-16 [2200-10-3] 07:42PM BLOOD Glucose-172* UreaN-10 Creat-0.1* Na-121* K-4.1 Cl-86* HCO3-26 AnGap-13 [2200-10-3] 02:37PM BLOOD Glucose-108* UreaN-13 Creat-0.2* Na-119* K-4.5 Cl-83* HCO3-24 AnGap-17 [2200-10-3] 02:50PM BLOOD ALT-23 AST-33 LD(LDH)-370* CK(CPK)-99 AlkPhos-150* TotBili-0.1 [2200-10-4] 11:22AM BLOOD CK-MB-8 cTropnT-0.03* [2200-10-4] 04:27AM BLOOD CK-MB-10 MB Indx-12.5* cTropnT-0.04* [2200-10-3] 07:42PM BLOOD CK-MB-9 cTropnT-0.06* [2200-10-3] 02:37PM BLOOD cTropnT-0.09* [2200-10-10] 08:35AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8 [2200-10-3] 02:37PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.7 [2200-10-3] 02:50PM BLOOD Osmolal-253* [2200-10-8] 09:30AM BLOOD TSH-2.6 [2200-10-3] 03:00PM BLOOD Type-ART Temp-35.8 Rates-/18 O2 Flow-2 pO2-200* pCO2-47* pH-7.36 calTCO2-28 Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NC . CT [2200-10-9] IMPRESSION: No acute intracranial process. Brief Hospital Course: # Pneumonia/Hypoxemic respiratory failure - On admission, CXR showed no evidence of pneumonia. On [10-13] (HD 11), pt was noted to be more somnolent in the afternoon by daughter with poor sounding breath sounds. Portable CXR showed large right perihilar opacity concerning for infection, probable right middle and lower lobe collapse possibly due to mucus. Vancomycin and Zosyn were started for empiric coverage of hospital-acquired pneumonia. She was transferred from Neuro to the Medicine service, however became hypotensive and required readmission back to the MICU. In the MICU, she continued to have a progressive oxygen requirement and was placed on BiPap with increasing support. The patient was DNR/DNI and after a family meeting with neurology, palliative care, social work, and Medicine with the HCP, the decision was made to make the patient CMO. Bipap was removed and the patient placed on 100% NRB. She was given morphine PRN to keep her comfortable and passed away quietly with her daughter at the bedside. # Altered Mental Status - Altered mental status was initially thought to be a metabolic encephalopathy secondary to infection and hyponatremia. As her infection and hyponatremia were treated, Ms. [Known lastname 1226] mental status did not improve. She was only oriented to self, confused and hallucinating intervally, which was concerning for delirium. Renal was consulted and did not believe hyponatremia was secondary to sodium levels or that sodium could have contributed to seizure. On HD 7, she developed a rigid tongue, and facial and eye twitching and was not responsive and non verbal. Neurology was consulted promptly. She was loaded with Keppra and a 24 hour EEG demonstrated episodes of rhythmic [3-28] Hz slowing in the right temporal region, sometimes with evidence on the left as well, all indicative of focal electrographic seizures. CT head did not show any acute intracranial pathology. She did not tolerate receiving MRI. She was maintained on Keppra 1500 mg [Hospital1 ] and Dilantin was also loaded and maintained at 100 mg TID. Long term EEG monitoring demonstrated gradual improvement. She also had resolution of facial/eye twitching and tongue protrusion episodes. She however was still disoriented, somewhat better at times and worse at others. Her daughter later endorsed that she had actually been on Valium 8-10 mg QD. There was concern for a benzodiazepine-withdrawal component to her confusion and she was started on diazepam 4 mg QHS and lorazepam 0.5 mg Q8H. Dilantin dose was changed to 100 mg [Hospital1 ] since free level was above 2 on HD 11 which may have added to confusion. After transfer bqck to the MICU, she continued to experience waxing and [Doctor Last Name 688] mental status. 24 hour EEG was performed and showed no evidence of seizure activity. She was continued on dilantin, keppra, and ativan for control of her seizures. # Hyponatremia - Ms [Known lastname ] presented to ICU with symptomatic hyponatremia with likely seizure activity. Initially [Doctor Last Name ] sodium hypovolemic hyponatremia given underlying infection, decreased PO intake, and overall clinical appearance. Cr low but she has minimal muscle mass. Urine osms 360, Feurea 39% which is mixed picture but has been fluid resuscitated already. Hypovolemia and hyponatremia likely exacerbated by renal losses of sodium in setting of diuretic use. She was given IV normal saline in the ICU with slow improvement of her sodiuim. She was transferred to the floor on HD 4. At this time, her FeNa was >1 so she was felt to be euvolemic with low sodium concerning for mixed picture of SIADH and continued low solute intake. A fluid restriction was started without improvement of her sodium and large urine output with high urine osmoles concerning for salt wasting. Renal was consulted who agreed with treatment regimen and suggested adding salt tablets to her medications and her sodium corrected to 133 on HD 8. The sodium level has been stable since, ranging from 135-140. # Urinary tract infection - She had 2 positive UA's, at OSH and at [Hospital1 18]. Urine culture from outside hospital grew out E. coli >100,000 colonies. She was treated with ceftriaxone for a total of 7 days. A CXR showed no evidence of pneumonia. C. diff sent out on [10-5] as pt has leukocytosis though continues to be afebrile and was negative. Indwelling Foley catheter was changed on [10-7]. Repeat UA and urine culture were sent on [10-13]. # Multiple sclerosis - She was continued on her home medication regimen of baclofen and valium. On HD 8 it was discovered she was taking half her home baclofen dose, which was 10 mg TID. This was continued on this admission. There was concern that the baclofen pump was malfunctioning. Pump was interrogated by Anesthesia and found to be functioning properly at dose of 375 mcg/day. Otherwise, this is currently stable. # Elevated troponin: Likely secondary to increased demand in setting of hypotension. No ECG changes or chest pain to suggest ongoing or active ischemia. Troponins trended down. She has not had any subjective complaints of chest pain or discomfort since. Medications on Admission: -Lasix 20 mg [Hospital1 ] -Prozac 20 mg [Hospital1 ] -Baclofen 10mg TID -Macrodantin 100mg daily -Calcitonin QOD -Valium 4mg QHS -Valium 2mg PO Q4hrs PRN -Fluoxetine 20mg [Hospital1 ] -intrathecal baclofen pump (stable dose of 375 micrograms) -Lunesta prn -Tylenol/Advil prn Discharge Disposition: Expired Discharge Diagnosis: Primary: pneumonia, hypoxic respiratory failure, MS Discharge Condition: expired Discharge Instructions: Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560] Completed by:[2200-10-18]	[ "300.4", "599.0", "V46.2", "348.31", "790.5", "344.00", "560.1", "V12.61", "340", "V13.02", "345.3", "518.81", "253.6", "V46.3", "008.45", "174.9", "507.0" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]	11582, 11591	6051, 11245	338, 395	11687, 11696	2888, 6028	11776, 11906	2179, 2217				11612, 11666		11271, 11559			11722, 11722									2232, 2869																		1582, 2056					253, 300						423, 1562																2072, 2163
62,931	143,296	18741	Discharge summary	report	Admission Date: [2156-5-17] Discharge Date: [2156-5-22] Date of Birth: [2097-8-27] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Asymptomatic, known paroxysmal atrial fibrillation Major Surgical or Invasive Procedure: [2156-5-18] Transesophageal echocardiogram [2156-5-19] Minimally Invasive Maze Procedure History of Present Illness: This 58 year old white male with known coronary artery disease, who has had several years of intermittent atrial fibrillation which leaves him fatigued. Cardioversion had been successful only transiently and he continues to suffer paroxysmal atrial fibrillation. He has developed photosensitivity on Amiodarone and it has as well failed to control the arrhythmia. He is admitted now for surgical intervention. Past Medical History: Coronary Artery Disease Paroxysmal Atrial Fibrillation Hypertension Dyslipidemia Right knee arthroscopy s/p PCI/drug-eluding stenting to LAD [2150] s/p Tonsillectomy and adenoidectomy s/p Appendectomy Social History: Non smoker, social ETOH use.Works as superviser for town highway department Family History: Noncontributory Physical Exam: Admission: awake and alert in no distress. neuro- intact Lungs: clear Cor- SR at 70. No murmur extremeties- no edema Facial erythema from photosensitivity BP 126/70 bilaterally ht: 67 inches wt: 109kg Pertinent Results: [2156-5-17] BLOOD WBC-7.9 RBC-4.59* Hgb-13.8* Hct-40.5 MCV-88 MCH-30.2 MCHC-34.2 RDW-14.1 Plt Ct-248# [2156-5-17] BLOOD PT-18.2* PTT-25.0 INR(PT)-1.7* [2156-5-17] BLOOD Glucose-110* UreaN-22* Creat-1.1 Na-137 K-3.8 Cl-101 HCO3-28 AnGap-12 [2156-5-17] BLOOD ALT-22 AST-26 LD(LDH)-236 AlkPhos-40 TotBili-0.5 [2156-5-17] BLOOD Albumin-4.5 Calcium-9.3 Phos-3.1 Mg-2.4 [2156-5-17] BLOOD %HbA1c-5.6 [2156-5-18] TEE: No mass/thrombus is seen in the left atrium or left atrial appendage. No thrombus is seen in the right 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Mr. [Known lastname ] was admitted for heparinization and preoperative evaluation which included a transesophogeal echocardiogram(TEE). The TEE ruled out intracardiac thrombus. Preoperative workup was otherwise uneventful and he was cleared for surgery. On [5-19], Dr. [Last Name (STitle) 914] performed bilateral mini-maze procedure. Given inpatient hospital stay was greater than 24 hours prior to surgery, Vancomycin was used for perioperative antibiotic coverage. For surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Chest tubes and wires were removed per protocol. Mr. [Known lastname ] was transferred from the ICU on POD#1. He received paravertebral blocks for pain control with good effect.He was restarted on coumadin, plavix and ASA and amiodarone. Low dose betablocker was started. He was discharged to home on POD 3 with VNA follow up. Dr. [Last Name (STitle) 51358] will resume coumadin follow up. Medications on Admission: Lipitor 80mg/D ASA 81mg/D Zetia 10 mg/D Tricor 145mg/D Coumadin 4mg M & F, 3mg T/W/Th/Sat/Sun (LD [5-14]) Amiodarone 200mg/D Plavix 75mg/D (LD [5-12]) 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). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 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:65 Tablet(s) Refills:0 5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:0 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:1 14. Outpatient Lab Work INR check sunday and call to Dr. [First Name4 (NamePattern1) 21976] [Last Name (NamePattern1) 11679] 15. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day: Goal INR 2-2.5 INR check on sunday. Disp:90 Tablet(s) Refills:2 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Paroxysmal Atrial Fibrillation, s/p Mini-Maze Procedure Coronary Artery Disease, prior PCI/stenting [2150] Hypertension Dyslipidemia Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 6 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed your INR will be followed by Dr. [First Name4 (NamePattern1) 21976] [Last Name (NamePattern1) 11679]. Your INR will be checked on sunday. call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) Dr. [First Name4 (NamePattern1) 21976] [Last Name (NamePattern1) 11679] in 2 weeks Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [1-16] weeks ([Telephone/Fax (1) 8129]) Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in 2 weeks ([Telephone/Fax (1) 3342]) Please call for appointments Completed by:[2156-5-22]	[ "518.0", "412", "V45.82", "327.23", "401.9", "427.31", "414.01", "746.9", "V58.61", "272.4" ]	icd9cm	[ [ [] ] ]	[ "88.72", "37.33", "37.26", "37.36" ]	icd9pcs	[ [ [] ] ]	5588, 5643	2528, 3619	371, 470	5825, 5832	1503, 2505	6445, 6903	1248, 1265		3828, 5565		5664, 5804		3645, 3805			5856, 6422									1280, 1484																							281, 333						498, 911															933, 1139	1155, 1232
7,142	119,817	49532	Discharge summary	report	Admission Date: [2131-11-26] Discharge Date: [2131-12-6] Date of Birth: [2056-4-5] Sex: F Service: CHIEF COMPLAINT: Fever. HISTORY OF PRESENT ILLNESS: This is a 75 year old woman status post orthotopic liver transplant on [2130-12-5] for primary sclerosing cholangitis who has been undergoing chemotherapy for a Stage 3 [Year (4 digits) 499] cancer. The patient developed a fever on the day of admission up to 101.0 degrees. The patient had previously had two PTC drains removed on [10-26], with [Last Name ] problem. The patient had completed her last round of chemotherapy on [2131-11-21]. The patient denies any nausea, vomiting, chills, rigors, cough, chest pain, shortness of breath or diarrhea. PAST MEDICAL HISTORY: 1. Ulcerative colitis. 2. Primary sclerosing cholangitis. 3. Hepatitis C. 4. Stage 3 [Year (4 digits) 499] cancer. 5. Anemia. 6. Anxiety. 7. Status post orthotopic liver transplant. 8. Status post right hemicolectomy. MEDICATIONS ON ADMISSION: 1. Levofloxacin 500 mg p.o. q.d. 2. Linezolid 600 mg p.o. b.i.d. 3. Neoral 75 mg p.o. b.i.d. 4. Prednisone 5 mg p.o. q.d. 5. Protonix 40 mg p.o. q.d. 6. Epoetin 20,000 units every week. 7. Iron 325 mg t.i.d. 8. Actigall 300 mg t.i.d. ALLERGIES: Penicillin, Sulfa drugs. PHYSICAL EXAMINATION: The patient was in no apparent distress, alert and oriented times three. The lungs were clear to auscultation bilaterally. Cardiac examination was normal S1 and S2 with no murmurs, rubs or gallops. Her abdomen was soft, nontender, nondistended, and her surgical incision from the liver transplant was clean, dry and intact. LABORATORY DATA: Pertinent laboratory data on admission revealed white count 11.3, hematocrit 32.0, platelets 384. Sodium 135, potassium 4.4, chloride 99, bicarbonate 28, BUN 17, creatinine 0.8, glucose 104. ALT 31, AST 28, alkaline phosphatase 271, total bilirubin 0.7, albumin 4.0. HOSPITAL COURSE: The patient was admitted and started off on Zosyn and Linezolid. The patient had a CTA the morning of [2131-11-27] and blood cultures drawn. The CTA at the time showed multiple lesions within the liver, scattered between both the left and right lobes. The lesions measured between 2.6 cm for the largest which was located in Segment 8 down to 0.8 cm. There were also new lesions located in Segment 3 and biliary air both within the liver and the common bile duct. Due to the patient's fevers and known Enterococcus the patient had an infectious disease consult. Infectious Disease recommended doing an ultrasound-guided biopsy of the liver lesion for culture of questionable malignancy. Over the next couple of days, the patient became afebrile with good response to the change from Levofloxacin to Zosyn. On hospital day #3, the patient was transferred from the floor to the Intensive Care Unit due to labile hypotension. The patient's blood pressure had fallen to a systolic less than 100 and diastolic in the mid 30s. The patient's systolic blood pressure on the floor had reached a low of 70s after ultrasound-guided drainage of the liver abscess. After two days in the Intensive Care Unit the patient was transferred back to the floor without any further incidents. The aspiration of the ultrasound-guided drainage of the hepatic abscess yielded a small amount of clear yellow fluid. This was sent off to Microbiology where it revealed Enterococcus Faecium which was resistant to Ampicillin, Levofloxacin, Penicillin and Vancomycin. The patient was continued on Zosyn and Linezolid. Even though she had no fever, her white count continued to elevate from 9.8 up to 14.2. The patient was once again pancultured, but there was no growth in either the aerobic or anaerobic bottle from that date. On [12-4], the patient had a PICC line placed for continuation of antibiotics at home. The patient continued her two week course of Zosyn which was then discontinued and then as the patient remained afebrile and with white count declining the patient was discharged to home on Synercid. The patient was to continue with a six week course of Synercid and follow up with Infectious Disease. DISCHARGE CONDITION: The patient was discharged in good condition: Afebrile, pain well-controlled on oral medications, tolerating a regular diet without difficulty. DISCHARGE FOLLOW UP: The patient was instructed to follow up with Dr. [Last Name (STitle) ] on [12-12] as well as with the Infectious Disease Clinic on [12-21]. The patient was also discharged home with [Hospital6 407] provided by Critical Care Systems for infusion of the Synercid over the continuation of six weeks. DISCHARGE DIAGNOSIS: 1. Linezolid resistant Enterococcus abscess in liver. 2. Status post orthotopic liver transplant [2130-12-5]. 3. Primary sclerosing cholangitis. 4. Hepatitis B. 5. [Year (4 digits) ] cancer, Stage 3. 6. Anemia. 7. Anxiety. DISCHARGE MEDICATIONS: 1. Prednisone 5 mg p.o. q.d. 2. Ursodiol 3 mg p.o. t.i.d. 3. Protonix 40 mg p.o. q.d. 4. Aspirin 81 mg p.o. q.d. 5. Epoetin Alpha 30,000 units q. week. 6. Synercid 350 mg intravenously q. 8 hours for six weeks. 7. Neoral 50 mg p.o. b.i.d. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1331] Dictated By:[Name8 (MD) 846] MEDQUIST36 D: [2132-1-22] 11:29 T: [2132-1-22] 12:13 JOB#: [Job Number 103609]	[ "576.1", "458.29", "996.82", "041.04", "285.9", "V58.69", "070.30", "572.0", "V10.05" ]	icd9cm	[ [ [] ] ]	[ "38.93", "00.14", "50.91", "99.04" ]	icd9pcs	[ [ [] ] ]				4208, 4364					4974, 5479		4712, 4951		1039, 1320	1976, 4186																				4376, 4691			1343, 1958											149, 157						186, 760															782, 1013
3,169	187,303	30913	Discharge summary	report	Admission Date: [2188-4-17] Discharge Date: [2188-4-28] Date of Birth: [2112-3-29] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest Pain/Dyspnea on Exertion Major Surgical or Invasive Procedure: [2188-4-17] - Coronary Artery Bypass Graft x 4 (Lima->LAD, Vein to Ramus, Vein to Posterior descending artery, Vein to diagonal artery) History of Present Illness: Mr. [Known lastname 1617] is a 76-year-old male with worsening anginal symptoms. He underwent cardiac catheterization that showed severe 3-vessel disease. He is presenting for revascularization. Past Medical History: Myocardial Infarction, Diabetes Mellitus, Hypothyroid, Anemia, Arthritis, Gastroesophageal Reflux Disease w/ Duodenal Ulcer, Hemorrhoids, s/p Mastoidectomy, s/p Vasectomy, s/p Tonsillectomy Social History: Retired photographer. Smoked up to 100 cigs/day for 48 years quitting 14 years ago. Lives with his wife.Drinks 2oz of rum daily. Edentulous. Family History: Father MI in 60's, Brother with heart issues. Physical Exam: 70 SR 18 146/68 66" 187lbs GEN: NAD, lying flat in bed SKIN: Unremarkable HEENT: Perrl, anicteric sclera, MMM, oropharynx benign NECK: Supple, FROM, no carotid bruits HEART: RRR, No murmur ABD: Soft, NT, ND, NABS EXT: Warm, dry, 2+ pulses except for nonpalp bilateral PT pulses. No varicosities NEURO: Nonfocal Pertinent Results: [2188-4-28] 06:50AM BLOOD WBC-13.0* RBC-3.34* Hgb-9.9* Hct-29.3* MCV-88 MCH-29.8 MCHC-33.9 RDW-14.0 Plt Ct-593* [2188-4-21] 07:07AM BLOOD PT-17.9* PTT-32.1 INR(PT)-1.7* [2188-4-28] 06:50AM BLOOD Glucose-167* UreaN-7 Creat-1.0 Na-138 K-3.9 Cl-99 HCO3-32 AnGap-11 RADIOLOGY Final Report CHEST (PA & LAT) [2188-4-26] 9:00 AM CHEST (PA & LAT) Reason: evaluate for pleural effusions [Hospital 93] MEDICAL CONDITION: 76 year old man s/p CABGx4 REASON FOR THIS EXAMINATION: evaluate for pleural effusions PA AND LATERAL CHEST [2188-4-26] AT 0901 HOURS. HISTORY: Post CABG. COMPARISON: [2188-4-18]. FINDINGS: A somewhat dense linear opacity remains evident in the retrocardiac region, relatively smaller in size than that noted on [2188-4-18]. Small bilateral posterior pleural effusions are again evident. Otherwise, the remaining lungs remain clear. Again noted is evidence of prior median sternotomy and CABG consistent with given history. There is a tortuous aorta. The cardiac silhouette is top normal for size. No pneumothorax is seen. IMPRESSION: Decrease in size of retrocardiac opacity. Atelectasis is favored given time course. There are persistent bilateral small pleural effusions. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7411] Cardiology Report ECHO Study Date of [2188-4-17] PATIENT/TEST INFORMATION: Indication: Chest pain. Left ventricular function. Preoperative assessment. Right ventricular function. Valvular heart disease. Status: Inpatient Date/Time: [2188-4-17] at 10:37 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW2-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] R. [Doctor Last Name ] MEASUREMENTS: Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 3.7 cm (nl <= 3.4 cm) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate regional LV systolic dysfunction. LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - dyskinetic; mid inferior - akinetic; basal inferolateral - hypo; mid inferolateral - akinetic; septal apex - hypo; inferior apex - akinetic; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. Mild to moderate ([12-11]+) MR. Eccentric MR jet. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions: PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is moderate regional left ventricular systolic dysfunction. There is dyskinesis of the inferior base, akinesis and thinning of the remaining inferior wall. The is severe hypokinesis of the inferolateral and inferoseptal walls. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-11]+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric, directed posteriorly and may cause underestimation of true MR. POSTBYPASS LV systolic function is marginally improved (the anterior wall is more hyperkinetic) LVEF~35%. The previous RWMA's persist. RV systolic function remains preserved. The MR, although eccentric, now appears mild. Remaining study is unchanged from prebypass. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD on [2188-4-17] 11:24. Brief Hospital Course: Mr. [Known lastname 1617] was admitted to the [Hospital1 18] on [2188-4-17] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to four vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mr. [Known lastname 1617] had awoke neurologically intact and was extubated. Beta blockade, a Statin and aspirin were resumed. On postoperative day two, he was transferred to the step down unit for further recovery. Mr. [Known lastname 1617] was gently diuresed towards his preoperative weight. The physical therapy service was consulted of assistance with his postoperative strength and mobility. His abdomen was noted to be distended and an x-ray was obtained which was consistent with an ileus. A nasogastric tube was placed and feedings were withheld. A general surgery consult was obtained and it was recommended to leave the nasogastric tube in place until he developed flatus and to minimize narcotics. By post-op day seven he was passing gas and the NG tube was removed. Over the next several days he continued to make clinical improvements and worked with physical therapy for strength and mobility. He did require oxygen supplementation for several days d/t decreased O2 sats. Finally on post-op day 11 he appeared to be suitable for discharge home with the appropriate medications and follow-up appointments. Medications on Admission: Crestor 10', Lasix 40', Levoxyl 50mcg', Lisinopril 40', Spirinolactone 25mg M-W-F, Toprol XL 150', Iron 325', Aspirin 81', Imdur 30', Plavix 75', Prevacid 30' 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. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 3. 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 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:QS QS Refills:2 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 10. Prevacid 30 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 11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO every mon,wed,fri. Disp:30 Tablet(s) Refills:0 12. Levoxyl 50 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: please take twice a day for 10 days then decrease to once a day . Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: Myocardial Infarction, Diabetes Mellitus, Hypothyroid, Anemia, Arthritis, Gastroesophageal Reflux Disease w/ Duodenal Ulcer, Hemorrhoids, s/p Mastoidectomy, s/p Vasectomy, s/p Tonsillectomy Discharge Condition: Stable 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. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Follow-up with Dr. [Last Name (STitle) 3314] in [1-13] weeks. [Telephone/Fax (1) 3183] Call all providers for appointments. Completed by:[2188-4-29]	[ "250.00", "414.01", "244.9", "560.1", "530.81", "E878.2", "997.4" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.13", "36.15" ]	icd9pcs	[ [ [] ] ]	9382, 9437	5969, 7470	352, 494	9736, 9744	1506, 1909	10458, 10768	1110, 1157		7679, 9359	1946, 1973	9458, 9715		7496, 7656			9768, 10435						2923, 5946			1172, 1487																							282, 314	2002, 2897					522, 723															745, 936	952, 1094
3,640	141,027	29236+57629	Discharge summary	report+addendum	Admission Date: [2107-11-27] Discharge Date: [2107-11-28] Date of Birth: [2089-10-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 18 yo male with past medical history significant for asthma transferred from OSH for further evaluation of recurrent chest pain. One day prior to transfer, patient developed sharp chest pain over his left chest with occasional radiations to both shoulders while working as a cashier at CVS. Pain worsened somewhat with inspiration. Patient initially thought pain was indigestion and took several Tums without relief. Pain worsened and patient was taken to hospital by EMS. At hospital, patient's pain improved somewhat with morphine but with minimal improvement with nitroglycerine. At OSH, patient was diagnosed with myopericarditis and was started on continuous NSAIDs. There was also concern of vasospasm and he was started on 5mg amlodipine daily. Echo at OSH demonstrated EF 70% with no valvular or regional abnormalities. Then on the morning of transfer, patient developed another episode of chest pain [9-20], similar in character to his pain previously and patient was transferred to [Hospital1 18] for possible cardiac catheterization. Past Medical History: Asthma - Mild Intermittent Social History: [Male First Name (un) ] in high school Smokes - 1 PPD x 2 years EtOH - 8 beers a night, once a week, last drink 2 nights ago Illicits - Occasional marijuana use once a month, last use 5 days ago Family History: no cardiac disease Physical Exam: T 96 / HR 64 / BP 129/79 / RR 24 / PO2 99% RA Gen: lying in bed, in mild distress HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: ECHO Study Date of [2107-11-27]: Ejection Fraction: >= 60% (nl >=55%) - Normal LV wall thickness, cavity size, and systolic function (though apical segments not fully visualized due to very poor apical windows). - No MR [First Name (Titles) ] [Last Name (Titles) ], no MVP OSH Portable CXR - [2107-11-26] - possible lingular infiltrate OSH ECG - sinus brady at 55 bpm, normal axis, shortened PR interval, [Known lastname ] less than q waves in I, II, aVL, and aVF. No hypertrophy. Question of minimal diffuse ST abnormalitis. [2107-11-27] 07:17PM CK(CPK)-424* [2107-11-27] 07:17PM CK-MB-37* MB INDX-8.7* cTropnT-1.20* [2107-11-27] 01:01PM CK-MB-40* MB INDX-9.2* cTropnT-1.01* [2107-11-28] 05:58AM BLOOD WBC-5.6 RBC-3.98* Hgb-13.4* Hct-35.8* MCV-90 MCH-33.6* MCHC-37.2* RDW-12.9 Plt Ct-179 [2107-11-28] 05:58AM BLOOD WBC-5.6 RBC-3.98* Hgb-13.4* Hct-35.8* MCV-90 MCH-33.6* MCHC-37.2* RDW-12.9 Plt Ct-179 [2107-11-27] 01:01PM BLOOD WBC-7.7 RBC-4.16* Hgb-13.7* Hct-37.5* MCV-90 MCH-32.9* MCHC-36.5* RDW-13.0 Plt Ct-198 [2107-11-28] 05:58AM BLOOD Plt Ct-179 [2107-11-28] 05:58AM BLOOD PT-13.1 PTT-27.2 INR(PT)-1.1 [2107-11-28] 05:58AM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-139 K-4.2 Cl-103 HCO3-28 AnGap-12 [2107-11-28] 05:58AM BLOOD ALT-21 AST-40 LD(LDH)-252* CK(CPK)-232* AlkPhos-87 TotBili-1.1 [2107-11-27] 07:17PM BLOOD CK(CPK)-424* [2107-11-28] 05:58AM BLOOD CK-MB-19* MB Indx-8.2* [2107-11-27] 07:17PM BLOOD CK-MB-37* MB Indx-8.7* cTropnT-1.20* [2107-11-27] 01:01PM BLOOD CK-MB-40* MB Indx-9.2* cTropnT-1.01* [2107-11-28] 05:58AM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.8* Mg-2.2 Brief Hospital Course: ASSESSMENT: 18 yo male with past medical history significant for mild intermittent asthma only transferred from OSH for evaluation of persistent chest pain. . 1. Pericarditis Patient presented from OSH with ST elevations on ECG and elevated cardiac enzymes. Given the character of patient's pain, his age, and his ECG findings suggest pericarditis, likely viral in origin given patient's recent cough symptoms. Patient was maintained on NSAIDs for pain control with prn morphine and dilaudid. After initial day of hospitalization, patient's chest pain greatly improved and he was not requiring significant pain control. Patient was discharged to home with ibuprofen for pain control and then follow-up with his pediatrician. . Medications on Admission: Albuterol prn Discharge Medications: 1. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a day as needed for chest pain: Take with food. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Myopericarditis Discharge Condition: Good - chest pain under control with non-steroidal anti-inflammatory medications. Discharge Instructions: You have been diagnosed with inflammation of the heart and sac around the heart probably as a result of a viral infection. You did not have a heart attack. You should continue taking your ibuprofen 800mg three times a day as needed for chest pain. Followup Instructions: Followup with your primary care physician within the next two weeks. At that time you should be tested for other viruses including hepatitis, HIV, mono. Name: [Known lastname 3317],[Known firstname 11916] Unit No: [Numeric Identifier 11917] Admission Date: [2107-11-27] Discharge Date: [2107-11-28] Date of Birth: [2089-10-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 5306] Addendum: After discharge, patient noted to have a positive monospot. Spoke with patient's primary pediatrician's office (Dr. [Name (NI) 11918]) with this information. Discharge Disposition: Home [First Name8 (NamePattern2) 116] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 5308] Completed by:[2107-12-2]	[ "423.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6085, 6279	3936, 4664	330, 337	4962, 5046	2246, 3913	5344, 6062	1702, 1722		4728, 4873		4923, 4941		4690, 4705			5070, 5321									1737, 2227																							280, 292						365, 1419															1441, 1469	1485, 1686
76,630	158,373	48842	Discharge summary	report	Admission Date: [2189-4-19] Discharge Date: [2189-5-4] Date of Birth: [2135-8-10] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline Attending:[First Name3 (LF) 5123] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Coil Embolization History of Present Illness: 53F with minimal past medical history went to an OSH emergency department with nausea, vomitting and abdominal pain for 24 hours. On [2189-4-17] she developed a "stomach bug" with nausea. The PCP called in zofran and cipro for possible infection. Then the next day she developed nausea, dry heaves, and [10-25] abdominal pain. She went to OSH ED where she was found to have a 17 x 19 x 8 cm retroperitoneal mass with extension through gerota's fascia around the right kidney, IVC compression, and possible aneurysm or pseudoaneurysm in central portion of the mass. ROS revealed several week history of drenching night sweats but no fever. She was given Levofloxacin and Flagyl ([2179]) and tranferred to [Hospital1 18] for further management. . In the Emergency Department her initial vitals were 96.5, 90, 118/70, 18, 100% RA with a hematocrit of 32.4. At 11pm complained of more pain not responsive to morphine. Started on 2L NC for O2 sat 89%. Nausea and pain continued. Surgery saw her. At midnight she became unresponsive, and hypoxic, and was emergently intubated. She then dropped her blood pressure to the 60s. Right IJ was placed. Emergency PRBCs given and levophed started. . Repeat HCT was 24 at 12:30. 3+ L IVFS, Levophed continued, still dropped BP into 50s. Neo transiently started but then able to be turned off. She was transfused total of 6u PRBC, 4 FFP. CT was repeated, showing pseudoaneurysm with active blush, not present prior, concerning for a RP bleed. She was taken emergently to IR for mesenteric angiogram and possible coil embolization of the aneurysm. . In IR, she had coiling of pseudoaneurysm (with supply from SMA or possibly GDA), without any evidence of residual bleed. By the end of procedure, she had received total of [8-25] units PRBCs, 6 FFP, and 2 bags of plts. She was also given calcium. Her BP improved and she was able to be weaned off vasopressors. She required some doses of lasix due to low urine output. Her Lactate peaked at 5.7, but trended down to 2.9 on transfer to the medial floor. Her pH nadir was 7.11 (bicarb 15), but improved up to 7.36. Her last whole blood Hct was 31 prior to transfer to the medical floor. Past Medical History: Hypertension Chronic sinusitis Chronic migraines Chronic back pain H/o groin pain of unclear etiology ([Hospital3 10310] Hospital) H/o pneumonia Social History: Originally from [Location (un) ]. Secretary, out of work x 1 year. Rare glass of wine. Smokes 10 cig/day, h/o smoking 1 ppd. Remote h/o marijuana. Family History: Mother died of lung cancer in 70s, heavy smoker. Father died of "GI problem." Has 3 sisters (1 decreased), no known medical issues. Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Intubated and deeply sedated, not currently responding. HEENT: Sclera anicteric, pupils 3mm and minimally reactive right now, MMM, oropharynx clear Neck: supple, RIJ line in place, difficult to appreciate JVD, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: hypoactive bowel sounds, slightly tense, appears non-tender, non-distended, no rebound tenderness or guarding, no organomegaly or masses able to be appreciated Ext: warm and well perfused, angioseal in place in R groin. DP and PT pulses present bilaterally, left DP more easily palpable compared to right, no clubbing, cyanosis or edema Neuro: limited by sedation, not responsive currently Pertinent Results: ADMISSION LABS: WBC-14.6* HGB-10.6* HCT-32.4* MCV-96 PLT COUNT-259 DIFF: NEUTS-81.4* LYMPHS-15.5* MONOS-2.8 EOS-0.1 BASOS-0.2 PT-13.6* PTT-23.6 INR(PT)-1.2* GLUCOSE-165* UREA N-28* CREAT-1.3* SODIUM-138 POTASSIUM-5.5* CHLORIDE-111* TOTAL CO2-17* ANION GAP-16 ALT(SGPT)-10 AST(SGOT)-29 LD(LDH)-520* ALK PHOS-59 TOT BILI-0.4 LIPASE-24 ALBUMIN-3.4* LACTATE-2.4 . DISCHARGE LABS: WBC-11.5* Hgb-12.7 Hct-38.1 MCV-92 Plt Ct-395 PT-14.3* PTT-28.3 INR(PT)-1.2* Glucose-97 UreaN-15 Creat-0.6 Na-142 K-3.8 Cl-106 HCO3-25 AnGap-15 ALT-15 AST-12 LD(LDH)-628* AlkPhos-73 TotBili-1.0 Calcium-8.2* Phos-4.2 Mg-2.0 Lipase-52 . IMAGING: CT TORSO [2189-4-20]: CT OF THE CHEST: There are several hypoattenuating nodules within the right lobe of the thyroid gland, the largest measuring 2.2 x 1.2 cm. The heart, pericardium, and great vessels are normal. There is no mediastinal or hilar lymphadenopathy. The lungs are clear. An endotracheal tube is in place, terminating just above the carina. . CT OF THE ABDOMEN: Initial non-contrast images through the abdomen demonstrate IV contrast material within the renal cortices bilaterally as well as vicarious excretion of contrast in the gallbladder and biliary system. Both of these findings of retained contrast from prior CT performed at the outside hospital 7 hours prior are consistent with acute renal failure. Prior to contrast administration, there is extensive heterogeneous material in the retroperitoneum and extending into the paracolic gutters consistent with extensive retroperitoneal hematoma. Post-contrast images demonstrate the hematoma anterior to the aorta extending from the level of the celiac origin to the pelvis. The hematoma displaces the pancreas and SMA/SMV anteriorly and superiorly and surrounds the retroperitoneal duodenum. The mesenteric vessels and IVC are markedly compressed; however, remain patent. On the arterial phase imaging, there is a well-defined rounded focus of enhancement within the hematoma to the right of midline, just posterior/inferior to the pancreatic head. There is also a blush of contrast extending to the left of midline. Both areas do not change significantly in configuration on delayed images, and are concerning for a large pseudoaneurysm potentially from one of the SMA or celiac axis branches (4:76). No definite mass lesion is identified. . There is a 7-mm hypoattenuating lesion within segment [Doctor First Name 690] of the liver (4:52) which is too small to further characterize. The spleen and adrenal glands are unremarkable. The kidneys are hyperenhancing due to acute renal compromise. There are multiple hypoattenuating lesions within the kidneys, which are likely simple cysts but too small to further characterize. As noted previously, the gallbladder is heterogeneous and filled with previously administered contrast. The pancreas is enlarged and the head is distorted and compressed by the hematoma. The uncinate process is not clearly identified. Hemorrhage extends into the paracolic gutters and into the pelvis. The intra-abdominal small and large bowel loops are unremarkable. . CT OF THE PELVIS: Again complex fluid extends into the pelvis. The sigmoid colon, rectum, and bladder are unremarkable. The uterus is poorly visualized. The osseous structures are unremarkable with no lytic or sclerotic lesions. . IMPRESSION: 1. Extensive retroperitoneal hemorrhage with IV contrast extravasation posterior to the pancreas suggestive of a large pseudoaneurysm. Etiology of this pseudoaneurysm is unclear and may relate to prior trauma, pancreatitis or duodenal ulceration/inflammation. No definite retroperitoneal mass is identified. These findings were discussed urgently between radiology resident Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and surgical resident Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17470], and the patient was referred to interventional radiology for intervention. 2. Marked narrowing of the mesenteric vessels, presumably due to compression by the large hematoma, however these vessels should also be evaluated during angiography. 3. CT findings of acute renal compromise. 4. Incidentally noted thyroid nodules, the largest measuring up to 2.2 cm, for which thyroid ultrasound is recommended on a non-emergent basis. . MESENTERIC ANGIOGRAM [2189-4-20]: FINDINGS: 1. Large 2.8 x 1.8 cm pseudoaneurysm arising off of a SMA branch contributory to the pancreaticoduodenal arcade. Active extravasation is identified. 2. Successful coil embolization across the neck of the pseudoaneurysm, with absence of filling on post-embolization angiography. 3. No evidence of tumor blush or abnormal arterial vasculature in the region of the pseudoaneurysm. 4. High-grade stenosis of the celiac artery. The celiac artery ostium is patent, however, there is significant collateral flow from the SMA into celiac arterial system on SMA angiography, consistent with high-grade celiac artery stenosis. After embolization of a prominent collateral, angiography demonstrates continued high flow into the celiac system via the GDA, with filling of the hepatic and splenic arterial beds. This is consistent with patent collateralization and good arterial flow into the celiac arterial system. IMPRESSION: 1. 2.8 x 1.7 cm pseudoaneurysm arising off of a SMA branch contributing to the pancreaticoduodenal arterial system, with successful coil embolization across the pseudoaneurysm neck. 2. Patent but high-grade stenosis of the celiac artery origin, with prominent collateral flow from the SMA, which continues after embolization. 3. No evidence of abnormal enhancement to suggest an underlying tumor/mass in the location of the pseudoaneurysm. . EGD [2189-4-24]: Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Patchy erythema in the antrum of the stomach consistent with gastritis. Cold forceps biopsies were performed for histology at the antrum. Other No mass seen. Duodenum: Mucosa: Area of erythema and mild edema of the mucosa was noted on [1-17] folds in the second port of the duodenum. Cold forceps biopsies were performed for histology at the duodenum. Impression: Abnormal mucosa in the stomach (biopsy) Abnormal mucosa in the duodenum (biopsy) No mass seen. Otherwise normal EGD to second part of the duodenum . PATH BIOPSIES [2189-4-24]: Antrum, biopsy (A): Chemical (reactive) gastropathy. Duodenum, biopsy (B): Small intestinal mucosa with features suggestive of chronic inactive duodenitis. . CTA TORSO [2189-4-26]: 1. Acute pulmonary embolism involving the right upper lobe pulmonary artery. 2. Small bilateral pleural effusion and adjacent compressive atelectasis. 3. Interval organization and evolution of extensive retroperitoneal hematoma, status post coiling of a large pseudoaneurysm. No evidence of extension of the retroperitoneal hematoma. 4. Enlarged common bile duct measuring 10 mm in diameter with stable prominence of the pancreatic duct. Correlation with LFTs is recommended. 5. Air within the bladder lumen. Correlation for recent foley catheterization is recommended. . CYTOLOGY OF HEMATOMA [2189-4-30]: Hematoma (right abdomen, retroperitoneal), aspirate: NEGATIVE FOR MALIGNANT CELLS. (See note.) Blood with degenerated mixed inflammatory cells. Note: Evaluation is limited by degenerative changes. Brief Hospital Course: This is a 53 year old female who presented from an OSH for further evaluation of a right retroperitoneal mass with involvement of the right kidney and IVC compression, found to have hypotension and hemorrhagic shock from an acute RP bleed, who later developed a newly diagnosed PE on Lovenox, and difficult to control abdominal pain. . #. Retroperitoneal bleed/hematoma. The patient was found to be in hemorrhagic shock due to acute blood loss from a spontaneous RP bleed with the likely bleeding source being a pseudoaneursym. She was admitted to the MICU s/p emergent angiogram and coiling of a SMA branch pseudoaneurysm by interventional radiology. She had been hypotensive, hypoxic, with a lactic acidosis likely due to acute blood loss from a retroperitoneal bleed but by the time she was transferred to the floor was hemodynamically stable and off vasopressors following successful coil embolization. She received a total of 9 units of packed red blood cells, 6 units of FFP, and 2 units of platelets. Following coiling, she remained hemodynamically stable with a stable hematocrit. She was monitored on telemetry closely for any tachycardia that would indicate re-bleeding. Initially there was concern about the blood supply to the duodenum and potential for bowel necrosis s/p coiling, but there was no evidence of this during her stay. An EGD was performed [4-24] and showed chemical gastritis and duodenitis. Due to the patient's discomfort and suspicion for RP space infection, a JP drain was placed into the RP space by IR on [4-30] which drained clotted blood. The JP drain was pulled prior to discharge. Repeat CT imaging of the abdomen was suggested within 3-6 months as an outpatient. . #. Abdominal pain. At first, the patient developed RUQ abdominal pain which she described as new since her RP bleed. A RUQ U/S showed intrahepatic biliary ductal dilatation with diffuse dilatation of the common bile duct which tapered to the level of the pancreas. These findings were likely related to extrinsic compression from the large retroperitoneal hematoma. A heterogeneous area around the pancreatic head is likely secondary to the known retroperitoneal hematoma. At this time, a mass was not identified. Cholelithiasis was noted. The patient later also experienced mid epigastric and LUQ pain similar to her chronic abdominal pain which was relieved with Maalox/lidocaine PRN. She was transitioned from Dilaudid PO/IV for pain control to oxycodone 5mg PO PRN which also seemed to cause less stomach upset and improve her pain control. Otherwise, she was continued on a PPI q12 as well as ranitidine 150mg [Hospital1 ] given her refractory symptoms. . #. Pulmonary embolus. The patient became tachycardic to the 120s and developed a new O2 requirement on [4-26]. Initially a PE vs. a repeat RP bleed was suspected, and a CT torso with contrast was performed which showed an acute pulmonary embolism involving the right upper lobe pulmonary artery. The patient did not have physical exam findings consistent with a DVT in the lower extremities, which increased the concern for an occult malignancy. She was cautiously started on a heparin gtt given her recent bleed which was transitioned to Lovenox on [4-28]. She was carefully monitored for clinical signs of bleeding and her hct was trended closely with no signs of repeat bleeding after several days of antocoagulation prior to discharge. She was discharged on Lovenox given the concern for an occult malignancy. Colonoscopy, evaluation of her known thyroid nodules, and mammography should all be pursued as part of cancer screening work-up as an outpatient. . #. Fever. The patient developed several days of low grade fevers and leukocytosis, but both were improving upon discharge. A full infectious work-up was performed several times and all cultures were negative. Her central line was removed [4-25] and the tip culture was also negative. These findings may have all been related to her acute PE diagnosed [4-26]. There was no evidence of pneumonia on serial CXRs. It was also suspected that her RP hematoma may have become infected. Therefore, the patient had an IR procedure to place a JP drain into the RP space and the clotted blood that was aspirated was sent for gram stain, culture, and cytology on [4-30] which were all negative. . #. Hypertension. The patient's blood pressure increased to the 190s systolic at times. She was on atenolol only at home. Her home atenolol was initially discontinued given her GI bleed. Once her hct stabilized, she was transitioned to metoprolol 25mg [Hospital1 ] and she was discharged on metoprolol succinate 50mg daily. Despite her beta blocker, her pressures were still elevated and she was started on captopril which was titrated to 50mg TID which was then transitioned to lisinopril 30mg daily prior to discharge. . #. Chronic pain. The patient has chronic pain issues and migraines at home. At home she was on Topamax 50mg tid, Tramadol 200mg daily, Vicodin prn (~40 tabs a month), Excedrin XS 100 tab bottle q 3weeks, Carisoprodol 350mg [Hospital1 ], Diclofenac 50mg [Hospital1 ] prn pain, and Gabapentin 600mg 1-2 tabs tid prn. She was only continued on tramadol and gabapentin and was instructed to discontinue the rest of the meds listed above. NSAIDs were avoided given her chemical gastritis and recent RP bleed. . #. Anemia. Likely secondary to massive GI bleed. Iron studies were checked and essentially unremarkable. Her retic count was not as high as expected given massive hemorrhage. Her folate was borderline low and she was started on folate supplementation. . #. Respiratory failure. The patient developed hypoxic respiratory failure in the setting of an acute bleed and shock that required intubation on admission. She was extubated on [4-21] after 2 days. She had significant atelectasis due to splinting from her abdominal pain which improved with pain control and incentive spirometry. . # Hypothermia. Her temperature was 95 on arrival to the ICU. She was placed on a Bair hugger to maintain normothermia, which was stopped after 12 hours. There was no evidence of infection clinically or on imaging or cultures. . #. Acute Kidney Injury. Her creatinine peaked at 1.5 on [4-20] but quickly resolved back to a normal value. The etiology was likely prerenal given hemorrhagic shock from an RP bleed and it resolved with fluid resuscitation. . #. Thyroid nodules. The patient was noted to have multiple thyroid nodules, with the largest measuring 2.2 cm, that were incidentatlly found on CT imaging on admission. TSH and T4 were WNLs and T3 level was low at 57. A thyroid U/S should be completed as an outpatient for further work-up. . #. Communication: With patient and [Name (NI) ] (husband) cell - [Telephone/Fax (1) 102610] . #. Code: Confirmed full code. Medications on Admission: - Topamax 50mg tid - Tramadol 200mg daily - Prochlorperazine 5mg q6h prn nausea ([2189-4-18]) - Cipro 500mg [Hospital1 ] - Carisoprodol 350mg [Hospital1 ] - Atenolol 25mg daily - Diclofenac 50mg [Hospital1 ] prn pain ([2188-6-27]) - ?using - Gabapentin 600mg 1-2 tabs tid prn (used) - Excedrin XS 100 tab bottle q 3weeks - Vicodin prn for several years (husband's rx'd 100/month for RA), ~40 tabs a month - Sudafed Discharge Medications: 1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for pain. 2. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:60 Tablet(s) Refills:0 8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. Disp:255 grams Refills:2 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for constipation. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. Disp:60 Tablet, Chewable(s) Refills:0 11. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:60 injection Refills:2 14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 15. Magic Mouthwash- Please mix equal parts Maalox and Lidocaine, Take 30cc QID PRN for adbominal discomfort, Dispense 8oz, Refill-1 16. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:30 Tablet, Rapid Dissolve(s) Refills:0 17. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:30 Capsule(s) Refills:0 18. Dextromethorphan Poly Complex 30 mg/5 mL Suspension, Sust.Release 12 hr Sig: Five (5) mLs PO Q12H (every 12 hours) as needed for cough. Disp:120 mLs Refills:0 19. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 20. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO at bedtime as needed for cough. Disp:120 ML(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Retroperitoneal bleed Hemorrhagic shock Pulmonary embolus Secondary: Thyroid nodules Hypertension Chronic abdominal pain 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 further evaluation of a retroperitoneal mass, nausea, and abdominal pain. Your blood pressure and blood levels were dropping quickly and you were diagnosed with a retroperitoneal bleed. A special interventional radiology procedure was performed which was able to isolate and stop the blood vessel that was bleeding into your retroperitoneal space. You lost a tremendous amount of blood into this space and required several blood product transfusions. You were also briefly intubated on a ventilator to protect your airway. Your blood levels have remained stable for several days. You also developed a pulmonary embolus which is a blood clot in your lungs. You will need to be on Lovenox which is a blood thinner to prevent further clots from happening. Incidentally, some thyroid nodules were seen on a CT scan and will need to be followed up as an outpatient. You will also need a repeat CT scan of your abdomen in a month to re-evaluate the size of your retroperitoneal hematoma. . The following changes have been made to your home medication regimen: -You should stop taking your home Excedrin, Sudafed, Topamax, Vicodin, Carisoprodol, Diclofenac, and atenolol -You should start folic acid, pantoprazole, metoprolol succinate, docusate/senna/miralax/Dulcolax as needed for constipation, simethicone as needed for gas, lisinopril, oxycodone as needed for pain, Lovenox, ranitidine, Maalox/lidocaine as needed for abdominal discomfort, ondansetron ODT as needed for nausea, benzonatate/Delsym/guaifenesin with codeine as needed for cough, and Flonase for nasal congestion. Followup Instructions: #. Please follow-up with your primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 31469] [Last Name (NamePattern1) ]. His office phone number is [Telephone/Fax (1) 84800]. I have made an appointment for you on Wednesday [5-6] at 4PM. . #. Please get a follow-up CT scan in one month to re-evaluate the size of your retroperitoneal hematoma. . #. Thyroid nodules noted on CT torso. - You will need to schedule an ultrasound through your PCP to have these nodules evaluated further as an outpatient. . #. Please schedule an outpatient colonoscopy through your PCP's office.	[ "338.29", "535.50", "415.11", "V45.89", "442.89", "564.00", "241.0", "724.5", "285.1", "584.9", "785.59", "401.9", "346.90", "276.6", "473.9", "447.4", "518.81", "E878.8", "537.9", "568.81", "276.2" ]	icd9cm	[ [ [] ] ]	[ "54.91", "38.93", "45.16", "88.01", "96.72", "96.04", "96.07", "39.79", "88.47" ]	icd9pcs	[ [ [] ] ]	21353, 21359	11283, 18169	335, 354	21534, 21534	3916, 3916	23336, 23961	2949, 3085		18655, 21330		21380, 21513		18195, 18632			21685, 23313				4293, 11260					3100, 3897																							281, 297						382, 2587					3932, 4277				21549, 21661						2609, 2760	2776, 2933
52,615	105,547	35614	Discharge summary	report	Admission Date: [2163-4-16] Discharge Date: [2163-4-25] Date of Birth: [2131-9-11] Sex: M Service: NEUROSURGERY Allergies: Azithromycin / Rocephin Attending:[First Name3 (LF) 78] Chief Complaint: Headache Major Surgical or Invasive Procedure: CEREBRAL ANGIOGRAM History of Present Illness: 31 year old hispanic male who was in usual state of health until day of admission. He was doing stretching exercises at the local gym when he had a sudden onset of headache. He went to an OSH where CT scan demonstrated subarachnoid hemorrhage. He was transferred to [Hospital1 18] for further eval. Past Medical History: DM type I Social History: employed engaged - planning a wedding for this [Month (only) 216] rare tob, no ETOH, no drugs or steroids however admits to taking a "white pill" a week prior to admission for weight gain. He does not know the makeup of the pill and states he only took it once. Family History: non contibutory Physical Exam: 98 96 161/69 16 100% RA AAOx3 NAD RRR CTAB soft NT/ND no edema extrem warm CN II-XII Motor 5+ upper and lower extrem coordination intact sensation equal and intact Pertinent Results: [Known lastname 81043],[Known firstname ] [Medical Record Number 81044] M [2070-9-25] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [2163-4-16] 2:11 PM [Last Name (LF) ],[First Name8 (NamePattern2) ] [Doctor Last Name ] EU [2163-4-16] 2:11 PM CTA HEAD W&W/O C & RECONS Clip # [Clip Number (Radiology) 81045] Reason: ?aneurysmal bleed Contrast: OPTIRAY Amt: 80 [Hospital 93] MEDICAL CONDITION: 31 year old man with hx of sudden onset worst HA of life, mod/lg SAH on OSH non-con CT head. REASON FOR THIS EXAMINATION: ?aneurysmal bleed CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: AKSb SAT [2163-4-16] 5:25 PM Focal SAH in the perimesencephalic and prepontine cisterns. No definite aneurysm or AVM identified. Possible etiologies include perimesencephalic (venous) bleed, or AVM/aneurysm obscured by hemorrhage. d/w Neurosurg. Final Report INDICATION: 31-year-old with history of sudden onset worst headache of life with moderate subarachnoid hemorrhage on outside hospital CT. Evaluate for aneurysm. No prior examinations available for comparison. TECHNIQUE: Non-contrast CT of the head was performed, followed by enhanced CTA of the circle of [Location (un) 431] including multiplanar and volume-rendered images. NON-CONTRAST HEAD CT: There is high attenuation focal hemorrhage within the perimesencephalic and prepontine cisterns. No extension of hemorrhage within the ventricles and no evidence of hydrocephalus. No additional foci of subarachnoid hemorrhage. High attenuation area along the left tentorium likely represents a sagittal sinus (2:11). The visualized paranasal sinuses and mastoid air cells are normally pneumatized and aerated. CTA: The visualized course of intracranial carotid and vertebral arteries and their major branches are normal. There is no evidence of stenosis, occlusion, or aneurysm formation. IMPRESSION: Focal subarachnoid hemorrhage within the perimesencephalic and prepontine cisterns, without a definite aneurysm seen on the CTA. Differential considerations included a perimesencephalic (venous) hemorrhage or an occult aneurysm or AVM. Findings were discussed with the neurosurgical team at the time of the exam. The study and the report were reviewed by the staff radiologist. [Known lastname 81043],[Known firstname ] [Medical Record Number 81044] M [2070-9-25] Radiology Report MRA NECK W&W/O CONTRAST Study Date of [2163-4-17] 12:39 PM [Last Name (LF) ],[First Name3 (LF) 742] NSURG SICU-A [2163-4-17] 12:39 PM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # [Clip Number (Radiology) 81046] Reason: eval for bleed Contrast: MAGNEVIST Amt: 20 [Hospital 93] MEDICAL CONDITION: 31 M bodybuilder, stritching yesterday he had sudden onset HA. CT at OSH shows SAH. No other complaints or deficits. Loaded dilantin and given nimodpine at OSH. Transferred to [Hospital1 18] for further management. Angio neg for aneurysm REASON FOR THIS EXAMINATION: eval for bleed CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: DFDkq SUN [2163-4-17] 6:12 PM Subarachnoid hemorrhage in the perimesencephalic and prepontine cisterns, as well as in the sulci of both convexities. Normal MRA of the neck. MRA of the head is slightly limited by motion, but no aneurysms are identified. Final Report INDICATION: Subarachnoid hemorrhage. COMPARISON: Head CTA performed on [2163-4-16] and conventional cerebral angiogram performed on [2163-4-16]. TECHNIQUE: Sagittal T1-weighted and axial T1-weighted, T2-weighted, FLAIR, gradient echo, and diffusion-weighted images of the head. Three-dimensional time-of-flight MRA of the head. Dynamic coronal VIBE imaging of the neck obtained during intravenous gadolinium administration. Following intravenous gadolinium administration, multiplanar T1-weighted images of the head were obtained. HEAD MRI: T1 isointense and T2 hypointense blood products are seen in the perimesencephalic and prepontine cisterns, corresponding to the subarachnoid hemorrhage seen on the non-contrast portion of the preceding head CTA. In addition, there is high signal in the sulci on FLAIR images involving the right frontal, bilateral parietal, and bilateral occipital lobes. This is consistent with additional subarachnoid hemorrhage which is occult by CT. There is no evidence of edema, infarction, mass or other pathologic enhancement in the brain. There is no evidence of a meningeal mass. The ventricles are normal in size and configuration. NECK MRA: The cervical common carotid, internal carotid, and vertebral arteries appear normal. The distal cervical internal carotid arteries measure at least 4 mm in diameter. HEAD MRA: The study is slightly limited by artifacts. Flow is seen in the intracranial internal carotid and vertebral arteries, and their major branches, without evidence of stenoses or aneurysms. IMPRESSION: 1. Subarachnoid hemorrhage in the basal cisterns as well as in the cerebral sulci. 2. Normal neck MRA. 3. Unremarkable head MRA. [Known lastname 81043],[Known firstname ] [Medical Record Number 81044] M [2070-9-25] Radiology Report CHEST (PORTABLE AP) Study Date of [2163-4-18] 4:27 AM [Last Name (LF) ],[First Name3 (LF) 742] NSURG SICU-A [2163-4-18] 4:27 AM CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 81047] Reason: eval for infiltrate [Hospital 93] MEDICAL CONDITION: 31 year old man with SAH, w/ dark sputum and intermittent low-normal O2 saturation. To eval for infiltrate. REASON FOR THIS EXAMINATION: eval for infiltrate Preliminary Addendum Preliminary reports are not available for viewing. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] [Last Name (LF) ],[First Name3 (LF) 742] NSURG SICU-A [2163-4-18] 4:27 AM CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 81047] Reason: eval for infiltrate [Hospital 93] MEDICAL CONDITION: 31 year old man with SAH, w/ dark sputum and intermittent low-normal O2 saturation. To eval for infiltrate. REASON FOR THIS EXAMINATION: eval for infiltrate Final Report REASON FOR EXAMINATION: Decrease in saturations in a patient with subarachnoid hemorrhage. Portable AP chest radiograph was reviewed with no comparison to the prior studies. There is a large opacity in the left lower lung most likely involving the left lower lobe and lingula. There is additional opacity in the right lower lobe. The findings are concerning for bilateral aspiration or multifocal pneumonia. Slight left ventricle engorgement is present also may be projectional due to the position of this film. No appreciable pleural effusion is demonstrated. Brief Hospital Course: Pt was admitted through the emergency room after transfer from OSH for perimesencephalic hemorrhage after working out at gym. Pt was placed on dilantin and nimodipine and and a-line was placed. Systolic BP was controlled to less than 140. A cerebral angiogram was done on [2163-4-17] which was negative for aneurysm. A CXR was done on [2163-4-18] for low O2 sats and dark sputum. The findings were suggestive of pneumonia vs. aspiration however the pt is afebrile without elevated WBC, so no antibiotics were started at this time. A blood gas was obtained that showed poosr oxygenation. This was discussed with the ICU attending and CTA of the chest was then oobtained without evidence of PE. Pt was supported on increasing amounts of O2 throughout the night and on the am of [2163-4-19] it was decided that he would need ventilatory support. Prior to intubation he was mentating well and his neuro exm remianed stable. Consent for HIV testing was obtained and found to be negative. Bronchoscopy for sputum culture and or mucous plugging was performed. Lasix gtt was started for ARDS treatment. He required mechanical ventilation and was weaned to room air on [4-20] a CXR showed improved bibasilar opacities prior to transfer to floor. He was monitored on the surgical floor for 3 days and had a repeat CTA which showed a Normal CT of the head with no evidence of aneurysm formation. Mild vasospasm is noted at the distal basilar artery. He was cleared for discharge he had no focal neurological deficits on discharge and his headache was minimal. The patient felt comfortable managing his diabetes as to his prior regiman. He was sent with a prescription of Levaquin to finish his treatment of his pneumonia. Medications on Admission: lantus, novuloge, body building proteins and supplements 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. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [1-28] Tablets PO Q6H (every 6 hours) as needed for headache: DO NOT DRIVE WHILE TAKING THIS MEDICATION. Disp:60 Tablet(s) Refills:0 3. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO TID (3 times a day): YOU WERE PRESCRIBED THIS MEDICATION TO PREVENT SEIZURE. DO NOT STOP TAKING IT UNLESS DIRECTED BY A PHYSICIAN. . Disp:360 Tablet, Chewable(s) Refills:2 4. Outpatient Lab Work DILANTIN LEVEL FRIDAY [2163-3-30] PLEASE FAX RESULTS TO PTS PRIMARY CARE OFFICE. 5. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 12 days: do not stop taking htis medication on your own....you must complete the full course prescribed for you. Disp:144 Capsule(s) Refills:0 6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 3 days. Disp:9 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Perimesencaphalic hemorrhage Respiratory failure/hypoxia requiring mechanical ventilation Pneumonia = Community aquired Hyperglycemia = DM I MEDICATION REACTION / NEW ALLERGY TO AZITHROMYCIN AND ROCEPHIN Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: Angiogram YOU HAVE BEEN PRESCRIBED DILANTIN FOR SEIZURE CONTROL. DO NOT STOP TAKING THIS ON YOUR OWN. YOUR PRIMARY CARE PHYSICIAN WILL FOLLOW YOUR LEVELS. YOUR FIRST LEVEL TO BE DRAWN IS IN 5 DAYS ?????? Continue all other medications you were taking before, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your groin site should be well healed at this point. ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications - You should not return to work for one week What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room Followup Instructions: YOU SHOULD FOLLOW UP AT DR. [Last Name (STitle) ]' OFFICE / NEUROSURGERY IN ONE MONTH - Please call [Telephone/Fax (1) ] to schedule an appointment YOU SHOULD BE SEEN BY YOUR PRIMARY CARE PHYSICIAN WITHIN TWO WEEKS OF DISCHARGE TO NOTIFGY HIM/HER OF YOUR HOSPITALIZATION AND DIAGNOSIS' YOU WERE SEEN BY [Last Name (un) ] DIABETES SPECIALISTS WHILE HERE AT [Hospital1 18]. THEY RECOMMEND YOU RETURN TO YOUR PRIOR GLUCOSE CONTROL REGIME UPON DISCHARGE. Completed by:[2163-5-9*]	[ "518.81", "300.00", "486", "401.9", "250.81", "430", "E932.3", "782.1", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "88.41", "38.91", "33.24" ]	icd9pcs	[ [ [] ] ]	10949, 10955	8069, 9808	295, 316	11204, 11228	1200, 1622	13203, 13704	983, 1000		9915, 10926	7301, 7412	10976, 11183		9834, 9892			11252, 12262	12288, 13180								1015, 1181																							247, 257	7444, 8046					344, 650				2534, 3968											672, 683	699, 967
69,745	167,016	37169	Discharge summary	report	Admission Date: [2188-8-28] Discharge Date: [2188-9-5] Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2297] Chief Complaint: Trach change, bacteremia, UTI Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]yo M with h/o anoxic brain injury [2-12] cardiac arrest, trach (on vent at home) and peg, presenting from home with respiratory distress. His family (wife and 2 daughters) are providing all of his care at home. He has had issues with tracheobronchomalacia and has had several trach replacements in the past. The family was concerned at home yest when he started having increased secretions and some difficulty breathing, so brought him to [Hospital 8] Hospital this morning who transferred him here to [Hospital1 18]. His settings on home vent are ?AC - rr 10, PS 20, PEEP 9, TV 500, FiO2 40%. He has otherwise been well - no fever or other signs of physical distress. He does have a decubitus ulcer. He was seen by IP in the ED who performed bronchoscopy and sequential trach replacements resulting in placement of [Initials (NamePattern4) ] [Last Name (NamePattern4) 295] TTS fixed ID 8.0 mm and L 120 mm. He rec'd Levaquin 500 IV x 12 . In the ED, initial vs were: T 98.5 78 141/68 21 100 on PS 20/9 R 10, TV 500. . On the floor, he appears comfortable with current vent settings. Past Medical History: Paroxysmal Atrial fibrillation Parkinson's disease Chronic respiratory failure, trached ventilator dependent (due to aspiration PNA/cardiac arrest in [1-18] at [Hospital 8] Hospital) [Hospital 5348] PCO2 60. Vent settings at rehab: TV300-400, RR17, PS 10 PEEP 10. Spontaneously breathing at [Hospital 5348]. Anoxic brain injury [2-12] cardiac arrest DMII CKD Tracheobronchomalasia h/o C. Difficile Chronic foley due to massive inoperable inguinal hernia, gets continuous bladder irrigation Hypothyroidism Social History: chronic habitation at [Hospital1 ] x2 years for vent weaning. Family denies any illicits (neg tobacco use, neg alcohol use or IVDU). Family History: no history of pulmonary or cardiac disease Physical Exam: Admission Exam: Vitals: 96.1, 140/59, 67, 13, 96% on SIMV 400, rr 12, PS 15, PEEP 5, FiO2 50% General: Pt is lying in bed - opens eyes on verbal stimulus, withdraws arm to touch, unable to follow commands or speak. HEENT: No oral lesions apparent Neck: trach in place, 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, large R inguinal hernia with catheter present. GU: Foley in place Ext: warm, well perfused, 2+ pulses, no edema, legs contracted b/l. Pertinent Results: [2188-8-28] 07:30AM URINE HOURS-RANDOM [2188-8-28] 07:30AM URINE GR HOLD-HOLD [2188-8-28] 07:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2188-8-28] 07:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-MOD [2188-8-28] 07:30AM URINE RBC-3* WBC-3 BACTERIA-MANY YEAST-NONE EPI-0-2 [2188-8-28] 07:30AM URINE CA OXAL-FEW [2188-8-28] 07:20AM GLUCOSE-305* UREA N-78* CREAT-1.8* SODIUM-131* POTASSIUM-5.1 CHLORIDE-93* TOTAL CO2-28 ANION GAP-15 [2188-8-28] 07:20AM estGFR-Using this [2188-8-28] 07:20AM WBC-14.6# RBC-3.58# HGB-9.6* HCT-31.1# MCV-87 MCH-26.7 MCHC-30.8* RDW-14.5 [2188-8-28] 07:20AM NEUTS-88.0* LYMPHS-7.9* MONOS-3.0 EOS-0.6 BASOS-0.4 [2188-8-28] 07:20AM PLT COUNT-420 [2188-8-28] 07:20AM PT-11.6 PTT-25.4 INR(PT)-1.0 Micro: URINE CULTURE (Final [2188-9-1]): STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 1 S NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [2188-8-28] 9:50 am BLOOD CULTURE FINAL REPORT [2188-9-3] Blood Culture, Routine (Final [2188-9-3]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. 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. ACINETOBACTER SP.. FINAL SENSITIVITIES. sensitivity testing performed by Microscan. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". PSEUDOMONAS LUTEOLA. FINAL SENSITIVITIES. sensitivity testing performed by Microscan. CIPROFLOXACIN = SENSITIVE ( <=0.5 MCG/ML ). MEROPENEM = SENSITIVE ( <=1 MCG/ML ). CEFEPIME = SENSITIVE ( <=2 MCG/ML ). PIPERACILLIN = SENSITIVE ( <=16 MCG/ML ). PROBABLE MICROCOCCUS SPECIES. ISOLATED FROM ONE SET ONLY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| ACINETOBACTER SP. \| \| PSEUDOMONAS LUTEOLA \| \| \| AMPICILLIN/SULBACTAM-- <=8 S <=8 S CEFEPIME-------------- 16 I S CEFTAZIDIME----------- 16 I 2 S CEFTRIAXONE----------- <=4 S CIPROFLOXACIN--------- =>2 R S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S <=1 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 4 R <=1 S <=1 S MEROPENEM------------- S OXACILLIN------------- =>4 R PIPERACILLIN---------- S PIPERACILLIN/TAZO----- <=8 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=2 S <=2 S VANCOMYCIN------------ 2 S Aerobic Bottle Gram Stain (Final [2188-8-29]): REPORTED BY PHONE TO [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] @ 0615 ON [8-29] - 4I. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [2188-8-29]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. REPORTED BY PHONE TO [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] #[Numeric Identifier ] [2188-8-29] AT 1145. Pertinent Imaging: ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with normal biventricular systolic function. No vegetations identified. CXR (prior to discharge) SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: Kyphotic deformity of the chest wall with related distortion of the bony thorax is noted. There is no focal consolidation with the exception of mild basilar atelectasis. There is no pleural effusion or pneumothorax. Mild vascular engorgement is noted without overt CHF. Heart size is normal. Hilar contours are exaggerated likely because of technique and perihilar vascular engorgement. The tracheostomy tube is in standard location terminating 4 cm above the carina. There are low lung volumes. IMPRESSION: No change with mild vascular engorgement and bibasilar atelectasis. Brief Hospital Course: Assessment and Plan: [Age over 90 ] yo M with h/o anoxic brain injury, vent dependent admitted with respiratory failure thought [2-12] trach malfunction. . # Respiratory Distress / Chronic Vent Dependence: Patient is chronically vent-dependent [2-12] anoxic brain injury and has tracheobronchomalacia requiring multiple trach tube replacements, now s/p placement of [Initials (NamePattern4) ] [Last Name (NamePattern4) 295] TTS fixed ID 8.0 mm and L120 mm. Per the procedure note, he will have a persistent cuff leak which is secondary to his abnormal trachea and his severe malacia. With adequate volumes, the trach should function adequately. The family discussed this at length with the attending physician due to concern for the persistent cuff leak. He was continued on PC with 29/9 and received adequate tidal volumes. A trial of PS was initiated early in the hospitalization, but he had a hypoxic induced VT, and he was placed back on PC ventilation; the day of discharge, he tolerated PS well. Of note, he continued to have copious secretions requiring frequent suction. Also, a chest x-ray was notable of [Hospital1 ]-basilar atelectasis, with no radiographic evidence of an infiltrate. . #Bacteremia: Two blood cultures grew COAG NEG STAPH, with one showing 3 morphologies. One of the cultures also grew ACINETOBACTER SP., PSEUDOMONAS LUTEOLA, and PROBABLE MICROCOCCUS SPECIES. He was broadly covered with Cefepime for GNR species and transitioned to PO Levofloxacin based on ID recommendations and sensitivities for a total course of 14 days ending [9-23] in light of the family's wishes for not placing a PICC. He was also covered with Vancomycin for GP species as detailed below. . # MRSA UTI: He was found to have a MRSA UTI. He was started on IV vancomycin, but the family declined a PICC line for intravenous antibiotics. ID was consulted and recommended PO clindamycin based on sensitivies for a total course of 14 days ending [9-13]. . # Anemia: He was transfused 1 unit of PRBCS for a low HCT. . # Hyponatremia: Resolved in house with free water flushes, and with-holding NS bladder irrigation. . # CKI: His [Month/Day (4) 5348] creatinine is 1.8. His kidney function was monitored while he was on Vancomycin. . # Nutirition: He was continued on his home regiment of tube feed boluses. . # T2 DM: Blood sugars were well controlled on a RISS and Glipizide. Medications on Admission: Levoxyl 50 mcg po qam Glipizide 7.5mg po daily Combivent 3-4 puffs tid Insulin (Regular) sliding scale: 180-240 (1 unit), 240-280 (2 units), 280-320 (3 units)... Allergies: Sulfa (per OMR) Discharge Medications: 1. Levothyroxine 50 mcg Tablet [Month/Day (4) ]: One (1) Tablet PO DAILY (Daily). 2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [Month/Day (4) ]: [1-12] Puffs Inhalation Q6H (every 6 hours). 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Month/Day (2) ]: [1-12] Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:1 30 days Refills:0 4. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment [Month/Day (2) ]: One (1) Appl Ophthalmic Q8H (every 8 hours). Disp:1 30 days Refills:2 5. Polyethylene Glycol 3350 17 gram/dose Powder [Month/Day (2) ]: One (1) PO DAILY (Daily) as needed for constipation. 6. Glipizide 5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 7. Clindamycin HCl 150 mg Capsule [Month/Day (2) ]: Two (2) Capsule PO Q6H (every 6 hours) for 9 days. Disp:36 Capsule(s) Refills:0 8. Levofloxacin 250 mg Tablet [Month/Day (2) ]: One (1) Tablet PO Q24H (every 24 hours) for 9 days. Disp:9 Tablet(s) Refills:0 9. Glipizide 5 mg Tablet [Month/Day (2) ]: [1-12] Tablet PO once a day. 10. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen [Month/Day (2) ]: One (1) unit Subcutaneous every six (6) hours as needed for hyperglycemia: Per sliding scale. Disp:360 pen Refills:3 Discharge Disposition: Home With Service Facility: [Hospital ] HEALTH CARE Discharge Diagnosis: Primary Diagnosis: MRSA UTI Staph Coaguluase Negative Bacteremia Secondary Diagnosis: Anoxic Brain Injury Chronic Respiratory Failure Discharge Condition: Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: It was my privilege to take care of you as your physician in the ICU. You had a tracheostomy that was replaced, and you were found to have bacteria in your blood and urine. You will need to take antibiotics for a total of 14 days for the infections. Your outpatient medications were not changed other than the following: # Levofloxacin 250 mg PO/NG Q24H, last day [2188-9-13] # Clindamycin 300 mg PO/NG Q6H, last day [2188-9-13] Followup Instructions: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2188-10-7] 11:10 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2188-10-7] 11:30 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 3688] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2188-10-7] 11:30	[ "707.07", "348.1", "585.9", "V44.1", "041.12", "550.90", "519.02", "748.3", "253.6", "790.7", "244.9", "707.20", "285.29", "518.83", "E878.8", "599.0", "427.31", "707.05", "486", "250.00", "332.0" ]	icd9cm	[ [ [] ] ]	[ "97.23", "96.72", "96.6", "33.21" ]	icd9pcs	[ [ [] ] ]	13309, 13367	9333, 11753	268, 274	13546, 13624	2891, 9310	14112, 14556	2146, 2190		11994, 13286		13388, 13388		11779, 11971			13648, 14089									2205, 2872																							199, 230						302, 1425			13475, 13525			13407, 13454									1447, 1974	1990, 2130
73,395	186,410	41551	Discharge summary	report	Admission Date: [2139-2-23] Discharge Date: [2139-3-13] Date of Birth: [2098-1-22] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 949] Chief Complaint: jaundice Major Surgical or Invasive Procedure: Diagnostic and Therapeutic Paracenetesis Dialysis Catheter Placement History of Present Illness: Ms. [Known lastname 25682] is a 41 year old woman with a history of hepatitis C, alcohol use, and cirrhosis who does not see a liver doctor. She reports 5 days of worsening abdominal pain and distension. She has also noted subjective fevers and night sweats over the same time frame. She states her sister told her she started looking jaundice today. She reports her last drink was 24 hours ago. She has been having some nausea and emesis over the last two days. She reports her emesis is yellow colored. She denies any blood. She states her urine output has been normal, but the color slightly darker. She has not had any recent stool, but is passing flatus. She has had a dry cough over the last couple of days. She presented to [Location (un) ] where a diagnostic para was performed which showed SBP (WBC of 1120 with 58% polys). Cultures were drawn and are pending (lab called overnight). She was given one dose of Zosyn and then transferred. . In the ED, initial VS: 97.2 88 101/73 20 97% 2L. Her blood pressures remained in the 110's throughout her ED course. Her repeat Hct was 22.5 (27.6 at [Location (un) ] after approximately 4 L IVF). She had brown, guiac positive stool on rectal exam. Her labs were significant for new renal failure and an ultrasound showed reversal of portal flow. She had a tbili of 18 with direct bili 15. ERCP and transplant surgery were made aware of her prescence. . ROS: Denies headache, vision changes, rhinorrhea, congestion, sore throat, chest pain, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Hepatitis C Alcohol Abuse Cirrhosis Social History: Lives with sister. Helps take care of seven year old nephew. Smokes 6 cigarettes per day since teenage years. Reports 2 beers daily. Denies any illicits. However, per the family she was drinking large quantities of vodka daily. Family History: Reports mother may have also had a "liver problem" Physical Exam: VS: 96.6 107/56 77 18 93 on 2L GENERAL - thin woman, breathing is unlabored HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear LUNGS - decreased breath sounds at bases, no rhonchi or wheezes HEART - RR, no m/r/g ABDOMEN - +BS, tender to palpation, no rebound, large ascites EXTREMITIES - 2+ peripheral pulses SKIN - several 1-2 cm lesions behind neck with crusting/erythema NEURO - awake, A&Ox3, no asterixis Discharge Physical Exam: Patient is alert and awake. She answers questions appropriately HEENT: Jaundiced female RES: Speaks in short sentences with bilateral crackles CV: Normal S1 and S2, with Right Ventricular Heave. No S3 or S4 appreciated ABD: Distended tense abdomen with minimal bowel sounds. EXT: 3+ Pitting edema bilaterally Pertinent Results: Admission Labs: [2139-2-23] 08:30PM BLOOD WBC-7.6 RBC-1.93* Hgb-7.4* Hct-22.5* MCV-117* MCH-38.3* MCHC-32.9 RDW-21.4* Plt Ct-76* [2139-2-23] 08:30PM BLOOD Neuts-85* Bands-2 Lymphs-8* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2139-2-23] 08:30PM BLOOD PT-21.4* PTT-43.9* INR(PT)-2.0* [2139-2-24] 10:45AM BLOOD Fibrino-136* [2139-2-23] 08:30PM BLOOD Glucose-60* UreaN-68* Creat-3.0* Na-134 K-2.9* Cl-105 HCO3-18* AnGap-14 [2139-2-23] 08:30PM BLOOD ALT-71* AST-152* AlkPhos-95 TotBili-18.0* DirBili-15.0* IndBili-3.0 [2139-2-23] 08:30PM BLOOD Lipase-140* [2139-2-23] 08:30PM BLOOD cTropnT-0.02* [2139-2-23] 08:30PM BLOOD Albumin-1.9* Calcium-6.0* Phos-3.8 Mg-1.6 [2139-2-24] 10:45AM BLOOD calTIBC-114 Ferritn-327* TRF-88* [2139-2-24] 10:45AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE HAV Ab-POSITIVE No Discharge Labs were taken. Imaging: Please refer to OMR for further imaging studies. Microbiology: Two Urine cultures were positive for Yeast. Blood cultures were negative for bacteria. Brief Hospital Course: Ms. [Known lastname 25682] is a 41 year old woman presenting with decompensated cirrhosis in the setting of SBP and alcoholic hepatitis with and hepatorenal syndrome type 1 with hepatic encephalopathy grade 1. She had a hospital course that was complicated by ATN necessitating CVVH, and an episodes of aspiration and mucous plugging leading to respiratory distress and hypoxic respiratory failure. She was transfered to the MICU for further care. In the MICU she started to withdraw from alcohol and was hypotensive requirng pressors. Her liver function improved slightly and dialysis was initiated. Unfortunately, she developed multiple episodes of spontaneous intraperitoneal bleeding requiring transfusion of 10 units of pRBC's. In the context of this and her very poor prognosis suggested by her recent drinking, poor functional status, anuric renal failure, and need for frequent paracenteses, she elected to stop life prolonging therapies and desired transfer closer to home to a less medicalized environment. Therefore, she is being transferred to a [Hospital1 1501] with hospice services. Her treatments are to be focused on comfort with no further transfusions, parancenteses, or renal replacement therapy. Code Status is CMO/DNR/DNI. She is being discharged to [Hospital 19586] hospice tolerating PO nutrition and taking oral PO medications. Medications on Admission: none Discharge Medications: 1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 6. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea. Discharge Disposition: Extended Care Facility: Colonial Heights Care and Rehabilitation Center - [Hospital1 487] Discharge Diagnosis: Primary Diagnosis Acute on Chronic Liver Failure due to Hepatitis C / Alcoholic Cirrhosis Acute anuric renal failure due to acute tubular necrosis / hepatorenal syndrome Spontaneous Bacterial peritonitis Acute bacterial pneumonia ? aspiration vs community acquired Secondary Diagnosis: Acute blood loss anemia Hepatic encephalopathy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 25682]- You were admitted to the hospital for an infection in your belly and acute on chronic liver failure. Your hospital course was complicated by a pneumonia, bleeding in your belly, and worsening kidney function requiring you to have dialysis. Due to your liver failure, many of your organs are not functioning properly. You will be discharged to a hospice facility where they will help manage your symptoms from your liver and kidney failure. Followup Instructions: You will be discharged to a skilled nursing facility to receive hospice services. The hospice physician will serve as your doctor. You do not need additional follow up. Completed by:[2139-3-13]	[ "V66.7", "V49.86", "567.23", "070.44", "572.4", "584.5", "458.8", "285.1", "934.9", "507.0", "782.4", "578.0", "456.1", "571.1", "571.2", "486", "303.91", "789.59", "578.9", "518.81" ]	icd9cm	[ [ [] ] ]	[ "38.91", "45.13", "96.6", "54.91", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	6485, 6581	4223, 5599	312, 382	6959, 6959	3150, 3150	7650, 7852	2305, 2358		5654, 6462		6602, 6868		5625, 5631			7144, 7627									2373, 2793																							264, 274						410, 1983			6889, 6938		3166, 4200				6974, 7120						2005, 2043	2059, 2289					2818, 3131
69,650	192,695	43805+58664	Discharge summary	report+addendum	Admission Date: [2179-1-28] Discharge Date: [2179-2-2] Date of Birth: [2113-10-30] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 1350] Chief Complaint: Persistent back pain and prominent hardware in TL regoin Major Surgical or Invasive Procedure: 1. Removal of hardware S1 to T12. 2. Evaluation of fusion. 3. Bilateral laminotomy T10, T11, T12. 4. Revision instrumentation T10-L2. 5. Posterior arthrodesis T10-L2. 6. Application of local autograft for fusion augmentation. 7. Application of local allograft for fusion augmentation. History of Present Illness: Persistent pain in back and worsening of stature as well as worsening of hardware prominence Past Medical History: 1. 1st deg AV block severe MR/mod TR (echo preop 65% EF) 2. HTN 3. [2145] L5-S1 fusion 4. [2153] L5-S1 nonunion repair 5. [2158]-[2160] Posterior Cervical laminectomy 6. [2168]/[2169] Lumbar Laminectomy Social History: NC Family History: NC Physical Exam: [3-24] in bilateral lower extremities in iliopsoas, hamstrings, quadriceps, [Last Name (un) 938], TA, FHL, SILT In L2-S1 reflexes 2 + in knees and ankles bilaterally. Tenderness over TL spine. Prominent hardware over TL junction. Pertinent Results: [2179-1-28] 10:36PM TYPE-ART PO2-191* PCO2-36 PH-7.42 TOTAL CO2-24 BASE XS-0 [2179-1-28] 10:36PM freeCa-1.03* [2179-1-28] 07:12PM estGFR-Using this [2179-1-28] 07:12PM CALCIUM-8.2* PHOSPHATE-2.9 MAGNESIUM-1.6 [2179-1-28] 07:12PM WBC-8.8 RBC-3.34* HGB-10.4* HCT-29.7* MCV-89 MCH-31.2 MCHC-35.0 RDW-13.5 [2179-1-28] 07:12PM PLT COUNT-188 [2179-1-28] 05:14PM TYPE-ART PO2-262* PCO2-39 PH-7.50* TOTAL CO2-31* BASE XS-7 INTUBATED-INTUBATED Brief Hospital Course: Patient was admitted to the [Hospital1 18] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Life Care at Home of [State 350] Discharge Diagnosis: Pseudoarthosis D12-L1 Post operative acute blood loss anemia Discharge Condition: Stable, alert and oriented. Tolerating PO diet. Discharge Instructions: You have undergone the following operation: Revision thoracolumbar fusion Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You may have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Ambulation with assistance, Gait training, Stair climbing. Treatments Frequency: Physical therapy removal of staples in 3 weeks. Followup Instructions: Follow up with Dr [Last Name (STitle) 1007] in 2 weeks. Please call [Telephone/Fax (1) 9769] to make an appointment. Completed by:[2179-2-2] Name: [Known lastname 14901],[Known firstname ] [Initial (NamePattern1) ] [Last Name (NamePattern1) 201] Unit [Name2 (NI) ]: [Numeric Identifier 14902] Admission Date: [2179-1-28] Discharge Date: [2179-2-2] Date of Birth: [2113-10-30] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 147] Addendum: Of note, radiology noted a R lung opacity on CXR c/w PNA and rec repeat CXR in [2-23] weeks for further evaluation. We curbsided the medicine service who noted that he is not symptomatic, there is no need for abx at this time. We spoke w/ his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 14903] no [2179-2-2] at 11:15am and he made a note in pt's chart and will have him f/u with him in clinic in [11-21] weeks. We have instructed the pt to f/u with his PCP immediately should he develop a fever, cough, other concerns. Discharge Disposition: Home With Service Facility: Life Care at Home of [State 1145] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 148] MD [MD Number(2) 149] Completed by:[2179-2-2]	[ "401.9", "996.49", "737.30", "424.0", "V45.4", "E878.2", "285.1" ]	icd9cm	[ [ [] ] ]	[ "81.35", "84.52", "78.69", "81.63" ]	icd9pcs	[ [ [] ] ]	6958, 7180	1860, 2730	376, 663	3222, 3272	1359, 1837	5762, 6935	1081, 1085		2753, 3027		3138, 3201					3296, 3370									1100, 1340	5609, 5668	5690, 5739							5107, 5591						3404, 3614								280, 338					4102, 5095	691, 785															807, 1044	1060, 1065
27,404	161,243	34616	Discharge summary	report	Admission Date: [2140-8-31] Discharge Date: [2140-9-30] Date of Birth: [2065-10-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 12174] Chief Complaint: Hyperbilirubinemia, Ascites, Diffuse Body Pain Major Surgical or Invasive Procedure: Liver Biopsy History of Present Illness: OSH COURSE: 74 yo M with ETOH cirrhosis, no active ETOH x8 years, remote h/o Lung CA s/p lobectomy presented to OSH on [2140-8-26]. Pt admitted from [Date range (1) 61493] initially for coffee ground emesis, subsequently had hematemesis and hypotention. Pt fluid responsive to IVF and 2UPRBC, EGD showed grade I esophageal varices, & erosive gastritis, unclear if banding or sclerosis done. Pt was treated with octreotide and PPI IV. Pt remained HD stable, no further PRBC transfursion required. Pt was noted to have elevated Bili=32-36 unclear etiology, underwent ERCP - normal and MRCP done at OSH-also unremarkable. Further w/u included negative hemochromatosis gene, normal cerulospasm, negative HBC, HCV, HEV serologies, autoimmune hepatitis also negative. Liver bx deferred due to high risk of bleed, transferred to [Hospital1 18] for possible liver bx and further evaluation. Of note had a large volume paracentesis done on [8-24] prior to this admit, unclear volume, unclear whether received albumin with paracentesis, negative fluid for SBP; SAAG>1.1. UA notable for +UTI, started on cipro [8-29] Past Medical History: -GERD -ETOH Cirrhosis c/b esophageal varices -Lung CA s/p R lobectomy [2133] -?UGIB -urinary retention (?BPH) -cataract surgery [2136] -b/l inguinal hernia repair [2131] -Thalassemia minor Social History: -Hindi speaking only, recently bed bound in NH per d/c summary, significant decline in ADLs x2months. Immigrated from [Country 11150] 15 years ago -Quit TOB 15 years ago; sober ETOH x8 years-[2-21] drinks/night, denies any other drug use. Family History: -M:HTN -F:Died age 25 unclear infectious dz Unclear of liver disease in family Physical Exam: VS: T 95.4 BP 140/64 HR 62 RR 16 97%RA GEN: ill appearing, cachectic in NAD SKIN: Jaundiced throughout HEENT: Icteric sclera, OP clear, no cervical LAD RESP: CTABL Ant'ly, inspiratory crackles at bases b/l CV: Distant heart sounds, nml S1, S2, no M/R/G ABD: Soft, distended, +fluid wave, mild tenderness to palpation over lower quadrants, no rebound, no guarding EXT: 2+ pitting edema at ankles with dependent sacral edema NEURO: Difficult to assess due to language barrier, Alert, follows commands appropriately, minimal asterixis, no tremor, gait not assess. Pertinent Results: Admission Labs: . [2140-8-31] 10:37PM URINE HOURS-RANDOM CREAT-83 TOT PROT-73 PROT/CREA-0.9* [2140-8-31] 10:37PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.016 [2140-8-31] 10:37PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-12* PH-6.5 LEUK-SM [2140-8-31] 10:37PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2140-8-31] 08:00PM GLUCOSE-109* UREA N-18 CREAT-1.0 SODIUM-142 POTASSIUM-3.6 CHLORIDE-115* TOTAL CO2-19* ANION GAP-12 [2140-8-31] 08:00PM estGFR-Using this [2140-8-31] 08:00PM estGFR-Using this [2140-8-31] 08:00PM ALT(SGPT)-111* AST(SGOT)-140* LD(LDH)-214 ALK PHOS-112 TOT BILI-27.0* DIR BILI-19.2* INDIR BIL-7.8 [2140-8-31] 08:00PM TOT PROT-4.3* ALBUMIN-2.8* GLOBULIN-1.5* CALCIUM-8.4 PHOSPHATE-1.9* MAGNESIUM-2.0 IRON-65 [2140-8-31] 08:00PM calTIBC-126* FERRITIN-GREATER TH TRF-97* [2140-8-31] 08:00PM WBC-6.7 RBC-4.02* HGB-9.6* HCT-31.3* MCV-78* MCH-23.8* MCHC-30.6* RDW-23.3* [2140-8-31] 08:00PM NEUTS-72.4* BANDS-0 LYMPHS-22.3 MONOS-3.7 EOS-1.2 BASOS-0.4 [2140-8-31] 08:00PM PLT SMR-LOW PLT COUNT-91* [2140-8-31] 08:00PM PT-16.9* PTT-43.9* INR(PT)-1.5* [2140-8-31] 08:00PM RET AUT-3.5* . OSH Notable Labs: [8-23] Cr 3.2-->[8-24] 2.5 Hepatitis A serologies [Month (only) 205]/[2140-8-19] -HAV IgM-negative -HAV Ab-positive hepatitis B serologies [2140-6-19] -HBV SAg-negative -HBV SAb-negative -HBV CAb-negative . OSH-ECHO [2140-8-27] -EF 60%, normal wall motion, no pericardial effusion . CXR [8-31] -elevated R hemidiaphragm, no significant blunting of costophrenic angles b/l, no consilidation noted, deviated trachea to R . EKG [8-31] -NSR HR 62, diffuse low voltage, normal axis and intervals, no ST-T changes, unchanged from OSH EKG . Pertinent Labs: [2140-9-14] 06:30AM BLOOD WBC-12.9* RBC-3.59* Hgb-8.8* Hct-27.1* MCV-76* MCH-24.4* MCHC-32.3 RDW-22.7* Plt Ct-153 [2140-9-19] 06:45AM BLOOD WBC-13.5* RBC-4.79 Hgb-11.9* Hct-37.7* MCV-79* MCH-24.8* MCHC-31.5 RDW-23.3* Plt Ct-143* [2140-9-24] 03:37AM BLOOD WBC-21.3# RBC-4.28 Hgb-11.1* Hct-33.9* MCV-79* MCH-25.9* MCHC-32.7 RDW-22.9* Plt Ct-129* [2140-9-29] 06:10AM BLOOD WBC-13.3* RBC-3.93* Hgb-10.5* Hct-32.4* MCV-82 MCH-26.8* MCHC-32.5 RDW-22.1* Plt Ct-74* [2140-9-29] 08:54PM BLOOD WBC-26.9# RBC-4.27 Hgb-11.7* Hct-34.4* MCV-81* MCH-27.4 MCHC-34.0 RDW-23.5* Plt Ct-129# [2140-9-15] 05:55AM BLOOD PT-16.7 INR(PT)-1.5* [2140-9-24] 03:37AM BLOOD PT-20.1* PTT-40.2* INR(PT)-1.9* [2140-9-28] 05:20AM BLOOD PT-21.2* PTT-50.7* INR(PT)-2.0* [2140-9-29] 08:54PM BLOOD Plt Ct-129# [2140-9-4] 04:30PM BLOOD Glucose-89 UreaN-17 Creat-1.1 Na-138 K-3.5 Cl-109 HCO3-20* AnGap-13 [2140-9-12] 06:25AM BLOOD Glucose-124* UreaN-18 Creat-0.6 Na-140 K-3.9 Cl-109* HCO3-22 AnGap-13 [2140-9-19] 06:45AM BLOOD Glucose-130* UreaN-40* Creat-0.5 Na-139 K-4.2 Cl-96 HCO3-28 AnGap-19 [2140-9-24] 03:37AM BLOOD Glucose-73 UreaN-58* Creat-0.5 Na-147* K-4.5 Cl-109* HCO3-22 AnGap-21* [2140-9-25] 03:13AM BLOOD Glucose-82 UreaN-59* Creat-1.0 Na-150* K-3.2* Cl-114* HCO3-22 AnGap-17 [2140-9-29] 08:54PM BLOOD Glucose-94 UreaN-43* Creat-0.6 Na-142 K-5.3* Cl-108 HCO3-20* AnGap-19 [2140-9-6] 06:20AM BLOOD ALT-90* AST-161* LD(LDH)-249 AlkPhos-145* TotBili-22.4* [2140-9-10] 05:30AM BLOOD ALT-107* AST-183* LD(LDH)-273* AlkPhos-207* TotBili-24.3* [2140-9-16] 06:20AM BLOOD ALT-95* AST-165* LD(LDH)-389* AlkPhos-191* TotBili-33.9* [2140-9-22] 06:10AM BLOOD ALT-170* AST-212* LD(LDH)-617* AlkPhos-233* TotBili-41.3* [2140-9-25] 03:13AM BLOOD ALT-152* AST-184* AlkPhos-167* TotBili-52.3* [2140-9-29] 08:54PM BLOOD ALT-77* AST-136* LD(LDH)-796* AlkPhos-179* TotBili-49.8* [2140-8-31] 08:00PM BLOOD TotProt-4.3* Albumin-2.8* Globuln-1.5* Calcium-8.4 Phos-1.9* Mg-2.0 Iron-65 [2140-9-18] 05:40AM BLOOD Albumin-3.2* Calcium-9.3 Phos-4.2 Mg-3.1* [2140-9-24] 03:37AM BLOOD Albumin-2.9* Calcium-9.7 Phos-5.3# Mg-3.6 [2140-9-27] 03:48AM BLOOD Albumin-4.0 Calcium-10.2 Phos-2.8 Mg-2.9* [2140-9-29] 08:54PM BLOOD Albumin-3.7 Calcium-10.3* Phos-1.6* Mg-3.0* [2140-9-6] 11:05AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2140-9-26] 02:02PM BLOOD Cortsol-16.0 [2140-9-26] 03:11PM BLOOD Cortsol-25.2* [2140-9-26] 10:39PM BLOOD PTH-55 [2140-9-9] 05:20AM BLOOD TSH-4.9* [2140-9-25] 03:13AM BLOOD Osmolal-328* [2140-9-10] 05:30AM BLOOD AFP-2.8 [2140-9-27] 03:26PM BLOOD Vanco-26.8* [2140-9-29] 06:10AM BLOOD Vanco-13.8 [2140-9-6] 11:05AM BLOOD HCV Ab-NEGATIVE [2140-9-1] 11:37AM BLOOD Type-ART pO2-81* pCO2-30* pH-7.37 calTCO2-18* Base XS--6 [2140-9-23] 07:13PM BLOOD Type-ART pO2-109* pCO2-36 pH-7.40 calTCO2-23 Base XS--1 [2140-9-23] 07:13PM BLOOD Lactate-4.5* [2140-9-23] 09:34PM BLOOD Lactate-4.1* [2140-9-6] 11:05AM BLOOD HEPATITIS E ANTIBODY (IGM)-Test [2140-9-6] 11:05AM BLOOD HEPATITIS E ANTIBODY (IGG)-Test. . Pertinent Microbiology: DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [2140-9-25] 10:27AM MOD NEG NEG NEG NEG LG 8* 7.0 NEG Source: Catheter [2140-9-24] 03:38AM NEG NEG NEG NEG NEG LG 4* 7.5 NEG Source: Catheter [2140-9-20] 03:55PM NEG NEG NEG NEG NEG LG 4* 8.0 NEG . [2140-9-1] 2:27 pm PERITONEAL FLUID PERITONEAL FLUID. . FINAL REPORT [2140-9-7] GRAM STAIN (Final [2140-9-1]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2140-9-4]): NO GROWTH. ANAEROBIC CULTURE (Final [2140-9-7]): NO GROWTH. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2140-9-19]): Feces negative for C.difficile toxin A & B by EIA . Blood Culture, Routine (Final [2140-10-1]): NO GROWTH . [2140-8-31] Abdominal Ultrasound: IMPRESSION: 1. Marked ascites. Spot marked in the right lower quadrant for paracentesis. 2. Cirrhosis. 3. Slow flow within patent main portal vein. 4. Patent umbilical vein indicative of portal venous hypertension. 5. Enlarged spleen measuring 15 cm. . ([2140-8-31]) Peritoneal Fluid: NEGATIVE FOR MALIGNANT CELLS. . ([2140-9-20]) CXR: HISTORY: Lobectomy with increased white count, to evaluate for pneumonia. FINDINGS: In comparison with study of [9-19], there is little change. Specifically, no evidence of acute pneumonia. The Dobbhoff tube remains coiled in the upper stomach. ([2140-9-24]) LENIS IMPRESSION: No evidence of DVT in either lower extremity . [2140-9-29] CXR: Lungs remain low in volume but clear. No pneumonia. No pleural effusion or pneumothorax. Heart size is normal. Stomach distended. Feeding tube ends near the pylorus . Pertinent Cytology: Liver core biopsy: 1) Marked cholestasis, intracellular hyalin and focal mixed cell inflammation. 2) Mild steatosis. 3) Trichrome: Marked periportal and sinusoidal fibrosis with bridging, consistent with cirrhosis (stage 3-4). 4) Iron stain: Moderate iron deposition in hepatocytes. Note: The features are consistent with toxic/metabolic liver disease. Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] and Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] were notified on [2140-9-7]. ADDENDUM: Test performed by [Hospital3 14659], [Hospital ] Medical Laboratories, [Hospital1 ] Department of Lab Medicine and Pathology ?????? [Street Address(2) 79425], NW, [Location (un) 15739], [Numeric Identifier 79426] for specimen S08-[Numeric Identifier 79427], block A. Test requested Hi/Lo Reference Range Performance Site Iron, Liver Ts Iron, Liver Ts 1881 [Last Name (un) ]/g dry wt [Telephone/Fax (1) 79428] SDL Hepatic Iron Index 0.5 umol/g/yr <1.0 SDL Results of Hepatic Iron Index <1.0 are normal, indicating no iron accumulation. Results between 1.0-1.9 suggest mild, nonspecific iron accumulation as may be seen in alcoholic liver disease or heterozygous hemochromatosis. Results >1.9 indicate homozygous hemochromatosis or transfusion-related iron overload. Chronic blood loss or frequent phlebotomy will decrease the hepatic iron index. Brief Hospital Course: 74 yo M with ETOH cirrhosis (no etoh x10y), and h/o Lung CA s/p lobectomy, with a 3 month history of anorexia and transferred from OSH after UGI bleed with decompensated liver disease. . The patient had a long stay at [Hospital1 18] that consisted of the patient of being kept on the [Hospital Ward Name 121] 10, [Doctor Last Name 3271]-[Doctor Last Name 679] service, as well as a transfer to the unit. The patient was transferred back to the floor before expiring the early the morning of [2140-9-30]. . DECOMPENSATED ESLD: The pt presented to [Hospital1 18] from an OSH with a MELD score 24. Dopplar US was completed and indicated marked ascites, cirrhosis, slow flow within patent main portal vein, patent umbilical vein indicative of portal venous hypertension, as well as splenomegaly. There was no evidence of SBP by exam or on paracentesis. Lactulose was continued. Therapeutic paracentesis was completed on [2140-9-1] and 4.5 L was removed and 25 grams of albumin was given. On [2140-9-5] a liver biopsy was completed with ultrasound guidance, showing marked cholestasis, and c/w toxic/metabolic liver dz. He also had 1.9L removed at that time, and post-bx pt Hct dropped to 25.8 and became hypotensive 70s/40s. Pt was given 12.5gm albumin and pressures stablized. CT abd r/o'd occult bleed. Pt did not have any further bleeding on admission, and Hct and vitals remained stable throughout the remaining hospital course. . The pt's Tbili steadily increased over his hospital course from a baseline that was markedly elevated. Prednisone was started empirically since pt was classified as terminal (and did not have a current infection) possibly to help with alcoholic hepatitis. Pt's mental status improved once TF were started and pt began having regular bowel movements. But pt's mental status worsened on [9-17] when he began having sleep changes, and then on [9-19] was not A&Ox3. It was thought that this was due to hepatic encephalopathy. Although his energy increased, was conversing more, and eating more oral in addition to TF, his Tbili continued to rise, and on [9-19] with a TB of 40 his prednisone was discontinued. The patients TB peaked at 50 during his hospital course. In regards to the patients Mental Status his previous CT was negative on admission, and was not repeated. Pt's lactulose was increased to 45ml TID. However over the first week in [Month (only) 462] the patients mental status appeared to worsen on the floor, presumed encephalopathy, continued on lactulose and the pt was given Haldol and Zyprexa. The patient pulled out his Dobhoof tube on 3 occassions requiring IR placenent mulitple times. The pt was empirically started on Ceftriaxone to treat SBP although the pt was not compliant for a successful diagnostic paracentesis. Once Dobhoff was replaced, was able to give lactulose po. . On the 23rd day of admission the pt was transferred to the MICU with new hypoxia, hypotension. His hypotension was fluid responsive and he was given several doses of albumin with good results. While in the MICU, the pt had a leukocytosis with transient hypothermia. Due to concern of infection, he was pan cultured and flagyl was started in addition to his ceftriaxone. His ceftriaxone dose was also increased to full in order to cover for SBP. Mental status waxed and waned throughout his MICU course. The acute nature of his hypoxia had suggested aspiration from newly restarted tube feeds, or PNA. The pt was started on Vanc/Ceftriaxone. His CXR was with diminished lung markings on left likely due to RLL lobectomy and appears similar to prior films, but otherwise no infiltrate. LENIs were negative but pt was unable to cooperate so a V/Q scan was never completed. Over the course of his MICU stay, his O2 requirements lessened and he transferred back to the floor. A family meeting was held prior to transfer out of the MICU and he was made DNR/DNI and no pressors should he become hypotensive again. The patient was subsequently transferred back to the floor. The patient's mental status was evaluated through an interpreter on mulitiple ocassions where he was found to be alert to the country, the year, and to his wife. The patients clinical status did not improve once transferred back to the floor. . On the night of [9-29] the patient developed hemoptysis, low blood pressures and changes in mental status. The patient was treated supportively and passed away in the early the following morning with his wife at his side. . ANOREXIA: For the pt's anorexia other causes were investigated, like how pt had lung cancer with node involvement and never had adjunctive chemo/rad, but the CT chest proved negative for recurring lung CA causing the 3mo hx of anorexia. His h/o lung cancer is also what keeps him from being on the transplant list, and why only palliative care is the option for him. AFP was also not significantly elevated, and in the end his anorexia was attributed to his primary liver disease. The patients Dobhoff was pulled out on 3 occassions and needed replacement via Interventional Radiology for placement. The pt's energy improved significantly when TF were originally started. The patient was given ritalin to help with energy, which was later d'c when the pt appeared to become aggitated. Discussed his goals of care extensively. He and his wife understand his time left is very limited. Pt's goal was to be healthy enough to fly back to [Country 11150] to see his sons one last time before dying, which clarified why he was not originally DNR/DNI. H/O LUNG CA S/P R LOBECTOMY: Pt had node invovlement but never received adjuvant chemotx/radiation and it was investigated whether this was causing the pt's anorexia and or mental status change. A CT chest was ordered but did not show any evidence of axillary or mediastianal lymph node changes worrisome for malignancy. UTI: [Month (only) 116] have been cause of pt's incontience, Pt was given 14 day course of cipro. Medications on Admission: -Protonix 40mg PO BID -Cipro 250mg PO bid -Lactulose 20mg q2hr -Dulcolax 10mg PR as needed -Acetominophen 650mg q6hr prn -received 3 doses -vitamin K 2mg PO x1 on [8-30]; 2.5mg PO x1 on [8-30] Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "571.1", "584.9", "789.59", "530.81", "799.4", "V10.11", "276.52", "572.2", "282.49", "518.81", "567.23", "571.2", "585.9", "572.3", "276.0", "456.20" ]	icd9cm	[ [ [] ] ]	[ "54.91", "96.6", "50.11", "45.13" ]	icd9pcs	[ [ [] ] ]	17482, 17491	11195, 17196	364, 378	17542, 17551	2715, 2715	17607, 17617	2039, 2119		17447, 17459		17512, 17521		17222, 17424			17575, 17584									2134, 2696																							278, 326						406, 1535					2731, 4554						4570, 11172				1557, 1759	1775, 2023
23,883	116,938	3536	Discharge summary	report	Admission Date: [2120-8-3] Discharge Date: [2120-8-13] Date of Birth: [2052-9-12] Sex: M Service: MEDICINE Allergies: Codeine Attending:[Last Name (NamePattern4) 290] Chief Complaint: Self-transferred from [Hospital 1474] Hospital for further workup Major Surgical or Invasive Procedure: 1. Bone marrow aspirate History of Present Illness: 67 yo M, PMH of DM, CAD (CABG), DJD (disc surgery), COPD, presents with epistaxis, purpura, lymphadenopathy, back pain, anemia, thrombocytopenia, fevers, fatigue x 2.5 months, 30 lb weight loss over past month. Pt developed persistent epistaxis at 2 pm today, still bleeding 7 hours later. Pt states 30 lb weight loss over past month. His back pain has been so severe that he has not been able to walk properly for the past 2.5 months. The back pain projects down in and along the spinal canal, from the shoulder blades down to his buttocks, worst in disc surgery site in lower thoracic/upper lumbar spine. The pain radiates to his buttocks bilaterally, and radiates down his leg posterolaterally bilaterally. The pt has experienced motor weakness in both legs for the past 2.5 months, no tingling, no sensory loss. No bladder or rectal incontinence. No erectile dysfunction. Pt has felt fatigued and short of breath for the past few months. Pt has never had a bone marrow biopsy. . Pt also has 50 pk yr smoking hx and COPD, and chronic dyspnea on exertion. His PPD test has been negative, he has not traveled out of the country, been in shelters, or been incarcerated over the past several years. Pt has had unprotected sex with his girlfriend for the past 3 years. . Pt has been hospitalized in [Hospital 1474] Hospital for the past 4 weeks, for intractable back pain, bilateral hilar and mediastinal adenopathy, anemia, thrombocytopenia, pneumonia, MRSA. Mediastinoscopy and bronchoscopy were performed to sample lymph node tissue, which yielded benign findings. Bronch sample found MRSA in the sputum. Pt was placed on regimen of Vanco and Zosyn for coverage. . Pt had a fine needle aspiration of a right lower lung lesion, but before FNA, pt was noted as having low plts and hct of 19. The patient had hemoptysis with small amounts of bloody sputum. Pt received plts and red cell transfusions. Path for the needle biopsy is still pending. . Pt was in constant pain at [Hospital1 1474], and needed his pain regimen adjusted constantly until placed on a PCA pump. He is allergic to codeine. He wished a second opinion for his medical problems. . ROS: +30 lb weight loss, +fatigue, +weakness, +shortness of breath, +constipation, all other negative Past Medical History: PMH: 1. DM 2. HTN 3. DJD 4. CAD 5. Emphysema . PSH: Spinal fusion surgery [30] years ago. Social History: 50 pk yr smoking hx (nicotine patch), stopped drinking 35 yrs ago, lives with his children, getting married soon, 4 children. Enjoys hunting, fishing now. Strong social support. Family History: Healthy, uncle may have had cancer, no family member had or have similar symptoms Physical Exam: Vitals: 98.9 / 92 / 28 / 96% sat on 2 L / 132/70 Gen: Ambulatory, breathing loudly HEENT: No JVD, PERRL Lungs: CTAB Chest: No pain on palpation, purpura on chest, barrel-chested Heart: RRR, no m/r/g, clear S1/S2, no S3/S4 Abdomen: Distended, firm, bumpy on palpation, NT, +BS, purpura and petechiae on abdomen, hepatosplenomegaly is difficult to appreciate due to distension of abdomen and bowel Back: Tenderness to palpation along spine from shoulder blades down to buttocks, most tenderness in T8 area of disc surgery, tenderness with palpation of buttocks, less tenderness in cervical spine LYMPH: No anterior/posterior cervical/supraclavicular LN, no axillary or inguinal LN Genital: Vesicle/wart in suprapubic area, discomfort on palpation Extremities: 1+ pitting edema bilaterally Neuro: [6-13] motor, sensory equal and intact throughout, good rectal tone and sensation, leg raise to 80 degrees bilaterally without pain, 2+ pulses throughout, PERRL Pertinent Results: [2120-8-3] 08:15PM PT-12.7 PTT-20.4* INR(PT)-1.1 [2120-8-3] 08:15PM PLT SMR-VERY LOW PLT COUNT-56* [2120-8-3] 08:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ STIPPLED-1+ HOW-JOL-1+ [2120-8-3] 08:15PM NEUTS-52 BANDS-12* LYMPHS-19 MONOS-6 EOS-0 BASOS-1 ATYPS-1* METAS-5* MYELOS-3* PROMYELO-1* NUC RBCS-7* [2120-8-3] 08:15PM WBC-5.6 RBC-3.46* HGB-10.4* HCT-29.3* MCV-85 MCH-30.2 MCHC-35.6* RDW-15.9* [2120-8-3] 08:15PM calTIBC-235* FERRITIN-GREATER TH TRF-181* [2120-8-3] 08:15PM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-2.9 MAGNESIUM-2.0 URIC ACID-4.8 IRON-57 [2120-8-3] 08:15PM ALT(SGPT)-38 AST(SGOT)-90* LD(LDH)-4712* ALK PHOS-105 TOT BILI-0.8 [2120-8-3] 08:15PM GLUCOSE-114* UREA N-23* CREAT-0.7 SODIUM-133 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15 Brief Hospital Course: A/P: 67 yo M, PMH of DM, CAD (CABG), DJD (disc surgery), COPD, presents with epistaxis, purpura, lymphadenopathy, severe back pain, anemia, thrombocytopenia, fevers, fatigue x months, 30 lb weight loss over past month. . 1. MEDIASTINAL AND ABDOMINAL LAD: Diff Dx: LAD could be due to myeloma, lymphoma, primary lung ca, TB (no apparent exposure), granulomatous diseases, HIV (unprotected sex for 3 years, STD), fungus. Other possibilities are Wegener's (hemoptysis, but no renal failure), sarcoidosis (but unusual patient profile, and Ca is 9.4). . In [Hospital 1474] Hospital, the pt had undergone a CT Chest, which showed mediastinal LAD and a RLL lesion. Mediastinoscopy was performed, and the [Hospital1 1474] pathologist (Dr. [First Name (STitle) ] reported "benign findings" (detailed [Hospital1 1474] pathology report and phone numbers included in the chart). FNA of a RLL lesion was performed, and Dr.[Name (NI) 16211] initial impression was small cell ca of the lung. . At [Hospital1 18], a CT Torso was performed, demonstrating diffuse giant LAD throughout the mediastinum and abdomen, as well as a RLL lesion, 2 small liver lesions (one in caudate lobe, one in left lobe), and no splenomegaly. Since the patient had SOB, chest pain, and a R apical pneumothorax after his mediastinoscopy at [Hospital1 1474], it was decided that the giant lymph nodes found on CT Torso, the lung lesion, and 2 liver lesions would not be biopsied, in case the results of the bone marrow aspirate were sufficient for diagnosis. HIV and ANCA were negative. . 2. BACK PAIN: Diff Dx: Back pain could be due to myeloma (lytic lesions), colon ca (pathologic fx), mets to bone from lung ca (pathologic fx), slipped disc. . Metastases to the spine were suspected. T- and L-spine XR showed neither a pathologic fracture nor lytic lesions. SPEP/UPEP and PSA were negative. During admission, the pt experienced a fall, in which he was "walking normally, and then all of a sudden my legs went numb, and I went to take a step and my legs buckled like the batteries had been taken out of them". Neurologic findings showed R LE weakness. Pt was started on steroids with communication with Hem-Onc. MRI of the Head, C-, T-, and L-spine ruled out cord compression, but a possibility of an epidural tumor was noted at T10/T11. The next day, neurologic findings progressed to R LE and R UE weakness and decreased pinprick sensation, and decreased R lower face pinprick sensation. MRI Head showed a possible subacute pontine infarct. Pt has a h/o spinal fusion surgery [30] years ago, and an LP under fluoro was attempted to rule out carcinomatous meningitis. 2 units plts were transfused before LP. However, while attempting to lie on his abdomen, the pt was in excruciating pain and his O2 sat dropped to 90%, and the LP could not be performed. . 3. EPISTAXIS: Diff Dx: Epistaxis that does not stop after several hours, with a plt count of 56, in a non-uremic pt is unusual, and suggestive of myeloma, lymphoma, bone marrow aplasia, DIC, qualitative plt defects. . The pt presented with plts 56 and profuse epistaxis that did not respond to Afrin, pressure, tilting of his head. Epistaxis ceased only after infusion of 1 unit plts. Hct remained stable throughout admission. Epistaxis was on and off when pt had plts 78. . 4. PURPURA: Diff Dx: Purpura diffusely over the chest, abdomen, and legs, with a plt count of 56, in a non-uremic pt is unusual, and suggestive of myeloma, lymphoma, bone marrow aplasia, DIC, qualitative plt defects. . The pt presented with green-yellow purpura on his chest and abdomen, as well as petechiae on his abdomen with no h/o trauma. Purpura continued to resolve during admission. . 5. ANEMIA: Diff Dx: Anemia of Hct 29.3 suggests colon ca in a 67 yo male (but no black stools, normal bore stools), myeloma, lymphoma, hemolytic anemia, splenomegaly and reticuloendothelial system can be destroying RBC. With fever and thrombocytopenia, TTP is a possibility, but no renal failure or neuro changes (although these are late developments). . Results of uric acid, haptoglobin, retics, total bili, and no schistocytes indicated that a hemolytic anemia or TTP was unlikely. No splenomegaly was found on CT Abd. . CBC with diff twice showed selectively early myeloid precursors in the peripheral blood. Basophilic stippling and [Location (un) ]-Jolly body was noted on erythrocyte examination. A peripheral smear (showing erythroblasts and no tear drop cells) and bone marrow aspirate was performed by Hem-Onc (Dr. [First Name4 (NamePattern1) 16212] [Last Name (NamePattern1) ] and Dr. [Last Name (STitle) ]. A bone marrow biopsy could not be performed due to pt's "panic attack" during two attempts. The results of the BM aspirate revealed a diagnosis of small cell carcinoma of the lung with squamous morphology, an undifferentiated tumor. . 6. THROMBOCYTOPENIA: Diff Dx: Plts of 56 with epistaxis and purpura indicates a functional, qualitative thrombocytopenia, suggesting bone marrow suppression, production problem (liver failure and tpo, but bili is WNL), destruction by splenomegaly (should be increase in megakaryocytes). . 7. SOB: Pt's baseline SOB was attributed to COPD (emphysema), as CXR taken for possibility of post-obstructive pneumonia showed no infiltrates. Exacerbated SOB was attributed to R pneumothorax. Pt maintained >95% O2 sat on high flow 5L nasal cannula, and R pneumothorax was resolving. . Echo and daily CXR had not been performed on the day before transfer to OMED, due to more emergent testing. Echo had also been planned as preparation for possible future cancer therapy. . 8. PAIN: Both at [Hospital 1474] Hospital and [Hospital1 18], pt's pain was difficult to control. Pt's pain is diffuse, "all over", in the chest, and localized especially on the spine from T4 to the sacrum and down the LEs. Pt's pain is episodic, at times [3-21] to 10+/10, feels like "sharp, electric shock pain", helped by position of sitting or lying down on his back, and precipitated by muscle use. Pt's pain was successfully controlled on a morphine PCA pump at a maximum of 10 mg/hr. . 9. CAD: Pt's CAD is chronic. He had been maintained on Metoprolol and ASA, but no ACE-I or [Last Name (un) ]. Pt's ASA was discontinued due to pt's bleeding tendency. . 10. HTN: Pt's HTN is chronic, and well-controlled on Metoprolol. . 11. DM: Pt was maintained on Insulin SS. . 12. COPD (Emphysema): Pt has a 50 pk-yr smoking history and emphysema, and was maintained at >95% O2 sat on 2L O2 nasal cannula alone. High flow 5L O2 nasal cannula was maintained to help resolve pt's pneumothorax. . 13. FEN: Due to pt's 30 lb weight loss over the past month, decreased appetite, and possible cachexia, a house diet and periodic IVFs of D5 0.45NS were provided. . 14. PROPHYLAXIS: Due to pt's bleeding tendency, pneumoboots and no heparin sc were used. PPI was given for GI protection. . . 15. FAMILY CONTACTS: Have permission of the pt to have open communication with: [Name (NI) ] (son), [Name (NI) 6480] (daughter): [Telephone/Fax (1) 16213] [Name (NI) 1328] (sister). . The patient was kept comfortable until his family could arrive. He was then made CMO and expired on [2120-8-13]. Medications on Admission: Morphine Sulfate SR 15 mg PO Q12H Oxycodone 5 mg PO Q4-6H:PRN pain Nicotine Patch 21 mg TD DAILY Pantoprazole 40 mg PO Q24H Insulin SC (per Insulin Flowsheet) Sliding Scale Multivitamins 1 CAP PO DAILY Metoprolol 50 mg PO BID Albuterol 0.083% Neb Soln 1 NEB IH Q6H Ipratropium Bromide Neb 1 NEB IH Q6H Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] use with spacer Acetaminophen 1000 mg PO Q6H traMADOL 50 mg PO Q4-6H:PRN pain Zolpidem Tartrate 5 mg PO HS:PRN insomnia Oxymetazoline HCl 1 SPRY NU [Hospital1 ] Duration: 3 Days for epistaxis Discharge Medications: None - patient expired Discharge Disposition: Expired Facility: [Hospital1 18] Discharge Diagnosis: Respiratory Failure Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "V45.81", "197.2", "162.8", "401.9", "196.1", "197.7", "518.81", "287.5", "492.8", "198.5", "784.7" ]	icd9cm	[ [ [] ] ]	[ "99.25", "41.31", "99.04", "34.04", "99.05" ]	icd9pcs	[ [ [] ] ]	12940, 12979	4964, 12287	344, 370	13042, 13051	4094, 4941	13107, 13253	3005, 3088		12893, 12917		13000, 13021		12313, 12870			13075, 13084									3103, 4075																							235, 306						398, 2676															2698, 2793	2809, 2989
62,190	177,103	4686	Discharge summary	report	Admission Date: [2121-1-17] Discharge Date: [2121-1-24] Date of Birth: [2054-3-23] Sex: M Service: MEDICINE Allergies: Azulfidine / Remicade / Sulfa (Sulfonamide Antibiotics) / Methotrexate / Azathioprine Attending:[First Name3 (LF) 1945] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 66 year old male with history of Crohn's disease c/b fistulas s/p multiple surgeries, ESRD on HD qMWF, who originally presented to OSH with sudden onset of neck pain and blurry vision. Patient reports that he woke up this morning, and when he stood up, suddenly felt acute onset of neck pain in the back of his neck. The pain was both at the midline and sides, described to be pressure like. No trauma to neck. Also felt lightheaded, vision blurry, and felt like he might pass out. Sitting down relieved his symptom somewhat. Patient went to [Hospital1 2436] ED where he was noted to be hypotensive in the 70s. He received a 1 L bolus with some improvement of his symptoms. Noncontrast head CT and CXR at OSH reported to be normal. He was transferred to [Hospital1 18] for neurological evaluation for concerns for vertebral artery dissection. By the time patient arrived at [Hospital1 18] ED, his neck pain had resolved, and his blurry vision had improved. His Tmax at home was 100.0. Denies any chills or headaches. . In the ED, initial vs were: 98.6, 116, 115/55, 18, 100% RA. Neurology evaluated the patient, recommended CTA head and neck which is preliminarily read as no evidence of dissection. His labs were notable for a K of 6.6 on admission, for which he received kayexalate, as well as insulin/D50, which improved his K to 5.2. Patient then began to become hypotensive again, down to the 70s. He was started on levophed, given a total of <1 L of fluids, with recovery of his pressure to the 100s. Tmax in the ED was 103, for which he got 1 gram of tylenol. Also noticed to have thick yellow urine. Per patient, says he produces about half a cup of urine a day. Patient received vancomycin, zosyn, cipro, and 4 g of Mg. Vitals on transfer were: 102/52, 108, 20, 99%2L. . In the MICU, patient is feeling comfortable, neck pain resolved, blurry vision resolved, no longer feeling dizzy. No complaints. . Past Medical History: Crohns disease s/p multiple surgeries ESRD on HD nephrolithiasis h/o UTIs Social History: lives alone, never married, denies tobacco, alcohol, illicit drug use Family History: Father - DM, HTN Physical Exam: Vitals: T: BP: P: R: 18 O2: General: AAOx3, NAD, pleasant HEENT: PERRLA, EOMI, neck supple, no LAD, no JVD CV: S1S2, tachycardic, II/VI SEM Chest: CTA b/l, no w/r/r, left HD catheter clean and dressed Abd: several healed surgical scars, ostomy x2 clean and dressed, soft, ND, NT, +BS Ext: RUE AV fistula, LUE PICC line clean and dressed, no e/c/c, 2+ peripheral pulses Pertinent Results: CXR ([2120-1-18]) IMPRESSION: Right base atelectasis due to low lung volumes. No definite focal consolidation or superimposed edema. . CTA head/neck ([2120-1-18]) - PRELIM Prominent left vertebral artery likely related to tortuosity. No definite dissection. no aneurysm or thrombosis. Final read pending neuroradiology fellow input. . [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 19776] (Complete) Done [2121-1-22] at 3:25:23 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Hospital1 ] C [Location (un) 830], [Hospital1 ] 311 [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2054-3-23] Age (years): 66 M Hgt (in): 66 BP (mm Hg): 144/65 Wgt (lb): 145 HR (bpm): 85 BSA (m2): 1.75 m2 Indication: ?Endocarditis. ICD-9 Codes: 424.90, 424.1, 424.0 Test Information Date/Time: [2121-1-22] at 15:25 Interpret MD: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Test Type: TEE (Complete) Son[Name (NI) 930]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2011W000-0:00 Machine: Vivid i-3 Sedation: Versed: 1.5 mg Fentanyl: 75 mcg Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range TR Gradient (+ RA = PASP): 26 mm Hg <= 25 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV systolic function. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or vegetations on aortic valve. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on mitral valve. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Mild [1+] TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No vegetation/mass on pulmonic valve. Physiologic (normal) 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. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was monitored by a nurse in [Last Name (Titles) 9833] throughout the procedure. Local anesthesia was provided by benzocaine topical spray. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The posterior pharynx was anesthetized with 2% viscous lidocaine. 0.1 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No TEE related complications. Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis. Moderate mitral regurgitation. Mild aortic regurgitation. Globally normal biventricular systolic function. Dr. [Last Name (STitle) 9434] was notified by telephone on [2121-1-22] at 1 pm. . . [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier ]TTE (Complete) Done [2121-1-21] at 9:00:00 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Hospital1 ] C [Location (un) 830], [Hospital1 ] 311 [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2054-3-23] Age (years): 66 M Hgt (in): 66 BP (mm Hg): 126/73 Wgt (lb): 135 HR (bpm): 90 BSA (m2): 1.69 m2 Indication: Endocarditis. ICD-9 Codes: 424.1, 424.0, 424.2, 424.90, Test Information Date/Time: [2121-1-21] at 09:00 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], MD Test Type: TTE (Complete) 3D imaging. Son[Name (NI) 930]: [First Name8 (NamePattern2) 4134] [Last Name (NamePattern1) 4135], RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2011W000-: Machine: Vivid [7-17] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.5 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.8 m/s Left Atrium - Peak Pulm Vein D: 0.5 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 5.6 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 56% >= 55% Left Ventricle - Stroke Volume: 88 ml/beat Left Ventricle - Cardiac Output: 7.92 L/min Left Ventricle - Cardiac Index: 4.68 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 11 < 15 Aorta - Sinus Level: 4.3 cm <= 3.6 cm Aorta - Ascending: 3.9 cm <= 3.4 cm Aorta - Arch: 3.5 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 28 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 169 ms 140-250 ms TR Gradient (+ RA = PASP): 42 mm Hg <= 25 mm Hg Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: No mass or vegetation on mitral valve. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. Quantitative (3D) LVEF = 56%. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. No mass or vegetation is seen on the mitral valve. Moderate (2+) 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 no pericardial effusion. IMPRESSION: No vegetations seen (adequate-quality study). Mild aortic regurgitation. Moderate mitral and tricuspid regurgitation. Normal global and regional biventricular systolic function. In presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. Brief Hospital Course: 66 M with h/o Crohn's disease, ESRD on HD presents with hypotension, possibly due to urosepsis . # Hypotension - possibly due to urosepsis. He has a history of UTIs. He is also on chronic steroids for Crohn's disease. Patient admitted with fever, tachycardia, white count of 16.1, and a dirty UA. There were no other sources of infection to explain white count and septic physiology. CXR shows atelectasis, no evidence of pneumonia. Initially started on levophed in ED, able to wean and d/c by [2121-1-18]. Covered with vanc and zosyn. Blood culture showed staph species from PICC line which was discontinued. His HD line was discontinued and he had a line holiday. He was continued on vancomycin dosed ad HD. TTE and TEE both showed no evidence of vegetations. He was afebrile and HD stable with negative surveilence cultures for three days and a new HD line was placed. He was discharged home hemodynamically stable. . # Dizziness/blurry vision - likely [2-12] hypotension. Symptoms improved at OSH with IV fluid bolus and with initiation of pressors here. Symptoms resolved with stablization of blood pressure. CT showed no evidence of dissection. He was asymptomatic for the remainder of his stay. . # ESRD on HD - admitted with K of 6.6, improved to 5.2 with IV fluids, kayexalate, and D50/insulin. Continued HD as an inpatient. Nephrocaps were started. He was discharged with instructions to continue HD on his outpatient shcedule. . # Neck pain - unclear what etiology of his neck pain is, but it had resolved by the time he got to the MICU. CTA head and neck without evidence of dissection on prelim read. He had no more neck pain during his admission. . # Crohn's disease - complicated by fistulas s/p multiple surgeries. Prednisone continued. Otherwise stable. He will follow up with his Gastroenterologist as an outpatient. Medications on Admission: omeprazole 20 mg [Hospital1 ] metoprolol 50 mg [Hospital1 ] allopurinol 100 mg daily ropinirole 4 mg qhs prednisone 10 mg daily alprazolam 0.5 mg daily prn anxiety Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ropinirole 1 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 4. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:28 Cap(s) Refills:2 6. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 7. vancomycin in D5W 1 gram/200 mL Piggyback Sig: as directed Intravenous HD PROTOCOL (HD Protochol) for 24 days. Discharge Disposition: Home Discharge Diagnosis: MRSA bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were amditted to [Hospital1 18] because you had a blood stream infection caused by MRSA that caused you to go into shock. You were managed in the ICU overnight with medications to help maintain your blood pressures. The next morning you were able to maintain your blood pressure on your own and were transferred from the ICU to the floor. You have been treated with IV antibiotics and will continue with them until [2121-2-16]. You will receive these at dialysis. We changed your HD line. . While you were here we made the following changes to your medication: #) We STOPPED your metoprolol. You should discuss the need to restart this medication with your PCP at your next visit . #) We STARTED you on nephrocaps. You should take this once a day . #) We STARTED you on Vancomycin. This antibiotic should be given to you at each dialysis appointment until [2121-2-16] . You shoudl continue to take your other medications as prescribed Followup Instructions: Thursday [2121-1-30] at 530pm with Dr. [Last Name (STitle) ] for a follow up appointment. Please call them at [Telephone/Fax (1) 19777] if you need to reschedule for any reason. . You should also call your vascular surgeons to follow up with them regarding your dialysis graft. .	[ "723.1", "585.6", "790.7", "V45.11", "530.81", "041.04", "V45.89", "276.7", "285.21", "333.94", "733.00", "996.62", "555.9", "E879.1", "041.12", "V44.2", "426.4", "300.00", "599.0" ]	icd9cm	[ [ [] ] ]	[ "39.95", "88.72", "38.95" ]	icd9pcs	[ [ [] ] ]	14438, 14444	11709, 13566	360, 366	14504, 14504	2961, 11686	15631, 15926	2538, 2556		13788, 14415		14465, 14483		13592, 13765			14655, 15608									2571, 2942																							308, 322						394, 2337									14519, 14631						2359, 2434	2450, 2522
80,305	139,354	39777	Discharge summary	report	Admission Date: [2188-12-23] Discharge Date: [2188-12-31] Date of Birth: [2129-11-10] Sex: F Service: CARDIOTHORACIC Allergies: Iodine-Iodine Containing Attending:[First Name3 (LF) 922] Chief Complaint: wound dehiscence, bloody drainage Major Surgical or Invasive Procedure: [2188-12-24] sternal washout [2188-11-28] AVR On-x/Talon plating History of Present Illness: 59yoF s/p AVR (23mm On-X) and Talon plating as above on [2188-11-28]. Post-op course was uneventful and she was discharged to rehab on POD 5. She presents to clinic today for routine follow-up and is found to have sternal wound dehiscence without evidence of infection. She is admitted for further management. Past Medical History: Aortic Stenosis Atrial flutter s/p cardioversion [2188-10-9] Obesity GERD Diabetes mellitus type 2 - diet controlled Left lower extremity cellulitis - [2171] following a burn injury Hypertension Dissociative Indentity Disorder Depression Post Traumatic Stress Disorder - H/O sexual abuse as child Rheumatoid arthritis Past Surgical History: Tonsillectomy D+C Social History: Race: Caucasian Last Dental Exam: Every 6 months. Last in [Month (only) 205]. Lives with: Husband Occupation: Disabled Tobacco: Distant mild use 25 years ago. ETOH: Rare Family History: Father with CABGx5 in his 80's. Died of MRSA complications. Physical Exam: HR 66 B/P 166/74 RR 22 sat 97% Pre-op weight: 360 pounds Physical Exam- General:obese, poor hygiene Cardiac: RRR [x] Irregular [] Murmur-none, crisp valve click Chest: Lungs clear bilateral [x] Abdomen: Soft [x] Nontender [x] Nondistended [x] Extremities: Warm [x] Well perfused [x] Edema: Right -none Left-none Sternal incision: drainage no[] yes[x]serosanguinous well approximated yes [] no [x] sternal click no[x] yes[]; wound opening visibly at clinic; bloody drainage; no sign of infection Pertinent Results: Admission: [2188-12-23] 06:03PM PT-32.1* PTT-30.7 INR(PT)-3.2* [2188-12-23] 06:03PM PLT COUNT-624# [2188-12-23] 06:03PM WBC-7.1 RBC-3.72 HGB-11.3* HCT-34.8* MCV-94 MCH-30.5 MCHC-32.6 RDW-14.0 [2188-12-23] 06:03PM MAGNESIUM-1.6 [2188-12-23] 06:03PM GLUCOSE-165* UREA N-12 CREAT-0.7 SODIUM-138 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-31 ANION GAP-14 Discharge: [2188-12-30] 06:32AM BLOOD WBC-8.8 RBC-2.97* Hgb-8.9* Hct-27.8* MCV-94 MCH-30.1 MCHC-32.2 RDW-13.9 Plt Ct-619* [2188-12-31] 09:05AM BLOOD PT-21.3* PTT-24.8 INR(PT)-2.0* [2188-12-30] 06:32AM BLOOD Plt Ct-619* [2188-12-30] 06:32AM BLOOD ESR-135* [2188-12-30] 06:32AM BLOOD Glucose-97 UreaN-12 Creat-0.9 Na-140 K-4.1 Cl-98 HCO3-38* AnGap-8 [2188-12-30] 06:32AM BLOOD Mg-1.7 [2188-12-26] 01:22PM BLOOD T4-9.0 T3-90 [2188-12-26] 01:22PM BLOOD Cortsol-14.1 [2188-12-30] 06:32AM BLOOD CRP-133.1* [2188-12-30] 06:32AM BLOOD Vanco-18.8 Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [2188-12-30] 9:52 AM [Hospital 93] MEDICAL CONDITION: 59 year old woman with new PICC REASON FOR THIS EXAMINATION:Please assess PICC tip location right basilic. Wire 1cm prior to PICC tip end. Length 50cm IMPRESSION: Right PICC line ends in mid to low SVC, just proximal to tip of right IJ catheter. TISSUE STERNAL WOUND. FINAL REPORT [2188-12-28] GRAM STAIN (Final [2188-12-24]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. TISSUE (Final [2188-12-28]): CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. OF TWO COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Final [2188-12-28]): NO ANAEROBES ISOLATED. Brief Hospital Course: Ms [Known lastname 46630] was admitted to [Hospital1 18] with sternal drainage following AVR(mechanical) on [11-28]. Infectious diseases and plastic surgery services were consulted. Her INR was corrected with FFP and she was brought to the operating room on [12-24] for sternal debridement and removal of talon plates x4. She tolerated the operation well and post-operatively was brought to the cardiac surgery ICU in stable condition with a VAC dressing in the chest cavity. She was kept sedated and chemically paralyzed for protection given her open chest. Two days later she returned to the operating room for: delayed closure of a sternal wound dehiscence with sternal plating times five and bilateral pectoralis musculocutaneous advancement flaps. She again tolerated the operation well and was returned to the cardiac surgery ICU in stable condition. Following closure the paralytics were discontinued the patient woke, was weaned from the ventilator and finally extubated. Her tissue swabs showed: (Final [2188-12-28]): CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. OF TWO COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Final [2188-12-28]): NO ANAEROBES ISOLATED. She was continued on Vancomycin per Infectious disease recommendation. On POD5 she was transferred from the CVICU to the stepdown floor for continued post-operative care. She made slow progress in advancing her activity, but remained hemodynamically stable throughout this time. On POD7 she was discharged to rehabilitation at Catholic [Hospital1 107] Reahbilitation in [Location (un) 5450], NH. She is to follow up with Dr [Doctor Last Name 87592] surgery, Dr [Location (un) ] surgery, and infectious diseases Medications on Admission: BUPROPION HCL - 200 mg Tablet twice a day CITALOPRAM - 40 mg once a day DIAZEPAM - 5 mg prn HYDROXYCHLOROQUINE - 400 mg once a day as needed for bedtime METOCLOPRAMIDE - 10 mg four times a day METOPROLOL TARTRATE - 50 mg three times a day PROPOXYPHENE N-ACETAMINOPHEN - 100 mg-650 mg - 1 Tablet(s) by mouth once a day RABEPRAZOLE [ACIPHEX] - 20 mg 1 Tablet(s) by mouth once a day RAMIPRIL -5 mg once a day SIMVASTATIN [ZOCOR] - Dosage uncertain SULFASALAZINE 1000 mg twice a day TRAZODONE - 100 mg once a day WARFARIN - 4 mg Tablet - once a day ZIPRASIDONE HCL 20mg twice a day ASPIRIN - 81 mg Tablet twice a day CALCIUM-MAGNESIUM-ZINC - 1 Tablet(s) by mouth twice a day COENZYME Q10 - 100 mg Capsule -twice a day DOCUSATE SODIUM -100 mg twice a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] 1,000 unit Capsule - once a day MULTIVITAMIN - once a day VIT B COMPLEX 100 COMBO NO.2 -Dosage uncertain Discharge Medications: 1. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous once a day. 2. insulin lispro 100 unit/mL Solution Sig: sliding scale as directed Subcutaneous QAC&HS. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 14. neomycin-bacitracin-polymyxin Ointment Sig: One (1) Appl Ophthalmic [Hospital1 ] (2 times a day). 15. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for xerophthalmia. 16. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 18. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 19. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 20. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 22. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 23. furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection Q12H (every 12 hours). 24. vancomycin 500 mg Recon Soln Sig: 1000 (1000) mg Intravenous Q12H (every 12 hours): check trough before 4th dose 6 week course [Date range (1) 87593] per ID([Hospital1 18]) . 25. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: target INR [3-5]. 26. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [Hospital3 17921] Center Rehab Discharge Diagnosis: [2188-12-26] sternal debridement,B pec flaps, synthes plating [2188-12-24] sternal washout [2188-11-28] AVR On-x/Talon plating PMHx: Aortic Stenosis, Atrial flutter s/p cardioversion [2188-10-9], Obesity, GERD, Diabetes mellitus type 2 - diet controlled, Left lower extremity cellulitis - [2171] following a burn injury, Hypertension, Dissociative Indentity Disorder, Depression, Post Traumatic Stress Disorder - H/O sexual abuse as child, Rheumatoid arthritis, Tonsillectomy, D+C Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: sternal wound clean dry and intact, multiple retention sutures. JP drain x2 Edema: 1+ pedal edema bilat Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914] on [1-20] @1PM phone:[Telephone/Fax (1) 1504] Infectious disease: [First Name8 (NamePattern2) ] [Doctor Last Name ], Phone:[Telephone/Fax (1) 457] Date/Time:[2189-1-13] 4:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 27625], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2189-2-27] 11:30 Please call to schedule appointments with: Plastic Surgeon: Dr [First Name (STitle) ] in 1 week [Telephone/Fax (1) 1429], Cypress St....[Location (un) ], MA Primary Care Dr [First Name (STitle) ] in [5-5] weeks Cardiologist: Dr [Last Name (STitle) 39975] in [3-5] 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 ?????? Pulmonary embolus/Atrial fibrillation: Goal INR [3-5] First draw [1-1] Completed by:[2188-12-31]	[ "V43.3", "278.01", "511.9", "427.32", "278.00", "311", "714.0", "V85.44", "278.1", "530.81", "V58.67", "998.59", "309.81", "730.28", "V58.61", "250.00", "E878.1", "V45.81", "041.84", "401.9", "998.31", "300.14", "V15.41" ]	icd9cm	[ [ [] ] ]	[ "96.71", "77.61", "86.74", "34.79", "38.93", "34.01" ]	icd9pcs	[ [ [] ] ]	9261, 9322	3983, 5771	328, 403	9867, 10081	1975, 3012	11005, 12091	1348, 1410		6726, 9238	3049, 3081	9343, 9846		5797, 6703			10105, 10982								1120, 1140	1425, 1956																							254, 290	3109, 3960					431, 748															770, 1097	1156, 1332
25,049	193,225	10612	Discharge summary	report	Admission Date: [2141-11-27] Discharge Date: [2141-12-1] Date of Birth: [2078-1-6] Sex: M Service: MEDICINE Allergies: Vicodin Attending:[First Name3 (LF) 2474] Chief Complaint: Decreased urine output, SOB Major Surgical or Invasive Procedure: None History of Present Illness: 62 year old male with multiple medical problems significant for b/l fibrothoraces s/p lung decortication in [2-3], diastolic CHF (EF 55%), NSTEMI in setting of urosepsis in [2139], and 2 recent admissions for urosepsis and CHF/PNA, who presents from home with decreased urine output, chest pressure and SOB. He reports that since discharge 5 days ago his shortness of breath has gotten progressively worse. He denies orthopnea and says that his breathing is actually better when slightly reclined. He also says his LE edema is less than it has been. . He noted the decreased urine output yesterday, despite the presence of a foley. Denies any hematuria. . He also complains of a chest pressure/tightness, substernal, which does have some positional component and some association to breathing. It's [4-11] at it's worst and is not associated with N/V/D. . In the ED this admission, his initial BP was 126, however dropped to the 80s. He received 2L IVF without improvement in his BP, and was started on peripheral dopamine. Initial labs were notable for ARF with creatinine 3.8, a BNP of 32,800, and a UA with 11-20 wbc, many bacteria, positive LE. Lactate 1.6. Bcx, Ucx sent. CXR showed ?PNA in LLL and CHF. Given one dose of ceftriaxone and sent to [Hospital Unit Name 153] on peripheral dopamine. . 2 recent admissions: First from [Date range (1) 34884] with presumed urosepsis s/p penile implant surgery. He required levophed, and was treated with Vancomycin and Ceftriaxone, though urine and blood cultures were negative; vancomycin was discontinued, and he was discharged home on a 7 day course of PO cefpodoxime. A foley was left in place, as he was unable to void. This admission was also complicated by acute on chronic renal failure, with Cr increase to 4.3 (baseline 1.6) atributed to his hypotension. It was 2.1 on discharge. He had elevated (max 0.29) but decreasing troponins but no chest pain or ST changs, and he was thought to have demand ischemia. . He was readmitted on [2148-11-17] with chest pressure, found to have LLL PNA and CHF. He was diuresed with IV lasix and treated for pneumonia with levaquin. Of note, he was discharged on home O2 secondary to desaturation with ambulation. He continued to have urinary retention during this admission and was again discharged with a foley. Past Medical History: 1) CHF, EF 45% from most recent echo [6-5], mixed LV systolic and diastolic dysfunction, cardiomyopathy 2) CAD, NSTEMI in [3-6] during admission for urosepsis with hypotension and coma. 3) Type II DM c/b neuropathy, nephropathy, per pt no retinopathy 4) HTN 5) CRI, baseline creatinine of 1.7 6) Anemia of chronic disease. 7) Sleep apnea on BiPAP, currently [10-10] 8) Chronic restrictive ventilatory disease secondary to a bile duct leak with pulmonary fibrosis requiring decortication 9) Neuropathy - hands and feet 10) Lower extremity claudication 11) BPH. 12) Glaucoma; on carbonic anhydrase inhibitor 13) Bilateral cataracts s/p surgical removal 14) Depression 15) Osteoarthritis 16) Erectile dyscunction s/p Penile implant [11-6] .. Past surgical history: 1) [2138] Roux-en-y reconstruction after laparoscopic cholecystectomy c/b damage to CBD 2) [2139] Decortication for fibrothorax complicated by respiratory failure requiring tracheostomy. 3) Appendectomy. 4) Left knee/hip replacement Social History: The patient lives with his wife. [Name (NI) ] does not smoke. Only minimal ethanol. Otherwise, he is extremely sedentary. Family History: CVA - brother Breast [Name (NI) 3730] - mother emphysema - father Physical Exam: PE: 98.6, 89/36, 68, 19, 93% on 3L. Gen: Overweight caucasian male wearing BIPAP mask, appearing comfortable, communicative. HEENT: Anicteric sclerae, BIPAP in place. Neck: Unable to locate JVP secondary to body habitus. Cor: RR, normal rate, no m/r/g. Lungs: B/L rales about 1/3 up from the bases, decreased breath sounds at L base with dullness to percussion. Abd: NABS, subcutaneous nodules, NT/ND, oblique scar in RUQ. Extr: Trace to 1+ pitting edema of LE b/l. Genitals: Penile implant in place, erythematous and edematous penile shaft, yellow exudate on gauze coming from inferior portion of penile shaft, +aphthous ulcer on R base of penis. Pertinent Results: EKG: NSR at 70 bpm, normal intervals, normal axis, Q in III, TWI in V2-V5, no ST segment changes. . CXR [11-27]: IMPRESSION: Probable mild CHF. Bibasilar atelectasis. However, an early pneumonic infiltrate cannot be excluded. Pleural fluid versus thickening along left lateral chest wall. Probable small pleural effusions. Please note that these findings may be exaggerated to some degree due to low inspiratory volumes. Brief Hospital Course: 1. Hypotension: Patient was admitted to the [Hospital Unit Name 153] where he was treated with pressors including dopamine for his hypotension. His blood pressure medications were held. [Initials (NamePattern4) ] [Last Name (NamePattern4) 104] stim test was performed and was normal. He was noted to have a urinary tract infection on admission, as well as infiltrate at his left lung base on CXR. He was started on Vancomycin and Ceftriaxone. There was some concern for sepsis, especially in light of the patient's recent penile implant surgery. Urology was consulted and they felt that the surgical site was healing well without signs of infection. They recommended foley placement as they thought the patient's hypotension was likely secondary to mild urinary retention. They also recommended re-starting Proscar and Flomax. Patient was weaned off pressors and continued to have hypotension responsive to fluid boluses. Given that the patient remained essentially afebrile after admission, with no leukocytosis and negative blood cultures, it was deemed highly unlikley that the pateint was in septic shock. Given his response to fluid boluses, there was some though the hypotension was a result of over diuresis at home, possibly complicated by overuse of narcotics for his recent surgery. He was transferred to the [Company 191] service and continued to do well except for persistent penile pain secondary to surgery. He had a few episodes of sharp chest pain, reproducible with palpation, which he described as different from his anginal chest pain. There were no associated symptoms and no ECG changes when one was obtained immediately after an episode of pain. Pain was well controlled with PRN percocet. Patient failed a voiding trial and was discharged home in stable condition with his foley catheter still in place. . 2. Troponin elevation: Up to .21, from .11 on [11-17] in the setting of urosepsis. Given that his CK was flat and there were no ECG changes, the troponin elevation was attributed to chronic wall stretch from CHF with impaired troponin clearance in the setting of ARF. . 3. Acute Renal Failure: Creatinine was 3.8 on admission. FeNa was consistent with pre-renal etiology and resolved with fluids. Recent baseline appears to be around 1.4-1.7. His urine output transiently declined while in the unit, then returned to [Location 213]. Tamulosin was increased per urology recs. . 4. Hypoxia, ?hypoventilation: Unclear how much of the hypoxia is secondary to PNA versus CHF. Also some concern for hypoventilation from OSA. The picture is further compliated by the patient's fibrothorax s/p decortication. Bipap was continued for for OSA. Lasix was re-started at a low dose. Hypoxia improved but with intermittent oxygen saturation levels below 90, especially with ambulation, patient was dicharged on home oxygen. . 5. DM: That patient's normal dose of lantus 8U QHS was continued with a RISS for stict glucose control. . 6. Anemia: This is a chronic problem. Patient's baseline earlier this year was in the mid-30s, however more recently around 30 during repeated hospitalizations. Iron studies were sent and were consistent with anemia of chronic inflammation and likely is secondary to renal failure. . Medications on Admission: 1. Escitalopram 5 mg PO QAM 2. Escitalopram 10 mg PO QPM 4. Aspirin 325 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Senna 8.6 mg PO BID PRN 7. Pantoprazole 40 mg PO Q24H 8. Tamsulosin 0.4 mg PO HS 9. Calcium Carbonate 500 mg PO TID WITH MEALS 10. Oxycodone-Acetaminophen 5-325 mg PO Q4-6H PRN 11. Lisinopril 20 mg PO DAILY 12. Isosorbide Mononitrate 60 mg PO DAILY 13. Metoprolol Tartrate 12.5 mg PO BID 14. Zolpidem 5 mg PO HS PRN 15. Levofloxacin 250 mg PO Q24H (last dose today) 16. Furosemide 20 mg PO DAILY 17. Finasteride 5 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 2. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: urinary retention acute renal failure congestive heart failure hypoxia status post penile implant atypical chest pain Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Take all medications as directed. Do not stop or change any of your medications without first speaking to a doctor. Seek medical attention immediately if you experience: any kind of "pressure" chest pain; if you experience the sharp, stabbing chest pain and it persists long enough that you become concerned; any shortness of breath which does not resolve after 2-3 minutes of rest; fevers or chills. Followup Instructions: 1. You should call your primary doctor Dr. [Last Name (STitle) ] and schedule an appointment in [12-4] weeks. You should take a list of all of your medications so he can review them. You should discuss the intermittent sharp, stabbing chest pain which you experienced in the hospital with your doctor. 2. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3330], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 3331] Date/Time:[2141-12-6] 3:00 3. Provider: [Name Initial (NameIs) 9484]CC2 PULMONARY LAB-CC2 Date/Time:[2141-12-25] 1:30 4. Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2141-12-25] 2:15 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477] MD, [MD Number(3) 2478]	[ "715.90", "250.00", "V43.65", "458.9", "311", "997.5", "607.84", "599.60", "401.9", "276.52", "285.9", "607.89", "428.0", "412", "799.02", "E944.4", "327.23", "V43.64", "707.09", "V58.67", "788.20", "996.76", "428.30", "584.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10329, 10387	5072, 8351	296, 303	10549, 10558	4622, 5049	11111, 12027	3867, 3938		8948, 10306		10408, 10528		8377, 8925			10582, 11088								3464, 3707	3953, 4603																							229, 258						331, 2663															2685, 3441	3723, 3851
25,959	136,463	15078	Discharge summary	report	Admission Date: [2106-9-21] Discharge Date: [2106-10-14] Date of Birth: [2031-6-29] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 75 year old gentleman with a history of cervical stenosis and spondylolisthesis who was seen in evaluation here by Dr. [Last Name (STitle) 1327] for possible cervical fusion. He was discharged to rehab and then brought back on [2106-9-22]. He underwent transoral odontoidectomy and cervical spinal fusion. PAST MEDICAL HISTORY: Hypertension. Anxiety. Insomnia. Questionable history of Paget disease. Questionable history of rheumatoid arthritis. PHYSICAL EXAMINATION: Blood pressure was 110/70, heart rate 70, respiratory rate 23, temperature 98.3, sat 97% in room air. HEENT: anicteric. Pupils equal, round and reactive to light. Cardiac status: regular rhythm, S1, S2, no gallop or murmur. Lungs clear to auscultation. Abdomen flat, positive bowel sounds, nondistended, no organomegaly. Extremities had no cyanosis, clubbing or edema. Neurologically alert and oriented times two, sometimes three. Speech was fluent. Memory for recent events was poor. Cranial nerves II-XII intact. Bilateral upper extremities were intact with no pronator drift and 4+/5 strength. No tremor, although weak finger extension. Hand grasp was weaker on the left. Rapid alternating movements bilaterally were poor, more on the right than the left. Lower extremities were hyperreflexic on lateral movements of extremities. Lower extremities at best were [2-9] except distal strength dorsiflexion and plantar flexion were [5-9]. Left lower extremity was a bit stronger at 3/5 and again dorsiflexion and plantar flexion were [5-9]. Ability to range knees and hips was also better on the left side. Both toes were upgoing. Deep tendon reflexes were brisk at 4+ throughout. HOSPITAL COURSE: The patient was admitted to the surgical intensive care unit status post transoral odontoidectomy with removal of the odontoid and associated pannus and decompression of the foramen magnum from the second odontoid ligament and then posterior decompression and fusion from occiput to C-4 with iliac bone graft. Patient tolerated the procedure well. Post-op was intubated and sedated. Blood pressure was 113/56, temperature 97.7, heart rate 90, sat 100% on assist control 800, PEEP 5, O2 50%. Pupils were equal and sluggish to react bilaterally. Cardiovascular status was stable, regular rate and rhythm. Chest was clear to auscultation. Abdomen soft, nondistended, nontender, positive bowel sounds. Extremities no cyanosis, clubbing or edema, 2+ DP pulses bilaterally. Labs post-op were white count of 8.5, hematocrit 36.7, platelets 142. Sodium 142, K 4.0, chloride 105, CO2 30, BUN 29, creatinine 1.0. On post-op day one patient continued to be intubated, was awake, sticking out his tongue on command, breathing with a vent, squeezing hands to command weakly. Moves legs. Cannot lift arms or legs off the bed status post surgery. Question of whether this was medication effect, but will check MRI to evaluate spinal cord and possible presence of epidural hematoma. MRI showed no evidence of hematoma with good decompression of the cervical-occipital junction. Post-op day two patient's eyes opened spontaneously. EOMs were full. Tracked appropriately. Sticks out tongue on command. Hand grasp 4-/5 on the left with moderate left finger extensor. Spreads fingers against resistance. Increased tone in the left elbow. Grasp 4-/5 on the right with increased tone throughout the right arm. Hyporeflexic in the upper extremities with positive Hoffmann sign bilaterally. Hyperactivity in bilateral lower extremities with minimal left flexion of the knee. Wiggles toes slightly. Positive Babinski. Withdraws to painful stimulation in the lower extremities. MRI of the cervical spine demonstrated excellent decompression of the CMJ and subaxial C-spine. There is intrinsic cord signal abnormality in the region of prior maximal compression and this is not new from post-op. There are no new areas of increased T2 signal. Patient had PICC line placed on [2106-9-24] for IV access. Patient was extubated on [2106-9-24], however, respiratory status declined and patient required reintubation. On [2106-9-25] patient continued to have marked quadriparesis without antigravity strength in the upper and lower extremities. Patient again was extubated on [2106-9-29] which he failed and was reintubated. Patient was then set up for PEG and trach. On [10-1] patient was awake, mouthing words appropriately. He had [4-9] grasp, but unable to lift arms off bed. Leg strength improving with 2/5 strength, still not antigravity. On [2106-10-4] patient had trach placed at the bedside. He also had PEG feeding tube placed on [2106-10-5]. He tolerated both procedures well with no complications. He continued to improve neurologically. On [2106-10-7] he was awake, alert and following commands. Able to lift both legs off the bed. Grasp improving. Able to lift proximal arms off the bed. Continued to have copious secretions and continued to be weaned off the vent. On [10-4] patient spiked a temperature. Cultures came back with positive blood cultures from the 30th with staph coag negative. Catheter tip had Acetobacter and sputum was also coag negative staph MRSA. Patient was on Levaquin and vancomycin 1 gm IV q.12 hours. Was seen by physical therapy and occupational therapy and found to require acute rehab. DISCHARGE MEDICATIONS: 1. Colace liquid 100 mg p.o. b.i.d. 2. Zoloft 50 mg p.o. q.day. 3. Heparin 5000 units subcu q.12 hours. 4. Lorazepam 0.5 mg IV q.four hours p.r.n. 5. Acetaminophen 325 to 650 p.r. q.four hours p.r.n. 6. Insulin sliding scale. 7. Percocet one to two tabs p.o. q.four hours p.r.n. 8. Baclofen 10 mg p.o. t.i.d. 9. Atenolol 25 mg q.day. 10. Allopurinol 200 mg p.o. q.day. 11. Trazodone 50 mg p.o. q.h.s. p.r.n. 12. Doxazosin 2 mg p.o. q.h.s. 13. Senna two tabs p.o. q.h.s. 14. Clotrimazole cream one application topically p.r.n. to left ear. CONDITION ON DISCHARGE: Stable. Staples were removed on post-op day 14. His incision is clean, dry and intact with Steri-Strips. He is to remain in a hard collar for a total of 12 weeks. Followup with Dr. [Last Name (STitle) 1327] should be in 14 days. He is stable at this time and ready for discharge to rehab. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2106-10-14] 11:33 T: [2106-10-14] 11:40 JOB#: [Job Number ]	[ "722.71", "721.1", "997.3", "518.81" ]	icd9cm	[ [ [] ] ]	[ "81.01", "43.11", "31.1", "03.09", "38.93", "81.03", "77.89", "99.15", "77.79", "96.72", "96.04" ]	icd9pcs	[ [ [] ] ]									5602, 6151					1892, 5579																							663, 1874																	161, 495															518, 640		6176, 6736
19,583	199,105	6410	Discharge summary	report	Admission Date: [2138-4-24] Discharge Date: [2138-4-30] Date of Birth: [2065-8-1] Sex: M Service: SURGERY Allergies: Sulfonamides / Lipitor / Naprosyn / Penicillins / Amoxicillin / Chocolate Flavor / Crestor / Morphine / Ativan Attending:[First Name3 (LF) 5880] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 72-year-old male with complex medical history who was originally admitted to the hospital in [Month (only) 958] with a strangulated ventral hernia. He underwent small bowel resections x 2, had a prolonged recovery which included placement of a tracheostomy tube, and was discharged to a long-term rehabiliation facility. He was subsequently transferred back to [Hospital1 18] secondary to respiratory distress/?pneumonia as well as management of volume overload. Past Medical History: 1. CAD - s/p LAD and OM1 stent in [8-2], s/p RCA PTCA in '[28] 2. DM 2 3. HTN 4. PVD s/p bilat LE bypass surgeries (Dr.[Last Name (STitle) ]) 5. CRI - baseline Cr 1.6-2.0 6. cataracts 7. gout 8. BPH 9. Abd hernia 10. s/p CCY, ex-lap w/abd hernia resulting 11. Incarcerated ventral hernia containing strangulated small bowel and requiring small bowel resection. This was complicated by a leak leading to re-operation. Social History: Worked as head [Doctor Last Name 7051]. Hx Etoh abuse x 20 yrs, but quit [2124]. 86 ppy tob. Multiple family memebrs live nearby Family History: Fa: died secondary to colon ca Mo: died secondary to PNA Siblings: Etoh abuse, HTN Physical Exam: T: 100.1 HR: 77 BP: 147/81 RR: 12 SpO2: 100% Alert, no apparent distress Regular rate & rhythm Breath sounds course bilaterally, no wheezes or rhonchi Tracheostomy intact, + air leak Soft, non-tender, & non-distended. VAC in place. [2-1]+ upper & lower extremity edema Pertinent Results: [2138-4-24] 08:49PM BLOOD WBC-13.3# RBC-3.52 Hgb-11.0* Hct-34.5* MCV-98 MCH-31.3 MCHC-31.9 RDW-18.9* Plt Ct-145# [2138-4-27] 01:41PM BLOOD WBC-23.7# RBC-3.07* Hgb-9.9* Hct-30.1* MCV-98 MCH-32.2* MCHC-32.9 RDW-17.8* Plt Ct-159 [2138-4-30] 02:21AM BLOOD WBC-11.3* RBC-3.15* Hgb-9.4* Hct-30.9* MCV-98 MCH-29.9 MCHC-30.5* RDW-17.2* Plt Ct-182 [2138-4-24] 08:49PM BLOOD Glucose-113* UreaN-72* Creat-1.3* Na-156* K-4.0 Cl-117* HCO3-31 AnGap-12 [2138-4-30] 02:21AM BLOOD Glucose-152* UreaN-64* Creat-1.1 Na-144 K-4.2 Cl-110* HCO3-32 AnGap-6* [2138-4-24] 08:49PM BLOOD ALT-26 AST-25 AlkPhos-92 Amylase-193* TotBili-0.6 [2138-4-27] 01:41PM BLOOD Amylase-138* [2138-4-24] 8:50 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [2138-4-25]): [10-23] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2138-4-28]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. 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 PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ <=1 S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [2138-4-24] 10:02 pm BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2138-4-30] AEROBIC BOTTLE (Final [2138-4-30]): NO GROWTH. ANAEROBIC BOTTLE (Final [2138-4-28]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 24690] CC5B [Numeric Identifier 24691] [2138-4-25] 20:30. 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. VANCOMYCIN SENSITIVITY DONE BY E-TEST.. 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 PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S Brief Hospital Course: Mr. [Known lastname ] was readmitted to the surgical intensive care unit at [Hospital1 18] from the rehabilitation facility. He was alert and responsive, and looked well. Diuresis was initiated with good response, and he was weaned from the ventilator and placed on tracheostomy mask ventilation. He initially did well, but was noted to have a large cuff leak from his tracheostomy, and became somewhat tachypneic. He was placed back on the ventilator to which he responded well. He was then noted to have a fever and blood/urine cultures were sent. He was found to have staphylococcus in his sputum and blood, and pseudomonas in his urine. Appropriate antibiotic coverage was initiated (linezolid and cefepime), and he defervesced, with a corresponding drop in his WBC. In addition, his tracheostomy tube was removed and replaced with a similarly sized flexible [Last Name (un) 295] tracheostomy, angled specifically to have a longer down-arm. His air leak resolved with this maneuver. He continued to improve, and it was decided that he was again ready for transfer to a rehabiliation facility. Medications on Admission: 1. Lopressor 25 mg PO TID 2. ASA 81 mg PO DAILY 3. Lasix 40 mg PO BID 4. Ativan PRN 5. Albuterol IH 6. Lansoprazole 30 mg PO DAILY 7. Regular Insulin Sliding Scale 8. Epogen 9. Seroquel 10. Heparin 5000U SC TID Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (un) ]: 5000 (5000) Units Injection TID (3 times a day). 2. Albuterol Sulfate 0.083 % Solution [Last Name (un) ]: One (1) Neb Inhalation Q6H (every 6 hours) as needed. 3. Epoetin Alfa 2,000 unit/mL Solution [Last Name (un) ]: 1000 (1000) Units Injection QMOWEFR (Monday -Wednesday-Friday). 4. Zinc Oxide-Cod Liver Oil 40 % Ointment [Last Name (un) ]: One (1) Appl Topical PRN (as needed). 5. Miconazole Nitrate 2 % Powder [Last Name (un) ]: One (1) Appl Topical TID (3 times a day) as needed. 6. Acetaminophen 160 mg/5 mL Solution [Last Name (un) ]: Six [Age over 90 1230]y (650) mg PO Q4-6H (every 4 to 6 hours) as needed. 7. Docusate Sodium 50 mg/5 mL Liquid [Age over 90 ]: One Hundred (100) mg PO BID (2 times a day). 8. Lorazepam 0.5 mg Tablet [Age over 90 ]: 1-4 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Clonidine 0.1 mg/24 hr Patch Weekly [Age over 90 ]: One (1) Patch Weekly Transdermal QFRI (every Friday). 10. Aspirin 81 mg Tablet, Chewable [Age over 90 ]: One (1) Tablet, Chewable PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet [Age over 90 ]: One (1) Tablet PO TID (3 times a day). 12. Quetiapine 25 mg Tablet [Age over 90 ]: One (1) Tablet PO QHS (once a day (at bedtime)). 13. Ipratropium Bromide 17 mcg/Actuation Aerosol [Age over 90 ]: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for when on vent. 14. Albuterol 90 mcg/Actuation Aerosol [Age over 90 ]: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for when on vent. 15. Therapeutic Multivitamin Liquid [Age over 90 ]: Five (5) ML PO DAILY (Daily). 16. Linezolid 600 mg Tablet [Age over 90 ]: One (1) Tablet PO Q12H (every 12 hours). 17. Papain-Urea 830,000-10 unit/g-% Ointment [Age over 90 ]: One (1) Appl Topical DAILY (Daily). 18. Furosemide 40 mg Tablet [Age over 90 ]: 1.5 Tablets PO BID (2 times a day). 19. Cefepime 1 g Recon Soln [Age over 90 ]: One (1) Recon Soln Intravenous Q24H (every 24 hours). 20. Insulin NPH Human Recomb 100 unit/mL Suspension [Age over 90 ]: Ten (10) Units Subcutaneous twice a day: At breakfast and dinner. 21. Regular Insulin Sliding Scale Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: 1. Respiratory distress 2. Congestive heart failure 3. Air leak from tracheostomy 4. Pancreatitis 5. Pneumonia 6. Incarcerated strangulated ventral hernia, Small bowel resection with primary reanastomosis, multiple abdominal abscesses, respiratory failure, myocardial infarction 7. CAD s/p LAD and OM1 stent in [8-2], s/p RCA PTCA in '[28] 8. DM 2 9. HTN 10. PVD 11. CRI (Cr 1.6-2.0) 12. cataracts 13. gout 14. BPH, 15. h/o EtOH abuse (quit 13 yrs ago), h/o heavy tobacco use Discharge Condition: Stable Discharge Instructions: Take your medications as directed. You will be seen by doctors [Name5 (PTitle) 1028] in rehab. Call your doctor or go to the ED for: -chest pain or shortness of breath -fever>102 -significant drainage or blood from your wound Followup Instructions: Please follow up with Dr. [First Name11 (Name Pattern1) 569] [Last Name (NamePattern4) 12637], M.D. on [2138-5-16] 10:20am You will need an repeat echo in [2-2] months, please see Dr. [First Name (STitle) ] to arrange this. Please follow up with Dr. [Last Name (STitle) ] on [5-6]-call [Telephone/Fax (1) 24689] to make the appointment Completed by:[0-0-0]	[ "707.03", "428.0", "250.00", "518.81", "577.0", "585.9", "599.0", "482.40", "519.09", "041.7", "414.01", "274.9", "276.0", "403.90" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93", "96.72" ]	icd9pcs	[ [ [] ] ]	8827, 8870	5203, 6323	390, 396	9398, 9406	1950, 3886	9686, 10081	1553, 1637		6585, 8804		8891, 9377		6349, 6562			9430, 9663									1652, 1931								3919, 5180															330, 352						424, 929															951, 1382	1398, 1537
27,308	181,962	9962	Discharge summary	report	Admission Date: [2137-12-5] Discharge Date: [2137-12-5] Date of Birth: [2059-5-27] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: Massive intracerebral hemorrhage Major Surgical or Invasive Procedure: Intubation History of Present Illness: Patient is a 78 yo man with PMH of glaucoma, HTN, DM, Mood do, Hypothyroid who was well until this afternoon when he suddenly became aggiatated at 445 PM. Nephew was with the patient and noted that he was confused, aggitated, talking. Then deteriorated. There was no trauma. When EMS arrived patint was diaphoretic, slumped, posturing. Intubation attempted and failed. LMA placed. Brought to [Hospital1 18]. Large ICH hemorrhage 6 x 10 cm found on CT and Neuro [Doctor First Name ] evaluated patient. Bleed assessed to be devastating and not compatible with meaningful recovery. Patient no a surgical candidate and explained to wife that he could expire soon. ROS: cannot obtain Past Medical History: Glaucoma, HTN, DM, mood disorder, hypothyroid Social History: NA Family History: NA Physical Exam: T- BP- 220/90 HR- 33 RR- 12 O2Sat 100 vented Gen: Lying in bed, NAD, no posturing noted. HEENT: NC/AT, moist oral mucosa Neck: supple Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft ext: no edema Neurologic examination: Intubated. Had received paralytics about 1 hour earlier, but no sedation. Unresponsive to noxious stim. No commands. No speech. No mvmts or posturing. CN: Occasioually blinks sponatneously during exam. Eyes disconjugate with left eye deviated upwards (wife says this is not his baseline). No blink to threat. Pupils fixed bilaterally with right 4 and left 5. Left pupil also eccentric and irregular. Left eye also noted to have opacified cornea which wife says secondary to glaucoma. No occulocephalics. Right corneal reflex intact, left absent. Gag present. \ Motor: No spontaneous movements. No withdrawl tone flaccid. [Last Name (un) ]: no withdrawl Reflexes: symetric. Right toe up, left equivocal Pertinent Results: [2137-12-5] 11:10AM UREA N-30* CREAT-2.0* SODIUM-150* [2137-12-5] 11:10AM ALT(SGPT)-22 AST(SGOT)-44* LD(LDH)-452* ALK PHOS-161* TOT BILI-0.5 [2137-12-5] 11:10AM ALBUMIN-4.7 [2137-12-4] 06:00PM GLUCOSE-255* UREA N-32* CREAT-1.8* SODIUM-138 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14 [2137-12-4] 06:00PM estGFR-Using this [2137-12-4] 06:00PM CK(CPK)-157 [2137-12-4] 06:00PM CK-MB-7 cTropnT-<0.01 [2137-12-4] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2137-12-4] 06:00PM URINE HOURS-RANDOM [2137-12-4] 06:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2137-12-4] 06:00PM WBC-7.4 RBC-3.69* HGB-12.0* HCT-34.4* MCV-93 MCH-32.6* MCHC-35.0 RDW-12.9 [2137-12-4] 06:00PM NEUTS-58.1 LYMPHS-34.9 MONOS-4.5 EOS-2.3 BASOS-0.2 [2137-12-4] 06:00PM PT-12.8 PTT-26.2 INR(PT)-1.1 [2137-12-4] 06:00PM PLT COUNT-213 [2137-12-4] 06:00PM URINE COLOR-Pink APPEAR-Hazy SP [Last Name (un) 155]-1.017 [2137-12-4] 06:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2137-12-4] 06:00PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 NON-CONTRAST HEAD CT [2137-12-4]: There is a large acute left-sided intraparenchymal hemorrhage extending from the left midbrain and thalamus into the left temporoparietal and frontal subcortical white matter. There is also blood extending into the subarachnoid and subdural spaces of the left cerebrum. There is intraventricular extension, with a small amount of blood layering within the occipital [Doctor Last Name 534] of the right lateral ventricle and presumably the left lateral ventricle which is effaced. There is evidence of obstructive hydrocephalus with dilation of the right lateral ventricle and prominence of the right temporal [Doctor Last Name 534] consistent with entrapment. There is subfalcine herniation with approximately 1.5 cm of rightward midline shift. The right basal cistern is effaced suggesting impending uncal herniation. There is moderate underlying periventricular hypoattenuation suggesting chronic microvascular ischemic disease. CXR AP [2137-12-4]: Large left intraparenchymal hemorrhage extending into the left basal ganglia, thalamus, midbrain, and throughout the subcortical white matter with intraventricular extension, obstructive hydrocephalus, 1.5 cm of midline shift, and signs of impending uncal herniation. AP supine portable chest radiograph is obtained. An endotracheal tube is seen with its tip 2.5 cm above the carina. Cardiomediastinal silhouette appears somewhat prominent which may be related to supine portable technique. Left retrocardiac density may reflect underlying atelectasis in the left lower lobe, though pneumonia cannot be excluded. The right lung appears grossly clear. Visualized osseous structures are unremarkable. Atherosclerotic calcification noted along the thoracic aorta. Additionally degenerative changes are noted in the thoracic spine. IMPRESSION: Endotracheal tube in good position. Left retrocardiac density, question atelectasis versus pneumonia. Brief Hospital Course: Given the poor prognosis, the wife of the patient decided to keep the patient on the ventilator with limited care for comfort until family arrived to pay their final respects. A palliative care consult was called. The patient was pronounced dead at 12:45 pm on [2137-12-6], due to respiratory failure secondary associated with the intracranial hemorrhage. Medications on Admission: Lamictal for mood Zocor 40 ASA 81 Effexor FA Flomax seroquel proscar arricept atenolol levoxyl insulin eye drops Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Intracranial hemorrhage Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023]	[ "431", "244.9", "780.6", "250.00", "365.9", "348.4", "V66.7", "331.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	6087, 6096	5521, 5884	349, 361	6163, 6172	2274, 5498	6235, 6367	1193, 1197		6048, 6064		6117, 6142		5910, 6025			6196, 6212									1212, 1504																							277, 311						389, 1088													1529, 2255		1110, 1157	1173, 1177
83,010	190,715	2947	Discharge summary	report	Admission Date: [2176-6-18] Discharge Date: [2176-6-27] Date of Birth: [2093-11-4] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: Left pleural effusion Major Surgical or Invasive Procedure: [2176-6-20] Left video-assisted thoracoscopy, evacuation of left hemothorax. [2176-6-18] Flexible bronchoscopy, left video-assisted thoracoscopy, drainage of left pleural effusion, placement of PleurX catheter in the left pleural space. History of Present Illness: Mr. [Known lastname ] is an 82-year-old gentleman with history of previous right exudative pleural effusion who approximately 4 months ago presented with increasing shortness of breath. Workup included a CT scan that showed a significant left pleural effusion. He presented for drainage of the left pleural effusion as well as left pleural biopsy. Past Medical History: - pleural effusions s/p R pleurodesis and multiple thoracentesis with pleural fluid and pleural biospy negative for malignancy - stroke [5-11], right post central gyrus infarct with very mild residual left leg weakness - chronic renal insufficiency (baseline 2.8-3.3) - coronary artery disease - mitral insufficiency and aortic insufficiency - hypothyroidism - hypertension - gastroesophageal reflux disease - diabetes mellitus type 2 with retinopathy - glaucoma and macular degeneration Social History: Recently retired lawyer as above. Lives with wife and spent this past winter in [Name (NI) 108]. No tobacco or alcohol history. Family History: - father w/[Name (NI) 4278] - mother HTN - sibling diabetes Pertinent Results: [2176-6-25] WBC-7.6 RBC-3.54* Hgb-9.9* Hct-29.8* Plt Ct-241 [2176-6-23] WBC-8.2 RBC-3.58* Hgb-10.1* Hct-29.8* Plt Ct-224 [2176-6-20] WBC-8.0 RBC-3.80# Hgb-10.9# Hct-31.8* Plt Ct-158 [2176-6-20] WBC-7.4 RBC-2.43* Hgb-7.3* Hct-21.6* Plt Ct-218 [2176-6-20] Hct-25.7* Hct-26.8* [2176-6-19] WBC-7.9# RBC-2.33* Hgb-7.0* Hct-21.8* Plt Ct-225 [2176-6-18] WBC-3.6* RBC-3.02* Hgb-9.1* Hct-28.3* Plt Ct-250 [2176-6-20] Thrombn-12.5# Thrombn-21.7* [2176-6-20] FacVIII-165* [2176-6-25] Glucose-113* UreaN-59* Creat-2.3* Na-138 K-3.7 Cl-106 HCO3-24 [2176-6-20] Glucose-84 UreaN-65* Creat-3.9* Na-138 K-5.2* Cl-111* HCO3-18* [2176-6-18] Glucose-185* UreaN-61* Creat-3.4* Na-138 K-5.1 Cl-109* HCO3-25 [2176-6-24] ALT-55* AST-171* LD(LDH)-210 AlkPhos-193* Amylase-162* TotBili-2.1* DirBili-1.5* IndBili-0.6 [2176-6-23] ALT-72* AST-225* AlkPhos-204* Amylase-183* TotBili-2.6* [2176-6-25] Calcium-8.8 Phos-2.5* Mg-1.7 CXR: [2176-6-26] The right internal jugular line tip is at the level of mid SVC. The upper left chest tube is in unchanged position. The lower left chest tube has been removed in the interim. There is no evidence of newly developed pneumothorax. Bibasilar opacities are present, left more than right, accompanied by unchanged amount of pleural effusion. [2176-6-24] Substantial atelectasis persists in the lingula and virtually all of the left lower lobe. Large cardiac silhouette is stable. Small left pleural effusion changed, with an apical component where there was once a small pneumothorax. Right lung clear. Left pleural drain still ends in the posterior pleural sulcus. Brief Hospital Course: Mr. [Known lastname ] was admitted on [2176-6-18] for Flexible bronchoscopy, left video-assisted thoracoscopy, drainage of left pleural effusion, placement of PleurX catheter in the left pleural space. He was extubated in the operating room, monitored in the PACU. He transferred to the floor in stable condition. 24 hours postoperatively he was taken back to the TSICU for bleeding in the left chest. On [2176-6-20] he was taken back to the operating room for re-exploration with clot removal and placement of 3 chest-tube. He transferred back to the TSICU intubated and was successfully extubated on [2176-6-21]. He was transferred to the floor on [2176-6-23]. Remained stable. Respiratory: His oxygen saturations remained stable. His oxygen was weaned to room air with saturations of 97% with pulmonary toilet and nebulizers. The chest-tubes were removed. The left pleurex catheter was drained on [2176-6-26] for 70cc of serous fluid. Hematology: On [2176-6-19] he was transfused 4 units PRBC for HCT 22->27 (baseline 28-30). On [2176-6-20] his PTT was elevated and he got 2 Units FFP and protamine. His PTT normalized. Hematology was consulted for bleeding. They recommended DDAVP and Platelets for uremia and Aggrenox as an outpatient. In the OR he received 3 units of PRBC and 3 units of cystalloid. His HCT retuned to his baseline of 28-30 with no other bleeding issues following evacuation of the left pleural hematoma. Cardiac: His heart rate remained sinus brady 50-60's. His Labetalol was stopped. The Avapro was restarted at 150 mg when his blood pressure consistently >120. Renal: Chronic kidney disease with a baseline Creatinine of 2.7-3.3. A renal Ultrasound was suggestive of chronic parenchymal disease. Renal was consulted and renal failure was due to hypotension and low urine output. His renal function returned to baseline with volume. The Aranesp 100 mcg qweek will restart as an outpatient. Endocrine: He was maintained on an insulin sliding scale until he started taking POs then restarted on his Pioglitozone. The Actos was restarted when his PO intake improved. The levothyroxine was continued. GI: He tolerated a regular/diabetic diet. He was mildly distended from constipation. He was given stool softners with mineral oil fleet on [6-27] with a good result. Neuro: He continued on his Aricept with no neurological events. The aggrenox was held and can be restared as an outpatient. Dispositon: He was followed by physical therapy who recommended rehab. He continued to make steady progress and was discharged to rehab on [2176-6-27]. He will follow-up with Dr. [Last Name (STitle) ] and Interventional pulmonary as an outpatient. Medications on Admission: Avapro 150 mg daily, Amaryl 8 mg daily Levoxyl 137 mcg daily, Lasix 40 mg daily Labetalol 100 mg [Hospital1 ], Alphagan 0.15%, Folcaps 2.2-25-0.5 daily, Prilosec 40 mg daily, Aggrenox [Hospital1 ], Cosopt2-0.5 eye drops [Hospital1 ], Ferrex 150 mg daily Lipitor 80 mg daily, Lumigan 0.03%', Actos 45 mg daily, Aricept 10 mg daily, Norvasc 5 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 12. Aranesp (Polysorbate) 100 mcg/0.5 mL Syringe Sig: One (1) Injection once a week. 13. Avapro 150 mg Tablet Sig: One (1) Tablet PO once a day: increase to home dose 300mg when blood pressure tolerates. 14. Ferrex 150 150 mg Capsule Sig: One (1) Capsule PO once a day. 15. Folcaps 2.2-25-0.5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Amaryl 2 mg Tablet Sig: One (1) Tablet PO once a day: increase to home dose 4 mg when Blood sugars consistently elevated. 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 18. Polyethylene Glycol 3350 100 % Powder Sig: One (1) scoop PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Liberty Commons Nursing & Rehab Center - [Location (un) 4979] Discharge Diagnosis: Left pleural effusion. Discharge Condition: stable Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 4741] if experience: -Increased shortness of breath, cough or sputum production -Chest pain -Chest tube site cover with a bandaid until healed. Should site drain cover with a clean dressing and change as needed to keep site clean and dry. -Pleurex catheter -Call immediately if drain comes out. Cover site immediately with a clean dressing -[Month (only) 116] shower with water-proof occlusive dressing. -No bathing or swimming Pleurax site keep covered with a clean dressing. Drain every other day: keep log of drainage Do not drain more than 1 liter at a single drainage. Call if have questions or concerns, drainage around tube or if drainage less than 50 cc for 3 consecutive drains. [Telephone/Fax (1) 10651] Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 3020] Date/Time:[2176-7-9] 1:00pm in the [Hospital Ward Name 121] Building Chest Disease Center, [Hospital1 ] I. Follow-up with [First Name8 (NamePattern2) 14163] [Last Name (NamePattern1) 11710] IP for Pleurex catheter drainage Report to the [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiology for a Chest X-Ray 45 minutes before your appointment. Completed by:[2176-7-4]	[ "998.11", "530.81", "584.9", "294.10", "511.9", "285.1", "327.23", "403.90", "244.9", "331.82", "458.29", "250.00", "E878.8", "564.00", "511.89", "585.9", "286.9" ]	icd9cm	[ [ [] ] ]	[ "34.20", "99.04", "38.93", "34.04", "34.06", "99.05", "33.23" ]	icd9pcs	[ [ [] ] ]	8126, 8218	3417, 6151	343, 590	8285, 8294	1742, 3394	9132, 9629	1658, 1723		6566, 8103		8239, 8264		6177, 6543			8318, 9109																																282, 305						618, 974															996, 1490	1506, 1642
1,095	169,237	24053	Discharge summary	report	Admission Date: [2145-5-14] Discharge Date: [2145-6-2] Date of Birth: [2122-8-12] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 38982] Chief Complaint: "worse headache of my life", diplopia, nausea. Major Surgical or Invasive Procedure: suboccipital craniotomy for tumor resection. ventriculostomy placement. lumbar drain placement. History of Present Illness: 22 year-old white male with history of migrane, presented to ED c/o incresed headache for 3 days, nausea, diplopia, diziness, photophobia, and blurred vision. patient trie dhis imitrex and excedrin for headache but didn't helped the headache.patient headache intensity was [11-15] day before to emergency visit, [6-15] while in ED.Head CT revieled 4th ventricle mass and hydrocephalus, no midline shift.Patient admitted to TSICU where ventriculostomy drain placed openin pressure 14-16 with clear CSF for closer management of ICP and posiible surgery. Past Medical History: Migrane Headache 4 rt ventricule mass since age 5, no F/U until now. left knee surgeryx2. Social History: Will be graduating this summer from [University/College 5130] Universiy in accounting major.somekes on weekends. occ ETOH with friends.Denies recreational drug use. Family History: Father has DM Physical Exam: General: temp;97.9 pulse;94 bp; 109/68 RR;18 SaO2; 99 RA. patient lying in bed, NAD. CVS: RRR, S1, S2, no M/G/R. Lungs: CTA A/P bilat. Abd: soft, nontender,bowel sounds are present. Ext: no edema. Neuro:alert, orientedx3, language fluent. PERRL, positive fine nystagmus on horizantal line.CN II-V,VII , VIII-XII intact. CN VI paralysis. Strenght [6-10] in all muscle group.sensation intact T/O to light touch.Positive for vibration T/O. Coordination mild bilateral dysmetria.DTR:2+ T/O, toes downward. Pertinent Results: [2145-5-14] 10:25AM GLUCOSE-82 UREA N-11 CREAT-1.0 SODIUM-134 POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-30* ANION GAP-14 [2145-5-14] 10:25AM GLUCOSE-82 UREA N-11 CREAT-1.0 SODIUM-134 POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-30* ANION GAP-14 [2145-5-14] 10:25AM WBC-4.4 RBC-4.98 HGB-15.4 HCT-43.3 MCV-87 MCH-30.9 MCHC-35.6* RDW-12.5 [2145-5-14] 10:25AM PLT COUNT-144* [2145-5-14] 10:25AM PT-12.8 PTT-29.2 INR(PT)-1.0 [2145-5-14] 10:25AM D-DIMER-185 Brief Hospital Course: 22 year-old white male with history of migrane, presented to ED c/o increased headache for 3 days, nausea, diplopia, dizziness, photophobia, and blurred vision. Head CT revealed TH ventricle mass and hydrocephalus, no midline shift .Patient admitted to TS ICU where ventriculostomy drain placed opening pressure 14-16 with clear CSF for closer management of ICP.MRI showed Large fourth ventricular mass consistent with ependymoma. Patient became intermittently agitated, confuse, and disoriented, attempted to pull his ventriculostomy on his way to Head CT on [2145-5-15]. Patient and family pursued with surgery for the fourth ventricle mass, which preformed on [2145-5-18] resection of the tumor with suboccipital craniotomy.Patient transferred from TSICU to neurosurgery stepdown unit on in the aftenoon of [2145-5-19].Patient neurologically remained stable.All preop symptoms resolved after surgery.Ventricular drain discontinued on [2145-5-22].Lumbar drain placed on [2145-5-26] for CSF leakage from his occipital incision site.Lumbar drain gradually weaned to D/C on [2145-6-2]. Pateint denies any headache, no leakage from the site. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:60 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 4. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): start [6-3] decadron 1mg(1/2tablet) twicwe a day for 3 days.Then decadron 1mg([2-7] tablet) once day for 3 days, then stop . Disp:10 Tablet(s) Refills:0 5. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Disp:20 Tablet(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: fourt ventricule mass Discharge Condition: neurologically stable. Discharge Instructions: Report increaed heaache, visual changes, double vision nausea, vomiting.Report any drainage, redeness, swelling from insicion site. Followup Instructions: Follow up for staples to be removed [2145-6-16] @ 11am in Dr. [Name (NI) 61185] office [Telephone/Fax (1) 2731] (lumbar [Last Name (un) ] to be removed at the same day of cranial staples removal) Follow up in brain tumor clinic: Provider: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Where: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 1844] Date/Time:[2145-6-21] 15:00 Completed by:[2145-6-2]	[ "378.54", "780.6", "331.3", "530.81", "998.89", "225.0" ]	icd9cm	[ [ [] ] ]	[ "03.31", "01.59", "02.2" ]	icd9pcs	[ [ [] ] ]	4498, 4504	2424, 3590	366, 464	4570, 4594	1925, 2401	4774, 5247	1369, 1384		3613, 4475		4525, 4549					4618, 4751									1399, 1906																							280, 328						492, 1053															1075, 1166	1182, 1353
23,669	103,579	21010	Discharge summary	report	Admission Date: [2178-5-15] Discharge Date: [2178-6-1] Service: CSU HISTORY OF PRESENT ILLNESS: This is an 81 year old male transferred from Bronkton for ST segment depression on stress test and drop in his blood pressure. He was transferred to the Medical Service and underwent a cardiac catheterization which showed 30 percent ostial disease, 40 percent proximal left anterior descending coronary artery and an right coronary artery disease. His past medical history is significant for hypertension, coronary artery disease, angina and high cholesterol. PAST SURGICAL HISTORY: Significant for an automatic implantable cardiac defibrillator. MEDICATIONS ON ADMISSION: Aspirin, Flomax, Plavix, Pepcid, Lovenox and Atenolol. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: He was afebrile with stable vital signs. His lungs were clear. His heart was regular. Abdomen was soft, nontender, nondistended. Bowel sounds were present. Extremities were warm and well perfused. LABORATORY DATA: His laboratory studies were all within normal limits. HOSPITAL COURSE: The patient went to the Operating Room on [2178-5-21], for a coronary artery bypass graft times two, please see the operative report for further details. Preoperatively he had a carotid study which showed no disease of his carotids. The patient did well postoperatively and was transferred to the Cardiac Surgery Recovery Unit. He was continued on pressors to maintain his blood pressure, and was kept intubated. He was weaned from the ventilator and extubated by postoperative day #1. His pacemaker was interrogated and because of the low index it was recalibrated to a rate of 80. The patient continued to do well and his chest tubes were kept in. His chest tubes were removed on postoperative day #3, and he continued to do well. His blood pressure was consistently low throughout the Intensive Care Unit course. Chest x-ray was done and there were no effusions. Physical therapy was consulted and it was found that the patient had pretty significant orthostatic hypotension, however, he was asymptomatic from this. He continued to improve and was transferred to the floor. On postoperative day #8, Electrophysiology Service was consulted for management of pacemaker as well as for his hypotension. It was decided the patient will be started on Florinef which he started, his beta blocker was also stopped. All of his cardiac medications were stopped at this time. He continued to improve and continued to do well from a cardiac standpoint. Physical therapy cleared the patient on postoperative day #9, however, he was still having mild orthostatic hypotension, therefore no [5-31], the patient was seen again by physical therapy. His hypotension was greatly improved and he was able to do stairs and it was decided that the patient could be discharged home in a stable condition to continue his Florinef. DISCHARGE INSTRUCTIONS: The patient was discharged on [2178-5-31] in stable condition and instructed to follow up with his primary care physician in one week, his cardiologist in three to four weeks and with Dr. [Last Name (STitle) 70] in four to six weeks. He was instructed to do no heavy lifting. DISCHARGE MEDICATIONS: Home medications except for his beta blocker and Atenolol and he was instructed to continue his Aspirin and he was started on Florinef .1 mg p.o. q.d. The patient was sent home with [Hospital6 407] in order to have his blood pressure checked as well as his wound monitored. CONDITION ON DISCHARGE: Stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Doctor Last Name 11225] MEDQUIST36 D: [2178-5-31] 11:10:02 T: [2178-5-31] 13:56:15 Job#: [Job Number 55831]	[ "411.1", "V45.82", "427.89", "272.0", "401.9", "V45.02", "414.01", "458.0" ]	icd9cm	[ [ [] ] ]	[ "37.21", "99.04", "38.93", "39.61", "96.71", "89.61", "96.04", "38.91", "89.62", "88.56", "36.15", "37.74", "36.11" ]	icd9pcs	[ [ [] ] ]									3274, 3555				696, 790	1106, 2939		2964, 3250								604, 669													813, 1088																	117, 580																	3580, 3853
65,824	118,760	47346	Discharge summary	report	Admission Date: [2132-9-21] Discharge Date: [2132-9-29] Date of Birth: [2049-11-29] Sex: M Service: MEDICINE Allergies: Vicodin / Percocet / Darvocet A500 / Oxycodone / Vancomycin Attending:[First Name3 (LF) 348] Chief Complaint: Fractured right hip (two-part intertrochanteric fracture) Major Surgical or Invasive Procedure: Operative repair of right two-part intertrochanteric hip fracture with dynamic hip screw, with procedure complicated by intraoperative cardiac arrhythmia and post-surgical upper extremity weakness which appears to be resolving History of Present Illness: The patient is a 82 y/o Man with a history CAD (s/p CABG in [2122]), PVD, AAA s/p repair in [2123], ESRD on HD, severe spinal and lumbar stenosis, transferred to medicine after ORIF of a right hip fracture, complicated by intraoperative cardiac arrhythmia and post-surgical upper extremity weakness which appears to be resolving. . Mr. [Known lastname 656] was in in usual state of health until Monday ([9-22]) morning when, while in his motorized wheelchair at home, he attempted to reach for a watch that he had dropped on the ground and fell out of his chair. He denies any loss of consciousness during the fall and was able to get back into the chair. He began to develop worsening pain in his right leg several hours later, and presented to [Hospital3 417] hospital for evaluation where a CT scan demonstrated a right intratrochanteric fracture. He was transferred to the [Hospital1 18] for ORIF that day. . During positioning on the OR table on [9-22] he had NSVT for ~3 beats (no strip available), followed by monomorphic sustained VT with hypotension (SBP of ~40) during preparation of the operation site. He received 1x300 Joule shock with return to sinus rhythym, followed shortly by recurrence of SMVT, was shocked again with 1x300 joules and again returned to sinus rhythm. The operation was aborted and he was transferred to CCU for further management. . In the CCU, post-op electrolytes were drawn and were normal,and he was started on amiodarone. An echocardiogram showed new posterior and inferior wall abnormalities compared to a previous echo ([2131-2-13]), with a LEVF of 40-50%. EKG did not show any evidence of new infarct. He was cleared for surgery the following day when no new arrhythmias developed. . On [9-23] he successfully underwent ORIF but experienced postoperative weakness. Per OMR and patient, his weakness was diffuse in both the upper and lower extremities, but was most prominent in his deltoids bilaterally (1+/5 L deltoid strength, 0/5 R deltoid strength). Neurosurgery was consulted, and noted subjective and objective improvement in muscular strength compared to previous neurological exam, but with persistent diffuse weakness. He was placed in a C-spine collar and received CT C-spine per neurosurgery recommendations which showed substantial narrowing of spinal canal which could represent old stenosis but would be potentially worrisome for acute cord impingement. During this time, patient's neuro exam gradually resolved with improved L arm strength, then R arm strength, ultimately with improvement to what patient states is his baseline. Past Medical History: 1)CAD -s/p 3-vessel CABG in [2122] (LIMA-LAD, SVG-RCA-occluded, SVG-OM1/OM3 occluded) -s/p NSTEMI in [2-3] (DES in L main) 2)ESRD -LUE AVF, HD MWF -Per patient, has congenital left kidney hypoplasia 3)AAA -s/p repair ([2123]) 4)PVD -s/p aortobililiac graft in [2123] -s/p left CEA in [2123] ([2132-5-22] US showed right ICA 70-79% stenosis, left ICA 1-39% stenosis) 5)Ischemic colitis -Admitted [2132-3-9] for bloody diarrhea, uneventful hospital course 6)Spinal stenosis -s/p discectomy and arthrodesis at C5-C6 and C6-C7 [2130-12-4] -Baseline impairment in walking (uses motoroized wheelchair or walker) 7)Right renal tumor, suspicious for RCC, undergoing watchful waiting, followed by Dr. [Last Name (STitle) 3748] 8)Prostate cancer -s/p brachytherapy in [2122] 9)Abdominal wall abscess in [5-5], s/p I&D, cultures grew Actinomyces 10)Cholangitis -s/p CCK in [2130-3-21] 11)Bullous pemphigoid (diagnosed in [7-/2132]) -Dermatologist is Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ] 12)s/p Cataract surgery on left eye Social History: Lives alone at [Location (un) 33866] [Hospital3 400] Residency. He previously worked as a district manager for Metropolitan life. 60 pack-year smoking history, quit 10 years ago. Occasional social alcohol use. Family History: One daughter (53) and son (57), both in good health. One sister with diverticulitis. Physical Exam: VS: T 98.0 HR 82 BP 148/68 RR 18 SaO2 95% on 2 L NC . General: Very pleasant man, appeared stated age in no apparent distress. Lying in bed with C-spine collar. HEENT: Thyromegaly and lymphadenopathy could not be assessed due to C-spine collar. Sclera anicteric, MMM. Chest: Lungs CTAB, no crackles, rhonchi, wheezing. Cardiac: Regular rate and rhythym, nl S1 and S2. Grade III/VI systolic murmur heard best at right sternal border at 2nd intercostal space. Abdomen: Large midline scars from sternotomy and AAA repair visible. Normal bowel sounds/ Back: Not assessed due condition. Ext: No cyanosis, clubbing. 1+ pitting edema in LE bilaterally. Skin: Multiple bruises throughout hands. Several bandages (including on right deltoid and left forearm) covering ruptured blisters from bullous pemphigoid, several other lesions visible. Neuro: Mental status: Alert and oriented x3, 30/30 on mini-mental status. Cranial Nerves: II-XII intact, could not assess SCM (C-spine collar). Left [Doctor First Name 2281] symmetric, likely [12-31] catarac surgery. Mild facial asymmetry (lip droop) which patient states he has had since a child. Sensory: Intact to light touch throughout, and to proprioception. Motor: Normal bulk and tone. Diffuse weakness present throughout, especially in UE extensors and IPs. Delt Bic Tri WrE FinEx IP Quad ham DF PF L 5 4+ 4 4 4 3 4 4 4+ 5 R 4+ 4+ 4 4+ 4 3 4 4 4+ 5 Gait: Not assessed due to clinical condition. Pertinent Results: ADMISSION LABS: =============== [2132-9-21] 09:00PM WBC-14.1* RBC-4.22* HGB-14.0 HCT-44.5# MCV-106# MCH-33.3 MCHC-31.6 RDW-16.7* [2132-9-21] 09:00PM NEUTS-84.1* LYMPHS-9.4* MONOS-3.6 EOS-2.2 BASOS-0.7 [2132-9-21] 09:00PM PLT COUNT-207 [2132-9-21] 09:00PM PT-13.9* PTT-30.2 INR(PT)-1.2* [2132-9-21] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2132-9-21] 09:00PM ALT(SGPT)-28 AST(SGOT)-48* LD(LDH)-337* ALK PHOS-173* TOT BILI-0.3 [2132-9-21] 09:00PM CALCIUM-8.8 PHOSPHATE-10.2# MAGNESIUM-2.4 [2132-9-21] 09:00PM GLUCOSE-128 UREA N-91* CREAT-9.0# SODIUM-137 POTASSIUM-5.0 CHLORIDE-92 TOTAL CO2-24 ANION GAP-26* [2132-9-21] 11:28PM LACTATE-1.0 INR TREND: =========== [2132-9-26] 10:20AM BLOOD PT-73.4* INR(PT)-8.6* [2132-9-26] 07:00AM BLOOD PT-64.5* INR(PT)-7.4* [2132-9-25] 05:38AM BLOOD PT-22.2* PTT-44.8* INR(PT)-2.1* [2132-9-24] 02:51PM BLOOD PT-15.8* PTT-34.3 INR(PT)-1.4* [2132-9-23] 04:29AM BLOOD PT-14.2* PTT-34.6 INR(PT)-1.2* [2132-9-22] 08:30PM BLOOD PT-14.1* PTT-31.6 INR(PT)-1.3* [2132-9-22] 06:55AM BLOOD PT-14.4* PTT-33.3 INR(PT)-1.2* MICRO: ====== [9-22] MRSA screen positive STUDIES: ======== HIP UNILAT MIN 2 VIEWS RIGHT ([2132-9-21]) IMPRESSION: 1. Faint lucency at the right hip suggesting intertrochanteric fracture. 2. Extensive degenerative change. 3. Atherosclerotic disease. The study and the report were reviewed by the staff radiologist. CT head/c-spine ([2132-9-23]): IMPRESSION: No acute fracture. A bone fragment in the posterolateral canal on the right at T2 is likely chronic in etiology, although not unambiguously characterized in this study. 2. Florid degenerative changes predispose this patient to spinal cord trauma with minor injury. Recommend MR for further evaluation. MRI C/spine w/o Contrast ([2132-9-25]): Provisional Findings Impression: BLjb FRI [2132-9-26] 9:37 AM Similar, though slightly progressive multilevel degenerative changes demonstrate ongoing multilevel cord compression with abnormal cord signal within the mid cervical spine as well as moderate-to-severe multilevel bilateral foraminal narrowing. Brief Hospital Course: # Hip fracture - patient intially presented to [Hospital3 417] hospital where a right two-part intratrochanteric fracture was demonstrated by CT on [9-22], and transferred to [Hospital1 18] for ORIF. The surgery was aborted to cardiac arrhytmias discussed below, but completed on [9-23] with placement of a dynamic hip screw. Per orthopedics, the right hip can now bear weight as tolerated. Patient should receive anticoagulation for 4 weeks with a target INR of 1.5-2.0, and followup at the orthopedic in 2 weeks. # Pulseless VT - occurred in OR; likely in the setting of being immediately post-HD and anesthesia induction. As the strip was not preserved, EP felt that a study would not be helpful, as it cannot be verified that any inducible VT during a study was the rhythm that the patient had experienced. The patient was kept on amiodarone during his time in the CCU, but per EP it was felt that continued therapy was not indicated at this time and so this was discontinued while the patient was in the unit. The patient will need evaluation by a cardiologist before any operations in the future. The patient had PVCs but no other signs of ectopic activity or abnormal rhythms during his time in the unit, nor after transfer to the medicine floor. # Neurologic weakness - The patient experienced transient weakness of his upper extremities, including his deltoids bilaterally immediately post-operatively after extubation. On initial exam, the patient had 0-1/5 strength of the deltoids bilaterally. Given his h/o severe cervical stenosis and recent h/o intubation/extubation, Ortho/NSGY were consulted. NSGY recommended CT C-spine and collar placement. The CT c-spine showed known severe spinal foraminal narrowing but no clear evidence of acute injury, with MRI showing no bone edema, no ligamentous damage, but substantial degenerative changes worsened mildly since previous MRI ([2130-12-1]). Over several hours post-operatively the patient had slow but spontaneous improvement of symptoms and returned to his baseline strength (per his report). # CAD - Continued ASA, BB, statin. Patient should not stop ASA for any minor surgeries in the future as he has a DES -> LMCA. # ESRD - Patient received hemodyalsis at [Hospital1 18] on Wednesday and Friday. Hemodynamically stable throughout stay except for mild hypotension post dialysis that responded well to fluids. Held metoprolol prior to HD sessions. Continued on sevelamer and calcium acetate. #Bullous Pemphigoid - followed by Dermatology while here, with regular changing of dressings in blistered areas and application of recommended medications. # Supratherapeutic INR - pt was on coumadin 2 mg daily post-operative per ortho; however, after 2 doses, INR climbed to 8.6. Held coumadin. Gave vitamin K 2 mg po x 1. Followed INR daily for goal 1.5-2. Needs coumadin x 4 weeks. TO DO FOR REHAB: [ ] monitor INR daily (goal is 1.5-2.0 x 4 weeks per orthopedics), please titrate coumadin as needed [ ] physical therapy [ ] occupational therapy [ ] hemodialysis on Mon, Wed, Friday -- HOLD METOPROLOL PRIOR TO HEMODIALYSIS SESSIONS [ ] check CBC and electrolytes daily x 1 week, then three times a week Medications on Admission: Ezetimibe 10 mg daily Celexa 20 mg daily Zocor 80 mg daily Mirtazapine 15 mg po qhs Citalopram 10 mg po daily Simethicone 80 mg po bid Compazine 10 mg po q8h prn Imodium 2 mg po q6h prn ASA 325 mg po daily Minocycline HcL 100 mg po bid Calcium Acetate 667 mg - 2 cap tid Metoprolol 25 mg po bid Omeprazole 20 mg po daily Lactobacillus 1 tab po bid Vitamin B complex with C Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Multivitamin,Tx-Minerals 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. Minocycline 50 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for on open wounds. 10. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 13. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for PAIN. 17. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. 18. Lactobacillus Acidophilus Oral 19. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for diarrhea. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: 1. R hip fracture 2. Ventricular Tachycardia 3. Post operative Weakness Secondary diagnosis: 1. End-Stage Renal Disease 2. Coronary Artery Disease Discharge Condition: Stable. On room air. Tolerating po's. Ambulating with assistance. Afebrile. Discharge Instructions: You were admitted to [Hospital1 18] from [Hospital3 417] Hospital for surgical repair of a right hip fracture. While being prepared for surgery and after anesthesia was induced, you experienced a cardiac arrhythmia. Your heart was shocked which corrected the arrhythmia, the operation was aborted, and you were transferred to the cardiac ICU. You were monitored for and after further studies of your heart by cardiologist you were cleared to go back to the OR. You succsefully underwent surgical repair of your right hip the following day ([9-23]), but when you awoke you experienced weakness, primarily in your upper arms. The weakness resolved spontaneously over the next several hours and returned to your baseline. Please continue your medications as prescribed. The following changes were made: (reconcile compared to home meds) 1. Your compazaine was discontinued 2. Your metoprolol was decreased from 25 mg po BID daily to 12.5 mg po BID 3. Your nephrocap was discontinued 4. We started you on Clobetasol 0.05% cream applied topically 5. We started you on Mupioricin cream 2% applied topically to open wounds 6. We discontinued your daily remeron, and have made it as needed 7. We starte Acetaminophen 1 gm every 8 hours as needed for pain 8. You are being continued on Celexa(Citalopram) 20mg. 9. Please take docusate and senna as prescribed for constipation. Please keep all your medical appointments as below. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever > 101, chest pain, shortness of breath, nausea / vomiting, abdominal pain, bright red blood per rectum, blood in urine, or any other concerning symptoms. Followup Instructions: 1) Deramatology follow-up With: Dr. [Last Name (STitle) ] Time: Thursday, [2132-10-2] at 4 pm Address: [Location (un) ], [Location (un) 55], MA Phone:[Telephone/Fax (1) 100223]; 2) Orthopedics follow-up With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Time: Thursday, [2132-10-9], at 8 am Address: [Location (un) 830], [Hospital Ward Name 23] Building, [Location (un) 551], Orthopedics Ph: [Telephone/Fax (1) 1228] 3) PCP [Last Name (NamePattern4) 702]: Please make an appointment with your primary care doctor, Dr. [Last Name (STitle) 1057] [Name (STitle) ], for continuing outpatient care and monitoring of your blood INR, which should be kept between 1.5-2.0 for 1 month on coumadin. Location: [Hospital1 ] HEALTHCARE - [Hospital1 ] Address: ONE PEARL ST, [Apartment Address(1) 17002], [Hospital1 ],[Numeric Identifier 9647] Phone: [Telephone/Fax (1) 14331] Fax: [Telephone/Fax (1) 86589] Email: [University/College 100224] 4. Neurosurgery follow-up With: Dr. [Last Name (STitle) 548] Time: Friday [2134-10-17]:[Street Address(2) 100225]: [Hospital3 ] Hospital, [Location (un) 830], [Hospital Ward Name 23] Building, [Location (un) 551], Spine Center Phone: [Telephone/Fax (1) 2992] Completed by:[2132-9-29]	[ "E884.2", "997.1", "E878.8", "414.01", "412", "V64.1", "585.6", "753.0", "342.90", "443.9", "V02.54", "724.02", "428.32", "694.5", "V45.11", "729.89", "414.02", "428.0", "820.21", "790.92", "416.8", "458.29", "427.1" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.62", "79.15" ]	icd9pcs	[ [ [] ] ]	13771, 13837	8502, 11708	378, 608	14048, 14126	6269, 6269	15860, 17219	4639, 4725		12131, 13748		13858, 13858		11734, 12108			14150, 15837									4740, 5585																							281, 340						636, 3264	5671, 6250		13971, 14027		6285, 8479	13877, 13950			5600, 5655						3286, 4388	4404, 4623
48,660	184,168	24386	Discharge summary	report	Admission Date: [2130-11-10] Discharge Date: [2130-12-25] Date of Birth: [2078-8-7] Sex: M Service: MEDICINE Allergies: Nafcillin Attending:[First Name3 (LF) 1377] Chief Complaint: multifocal pneumonia Major Surgical or Invasive Procedure: Tracheal intubation and extubation Lumbar puncture EEG monitoring EGD History of Present Illness: 52-year-old man with HCV cirrhosis, on transplant list, was transferred to [Hospital1 18] with obtundation. In the morning of [2130-11-10], patient's wife brought him to [Name (NI) ] Hospital in [State 1727] after patient had been increasingly confused and unresponsive with mostly nonproductive coughs and fever the night before. Was found to have hepatic encephalopathy, hypothermia, hypotension. WBC was reportedly elevated, and Cr 2.9. Was started on moxifloxacin. Was transferred to [Hospital1 18] for further care. On arrival to [Hospital1 18], SBP was in the 80s, HR 110s, O2 sat 87% on NRB. Patient was minimally responsive. WBC 21.8 with 22% bandemia. Cr 2.6. Patient was emergently intubated. Femoral line was placed. Patient was fluid resuscitated for about 5L NS. BP improved rapidly to SBP 120s. No pressor was required. Chest CT showed multifocal pneumonia. Received vancomycin, levoflox, and metronidazole--patient has allergy to PCN. Of note, patient was admitted to [Hospital1 18] in [2130-7-14] with hepatic encephalopathy and MSSA bacteremia, treated with vancomycin, nafcillin (which caused interstitial nephritis) and discharged on cefazolin. Subsequently patient had several episodes of UTI with concurrent hepatic encephalopathy. Past Medical History: Hepatitis C Cirrhosis, awaiting transplant c/b grade 2 esophageal varices Major depression with psychotic features PTSD Psoriasis GERD Social History: Patient is married with three children; has been on disability. Eldest daughter organizing benefit fun run for Hep C awareness, fundraising. Veteran with PTSD; per family, VA has denied that Hep C is the result of transfusion in military, while family believes this was source; VA has declined to pay for transplant costs. Denies current tobacco or alcohol use. Quit smoking 30 years ago. Family History: Brother had MI recently. Mother with esophageal or brain cancer - patient unsure. Physical Exam: ADMISSION EXAM AND VITALS on arrival: Tmax: 36.3 ??????C (97.3 ??????F) Tcurrent: 36.3 ??????C (97.3 ??????F) HR: 121 bpm BP: 93/49(57) {93/49(57) - 122/51(67)} mmHg RR: 20 (20 - 21) insp/min SpO2: 100% Heart rhythm: ST (Sinus Tachycardia) Height: 65 Inch Total In: 5,513 mL IVF: 513 mL Total out: 0 mL 50 mL Urine: 50 mL Balance: 0 mL 5,463 mL Respiratory O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 550 (550 - 550) mL RR (Set): 14 RR (Spontaneous): 0 PEEP: 5 cmH2O FiO2: 100% PIP: 14 cmH2O Plateau: 11 cmH2O SpO2: 100% Ve: 16.9 L/min Physical Examination Gen: middle-aged man intubated, not responsive to verbal commands HEENT: pupils miminally reactive bilaterally Lungs: rhonchi bilaterally Heart: normal rate, reg rhythm, nl S1/S2, no murmur Abd: soft, nondistended, no fluid wave, rare bowel sounds Ext: no edema Pertinent Results: Admission labs: [2130-11-10] 05:21PM GLUCOSE-90 UREA N-91* CREAT-2.6# SODIUM-145 POTASSIUM-4.4 CHLORIDE-118 TOTAL CO2-17* ANION GAP-14 [2130-11-10] 05:30PM LACTATE-2.0 [2130-11-10] 05:21PM ALT(SGPT)-40 AST(SGOT)-117* ALK PHOS-136* TOT BILI-1.9* [2130-11-10] 07:23PM AMMONIA-80* [2130-11-10] 05:21PM LIPASE-19 [2130-11-10] 05:21PM cTropnT-<0.01 [2130-11-10] 05:21PM WBC-21.8# RBC-3.68# HGB-13.4# HCT-37.9# MCV-103* MCH-36.5* MCHC-35.4* RDW-15.5 [2130-11-10] 05:21PM NEUTS-56 BANDS-22* LYMPHS-15* MONOS-3 EOS-0 BASOS-0 ATYPS-2* METAS-2* MYELOS-0 [2130-11-10] 05:21PM PLT SMR-NORMAL PLT COUNT-159 [2130-11-10] 05:21PM PT-22.2* PTT-34.5 INR(PT)-2.1* [2130-11-10] 05:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR [2130-11-10] 05:00PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.022 [2130-11-10] 05:00PM URINE RBC-[5-23]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2130-11-10] 05:00PM URINE HYALINE-0-2 [2130-11-10] 05:00PM URINE MUCOUS-MOD Discharge labs: [2130-12-11] 06:08AM BLOOD WBC-5.1 RBC-2.82* Hgb-9.7* Hct-28.2* MCV-100* MCH-34.5* MCHC-34.6 RDW-16.0* Plt Ct-163 [2130-12-11] 06:08AM BLOOD PT-17.4* PTT-64.7* INR(PT)-1.6* [2130-12-11] 06:08AM BLOOD Plt Ct-163 [2130-12-11] 06:08AM BLOOD Glucose-107* UreaN-12 Creat-0.4* Na-136 K-3.5 Cl-105 HCO3-25 AnGap-10 [2130-12-6] 04:00AM BLOOD ALT-34 AST-62* AlkPhos-141* TotBili-1.1 [2130-12-11] 06:08AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.5* . [2130-12-25]: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 3.6* 3.12* 10.6* 30.2* 97 34.0* 35.1* 18.0* 170 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap 87 19 0.5 136 3.9 103 27 10 . [2130-12-21]: ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos 50* 71* 160 176* 0.6 . Other labs: [2130-11-30] 04:36AM BLOOD Cryoglb-NEGATIVE [2130-11-19] 03:56AM BLOOD Hapto-115 [2130-11-18] 03:58AM BLOOD VitB12-1088* Folate-11.2 [2130-11-29] 04:12PM BLOOD Ammonia-34 [2130-12-8] 06:41AM BLOOD TSH-1.5 [2130-12-8] 06:41AM BLOOD Free T4-1.1 [2130-11-30] 04:36AM BLOOD CRP-1.4 [2130-11-30] 04:36AM BLOOD PEP-NO SPECIFI IgG-1538 IgA-293 IgM-30* IFE-NO MONOCLONAL BANDS [2130-12-3] 10:00PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO [2130-12-4] 02:48PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [2130-12-4] 02:48PM URINE RBC->50 WBC->50 Bacteri-MANY Yeast-MANY Epi-0 [2130-11-28] 01:16PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-95* Polys-0 Lymphs-100 Monos-0; WBC-2 RBC-24* Polys-0 Lymphs-40 Monos-60; TotProt-38 Glucose-66 HSV-PCR negative [2130-11-22] 04:13PM ASCITES WBC-21* RBC-21* Polys-0 Lymphs-48* Monos-40* Mesothe-5* Macroph-7* TotPro-0.5 Glucose-128 Creat-0.4 LD(LDH)-35 TotBili-0.1 Albumin-< 1.0 Cholest-6 Triglyc-74 Labs on discharge: Micro: [2130-11-11] 2:36 am SPUTUM Source: Endotracheal. FINAL REPORT [2130-11-14] GRAM STAIN (Final [2130-11-11]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [2130-11-14]): SPARSE GROWTH OROPHARYNGEAL FLORA. ESCHERICHIA COLI. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S [2130-11-12] 2:57 am BLOOD CULTURE Source: Line-CL. FINAL REPORT [2130-11-17] Blood Culture, Routine (Final [2130-11-17]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [2130-11-14]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2130-11-14] AT 7:50AM. GRAM POSITIVE COCCI IN CLUSTERS. [2130-11-16] 10:35 am SPUTUM Source: Endotracheal. FINAL REPORT [2130-11-19] GRAM STAIN (Final [2130-11-16]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2130-11-19]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. YEAST. SPARSE GROWTH. GRAM NEGATIVE ROD(S). RARE GROWTH. YEAST. RARE GROWTH. 2ND AND 3RD TYPES. [2130-11-23] 9:00 pm BLOOD CULTURE Source: Line-A line. FINAL REPORT [2130-11-29] Blood Culture, Routine (Final [2130-11-29]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [2130-11-25]): REPORTED BY PHONE TO [Initials (NamePattern4) ] [Last Name (NamePattern4) 61746], R.N. ON [2130-11-25] AT 0535. GRAM POSITIVE COCCI IN CLUSTERS. [2130-12-4] 12:55 pm URINE Site: CATHETER Source: Catheter. FINAL REPORT [2130-12-5] URINE CULTURE (Final [2130-12-5]): YEAST. >100,000 ORGANISMS/ML.. All other cultures negative RPR negative Cryptococcus negative C diff negative Rapid respiratory viral tests negative Legionella negative H.Pylory serology - negative. . MRI [12-9]: . There is a nonspecific left subinsular hyperintensity. Ventricles and sulci are prominent but unchanged from [2130-11-28]. Intracranial flow voids are maintained. There is no evidence for mesial temporal sclerosis, cortical dysplasia, or heterotopia. There is no pathologic enhancement. There is unchanged mastoid opacification. IMPRESSION: No lesion to account for patient's seizures. Speech and Swallow results. [2130-12-22]: . SUMMARY: Mr. [Known lastname 61747] [Last Name (Titles) 3780] significant improvement since his previous video swallow, most significantly with improved strength. He continues to have premature spillover and a mild swallow delay resulting in penetration ad intermittent aspiration. However the risk is judged to be no greater with thin liquids than nectar thick liquids based on this study. He can be advanced to thin liquids and regular consistency solids, but needs to avoid straws and take small single sips of thin liquid. Meds whole with purees. He will benefit from continued speech therapy services in rehab s/p d/c to make sure he is tolerating the above diet and following the recommendations. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of 6, wfl with modified independence. RECOMMENDATIONS: 1. Suggest advancing the pt to a PO diet of thin liquids and regular consistency solids. 2. Continue 1:1 supervision. 3. No straws. 4. Small single sips of thin liquid only. 5. Meds whole with puree or in liquid form. 6. Continued speech therapy services as necessary in rehab s/p d/c. . EGD: [2130-12-18]: . Impression: Friability, erythema, congestion and erosion in the antrum compatible with portal gastropathy Grade I varices at the lower third of the esophagus Otherwise normal EGD to third part of the duodenum Recommendations: Increase nadolol to 40 mg if tolerated from hemodynamic standpoint. Protonix 40 mg twice a day. Please check H. Pylori serology and treat if positive. Serial hct; transfuse as needed. Brief Hospital Course: Brief Summary of Course: 52 year-old man with HCV cirrhosis admitted with hypoxemic respiratory failure from multifocal pneumonia. Intubated for 2 weeks. Extubated [11-26]. Convulsive/shaking episodes following extubation. Evaluation of shaking episodes revealed that they were seizures AKA Epilepsia Partialus Continua. Pt was transferred to the Epilepsy Service for LTM and mgmt of his seizures. Pt experienced a number of small both electrographic and clinical seizures. He was started on keppra and increased to clinically therapeutic doses and started on neurotin to avoid liver toxicity and treat his seizures. The combination of Keppra and neurotin has controlled his seizures. Pt was noted to have guiaic positive stool which were followed along with following his hemocrit q12. Heptalogy was consulted for this matter. He received an EGD showing bleeding gastritis and he was treated with an increased dose of Nadolol to 40 mg daily and was transfused 2 Units PRBC's. Pt. HCT was stabilized on the above regimen, he was cotninued on a PPI. HCT at discharge was 30.2. Detailed Hospital Course: 1. Sepsis: Mr [Known lastname 61747] was admitted to the MICU on [11-10] with evidence of multifocal pneumonia, leading to septic shock. He had a prolonged course on the ventilator and had a vasopressor requirement until [11-24], after which he was entirely pressor-independent. He was given vancomycin, levofloxacin, and aztreonam on arrival. Aztreonam was discontinued on [11-15]. On [11-16] meropenem was started with concern for possible occult ESBL organisms, given that his pneumonia was continuing and he grew GNRs from his sputum; this was continued through [11-28]. Levofloxacin was stopped on [11-22]. In terms of microbiology, he grew pan-sensitive E. coli from his sputum on [11-11] and coag-negative staph from a blood culture on [11-12]; and yeast and GNRs from a sputum of [11-16]. He was treated with a 14 day course of vancomycin for the staph bacteremia. He was often agitated and dysynchronous with the ventilator and required sedation during his ventilator course. He was intubated for nearly two weeks. Mr. [Known lastname 61747] had a bout of acute renal failure in the setting of his sepsis. This resolved with treatment of his sepsis. Creatinine peaked at 2.6 and improved to 0.5. He was found to have coagulase negative Staph in one set of blood cultures from a periperhal site on [2130-11-23]. Repeated surveillance cultures from both his port-a-cath and the periphery were negative. However, the decision was made to treat him vancomycin ([Date range (1) 61748]). He was found to have a urinary tract infection, and was treated with ceftriaxone [Date range (1) 61749]. 2. Seizures: On [2130-11-28], two days after extubation, he was noted to have increased shaking of his extremities, more than a baseline "tremor" reported at home. Neurology consult felt that this was more likely to be action myoclonus related to his metabolic disturbances rather than epileptic seizures, and initial, routine EEG was normal. Other extensive neurologic workup, including LP, brain MRI and head CT, was unrevealing. He subsequently had a more prolonged episode of bilateral extremity shaking on [2130-12-4], followed by prolonged unresponsiveness (about 20minutes). Following these episodes he was started on levetiracetam 500mg [Hospital1 ] given concern that they actually represented seizures. Between [2130-12-5] and [2130-12-6], bedside video-EEG telemetry was performed. This [Month/Day/Year 3780] at least 11 episodes of stereotyped clinical and electrographic seizures. On video, these begin with frequent and rhythmic right arm jerking, followed by apparent stiffening and a lifting and tilting toward the left of his head/neck, followed by jerking of the RUE again. Duration was 20-60 secs. Mr. [Known lastname 61747] felt these events as "tightening". During one witnessed seizure, he was able to follow commands and answer questions during the event. Electrographically, they appeared to have onset in the left temporal region and were characterized by high amplitude rapid sharp activity centered there, but also visible more widely bilaterally. Interictally, left temporal epileptiform discharges were seen, sometimes with reflection over the right as well. He was treated with levetiracetam, which was gradually increased to 2000mg [Hospital1 ], and neurontin at 300mg/300mg/600mg. On this regimen, his clinical and electrographic seizures ceased. He became more alert and less encephalopathic. Notably, on other occasions, nurses saw increased RUE shaking when they were manipulating the patient, but those episodes do not appear to have electrographic correlate. It it likely that he has a mild baseline tremor, but rhythmic twitching in the arm is thought to be due to EPC (epilepsy partialis continua). Levetiracetam and neurontin were titrated up to control the EPC (as above). His EPC was under control. 3. Weakness: After extubation, he was noted to have dysphagia and generalized weakness, and reported a possible history of 3 years of wasting and weakness, though this was confounded by his encephalopathy. Examination revealed weakness in all muscle groups, most prominently in his hands, right more than left, arms more than legs, and distally more than proximally. He underwent EMG on [2130-11-30] with "electrophysiologic evidence for a generalized, motor>sensory polyneuropathy with predominantly axonal features, of at least moderate severity and a superimposed mild, chronic, generalized myopathy. Incidental note is also made of a mild ulnar neuropathy on the left." The polyneuropathy and myopathy were thought to be secondary to critical illness. During his hospital course, he appreciably improved, with examination prior to discharge notable for strength as follows (R/L): delts 4+/5-, [Hospital1 ] 5-/5, tri 4+/5, WE 3-/4, FE [2-14]+, IP [3-17], H [4-17], Q [4-17], limited movements of R ankle, flexion of L ankle, able to wiggle toes on L but only a small twitch on the R. He will likely benefit greatly from aggressive physical therapy. Pt was noted to have a bilateral foot drop, left worse than right so bilateral AFO should be worn. 4. Cirrhosis: Regarding his liver disease, the patient was was inactivated from the liver transplant list during his acute infection. His MELD scores were in the teens. His cirrhosis has been complicated by encephalopathy, though after treatment of his pneumonia, he showed few signs of encephalopathy. He continued rifaximin and lactulose for this. His cirrhosis is also complicated by grade II varices for which he received Nadolol for bleeding prophylaxis. He has a small amount of ascites, and underwent a paracentesis to evaluate for SBP on [11-22]. This was negative for SBP. On discharge, MELD score was 0. patient will require close monitoring of lactulose administration and ensurance that no dosese are missed. 5. Anxiety: The patient has a history of anxiety and PTSD. His Quetiapine was held during his hospital stay since it seemed to make him more sedate. 6. Dysphagia: Following extubation, he was noted to have dysphagia that was likely due to prolonged intubation. Video speech and swallow showed some aspiration initially, though this improved and the patient was cleared for regular solids, though nectar-thick liquids. He requires feeding (because of his tremors & myoclonus) as well as close supervision during meals. He should sit up for at least 30minutes after meals. Pt. was re-evaluated by speech and swallow study on [2130-12-22] which showed significant improvement and was advanced to thin liquids, still requiring aspiration precautions. Please see full report in studies above. He will require re-evaluation and treatment w/ speech and swallow therapists. 7. Pancytopenia: The patient was noted to have chronic, stable pancytopenia during his hospital stay that is likely due to his cirrhosis. His stools were guaiac negative and B12/folate were normal. He was not neutropenic. His stools later became guaiac positive and he was re-evaluated by the hepatology team and underwent an EGD. This showed that he had a bleeding gastritis that was most likely the cause of his drift down in hemoglobin. His nadolol was increased to 40 mg daily and he received a transfusion of 2 U PRBC's. On [2130-12-8], pt was noted to have heme postive stool. So his H/H were trended. EGD was performed which showed an active gastritis. He was transfused 2 units PRBCs on [2130-12-19] for a Hct of 23 to 29 post-transfusion. A HIT assay was sent. 8. Wound care: He was noted to have Stage 2 decubitus ulcer on admission. There were no active signs of infection at the site. He received wound care for this. He was also noted to have a R heel blister during his hospital stay & was given heel support for this. 9. Lines: Indwelling Port (PortaCath) - placed at outside hospital because patient is reportedly very difficult to get access on & draw blood from. Communication: with patient and family. Wife's cell [Telephone/Fax (1) 61750]. Pt's PCP in [Name9 (PRE) 1727] is Dr. [First Name4 (NamePattern1) 803] [Last Name (NamePattern1) 38758] #[Telephone/Fax (1) 61751]. Code status: Full code Medications on Admission: Rifaximin 200 mg PO TID Propranolol 10 mg PO TID Omeprazole 20 mg PO DAILY Calcium Carbonate 500 mg PO TID prn Zinc Oxide-Cod Liver Oil 40 % Ointment One (1) Appl Topical PRN (as needed) as needed for groin rash Lactulose Metoclopramide 5 mg PO HS prn Quetiapine 400 mg PO once a day Doxepin 25 mg PO HS Clotrimazole 10 mg Troche QID prn Spironolactone 50 mg PO DAILY Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup [Telephone/Fax (1) ]: Sixty (60) ML PO TID (3 times a day): titrate to [2-14] bowel movements a day . 2. Rifaximin 200 mg Tablet [Month/Day (3) ]: Two (2) Tablet PO TID (3 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day (3) ]: 5000 (5000) units Injection TID (3 times a day). 4. Miconazole Nitrate 2 % Powder [Month/Day (3) ]: One (1) Appl Topical QID (4 times a day) as needed. 5. Insulin Lispro 100 unit/mL Solution [Month/Day (3) ]: asdir Subcutaneous ASDIR (AS DIRECTED): 0-70mg/dL 4 oz. Juice 71-150mg/dL 0Units 151-200mg/dL 2Units 201-250mg/dL 4Units 251-300mg/dL 6Units 301-350mg/dL 8Units 351-400mg/dL 10Units > 400mg/dL Notify M.D. 6. Gabapentin 300 mg Capsule [Month/Day (3) ]: Two (2) Capsule PO TID (3 times a day). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 8. Levetiracetam 500 mg Tablet [Last Name (STitle) ]: Four (4) Tablet PO BID (2 times a day). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 10. Nadolol 20 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily): Hold for SBP < 85, page MD if holding. 11. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: 5000 (5000) units Injection TID (3 times a day). 12. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical QID (4 times a day) as needed. 13. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed: Do not exceed > 2g per 24hrs. 14. Insulin Lispro 100 unit/mL Solution [Last Name (STitle) ]: see sliding scale Subcutaneous ASDIR (AS DIRECTED). 15. Sucralfate 1 gram Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 16. Oxycodone 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for joint pain. 17. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 18. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 19. 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. 20. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [Last Name (STitle) ]: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 21. Calcium 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID PRN. Discharge Disposition: Extended Care Facility: river ridge Discharge Diagnosis: Primary: Multifocal pneumonia with septic shock Coagulase negative Staph bacteremia Urinary tract infection Acute renal failure Seizures Right arm myoclonus Critical illness polyneuropathy Critical illness myopathy Left ulnar neuropathy Stage 2 decubitus ulcer Secondary: Cirrhosis Pancytopenia Discharge Condition: Improved: Still with mild cough, but no longer febrile. Mental status is improved significantly, with better alertness and attention. Still slightly prolonged response latency, but otherwise oriented, able to say [Doctor Last Name 1841]/DOWeek backwards. Minimal bifacial weakness. Mild tremor of right arm, with movement more than at rest. Strength as follows (R/L): delts 4+/5-, [Hospital1 ] 5-/5, tri 4+/5, WE 3-/4, FE [2-14]+, IP [3-17], H [4-17], Q [4-17], limited movements of R ankle, flexion of L ankle, able to wiggle toes on L but only a small twitch on the R. No seizures. Does have signs of encephalopathy on exam with trace asterexis vs. tremor, but significantly improved. Discharge Instructions: You were admitted with severe pneumonia, requiring the treatment of a breathing machine for about two weeks. You were found to have seizures during your hospital stay as well. You have been treated for both problems. [Name (NI) ] will need to remain on these medications until otherwise instructed. You cannot drive for at least six months after a seizure per [State 350] regulations. Take all medications as prescribed. You will need to follow up with your PCP, [Name10 (NameIs) ] epilepsy doctor, liver doctor, and the neuromuscular doctors (with EMG). Call your doctor with any recurrent seizures, loss of consciousness, change in alertness, worsening cough, chest pain, fevers, chills, or any other concerning symptoms. Followup Instructions: On discharge from rehab, call your PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ] [Telephone/Fax (1) 61751]. Follow up with neurology for your seizures: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7025], MD Phone:[Telephone/Fax (1) 5285] Date/Time:[2131-1-8] 4:00 Follow up with neurology for your weakness: DRS. [Last Name (STitle) ] AND [Name5 (PTitle) ] Phone:[Telephone/Fax (1) 2846] Date/Time:[2131-2-8] 9:00 EMG LABORATORY Phone:[Telephone/Fax (1) 2846] Date/Time:[2131-2-8] 1:00 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] Completed by:[2130-12-25]	[ "309.81", "535.51", "584.9", "599.0", "995.92", "038.8", "345.70", "707.22", "276.0", "696.1", "787.91", "070.44", "486", "785.52", "530.81", "284.1", "789.59", "571.5", "518.81", "707.03" ]	icd9cm	[ [ [] ] ]	[ "45.13", "99.04", "96.04", "03.31", "96.72", "38.93", "54.91", "99.07" ]	icd9pcs	[ [ [] ] ]	24141, 24179	11573, 12667	292, 364	24519, 25233	3255, 3255	26021, 26754	2264, 2347		21389, 24118		24200, 24498		20996, 21366	12685, 20300		25257, 25998				4376, 5153					2362, 3236																							232, 254				6215, 11550	20312, 20970	392, 1682					3271, 4360										1704, 1841	1857, 2248				5165, 6195
50,445	151,528	897	Discharge summary	report	Admission Date: [2176-12-16] Discharge Date: [2177-1-5] Date of Birth: [2102-3-3] Sex: F Service: SURGERY Allergies: Zosyn / Penicillins / Dilantin Attending:[First Name3 (LF) 6088] Chief Complaint: AAA Major Surgical or Invasive Procedure: [2176-12-16] 1. Bilateral common femoral artery cutdown. 2. Right common iliac artery and external iliac artery stent grafts with angioplasty. 3. Abdominal aortogram. 4. Aorta right uniiliac endograft. 5. Right iliofemoral bypass with Dacron. 6. Right to left femoral-to-femoral bypass graft with polytetrafluoroethylene (PTFE). 7. Coil embolization of the right hypogastric artery. 8. Coil embolization of the left common iliac artery. History of Present Illness: 74F with a known 5.3x7.2cm AAA presented to her PCP for [Name Initial (PRE) ] non contrast CT screening test secondary to recent weight loss which revealed enlargement of the aneuysm. She was referred to Dr. [Last Name (STitle) ] for further evaluation and contrast enhanced CT revealed a 6.6x9.0cm aneurysm. Given the findings of enlargement, COPD and irregular shape she was at a high risk for rupture. Also secondary to her comorbidities she was not an open repair candidate. She was then evaluate for endovascular repair for which her imaging was sent for three-dimensional reconstruction and a suitable endovascular option was found. She agreed to the procedure given the risks of renal failure requiring dialysis, respiratory failure, and death. Past Medical History: - Coronary artery disease - negative MIBI in [8-8]. s/p MI in [2167] and has ?BMS stent placed - Diastolic heart failure - Hypertension - Hyperlipidemia - Diabetes Mellitius, complicated by neuropathy and nephropathy (last Cr is 1.66 in [1-10]) - COPD - CKD stage III - Thrombocytopenia - Abdominal aortic aneurysm--6.2cm by CT - Renal artery stenosis - Anemia - B12 deficiency - Depression - Gout Social History: Patient lives with her son [Name (NI) ] in [Name (NI) 1468]. She currently does not have any VNA services. She has a cane but does not consistently use it. Tobacco: quit 8 years ago, previously smoked 1 ppd x 50 years. ETOH: none Family History: Brother with [Name2 (NI) 499] cancer. Father with DM, h/o CVA. Mother with Parkinsons. Son with asthma and DM type II. Physical Exam: On admission: T 98.5 P 58 BP 129/56 RR 18 O2 96%RA Gen - alert and oriented, no acute distress CV - RRR Pulm - clear to ascultation bilaterally Abd - Soft, obese, nontender, nondistended, no rebound/guarding Ext - Palpable pulses bilaterally, no edema, warm Pertinent Results: [2176-12-16] 10:48PM TYPE-ART PO2-198* PCO2-33* PH-7.39 TOTAL CO2-21 BASE XS--3 [2176-12-16] 09:11PM GLUCOSE-159* UREA N-41* CREAT-1.7* SODIUM-143 POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-20* ANION GAP-20 [2176-12-16] 09:11PM CK-MB-2 cTropnT-<0.01 [2176-12-16] 09:11PM WBC-5.2 RBC-3.24* HGB-10.0# HCT-28.0# MCV-86# MCH-31.0 MCHC-35.9* RDW-18.4* [2176-12-16] 07:11PM CK-MB-1 cTropnT-<0.01 [2176-12-16] 07:11PM CK(CPK)-58 [2176-12-17] 01:53AM BLOOD Fibrino-169# [2177-1-5] 04:36PM BLOOD Glucose-204* UreaN-82* Creat-1.7* Na-137 K-4.8 Cl-111* HCO3-15* AnGap-16 [2177-1-5] 11:50AM BLOOD Glucose-150* UreaN-96* Creat-1.8* Na-138 K-4.6 Cl-110* HCO3-21* AnGap-12 [2177-1-5] 03:52AM BLOOD Glucose-89 UreaN-114* Creat-1.9* Na-147* K-4.9 Cl-116* HCO3-22 AnGap-14 [2177-1-5] 01:15AM BLOOD Glucose-73 UreaN-123* Creat-2.1* Na-145 K-4.6 Cl-116* HCO3-22 AnGap-12 [2177-1-4] 09:31PM BLOOD Glucose-111* UreaN-124* Creat-2.1* Na-144 K-5.0 Cl-116* HCO3-23 AnGap-10 [2177-1-4] 02:06AM BLOOD Glucose-83 UreaN-131* Creat-2.2* Na-142 K-4.6 Cl-112* HCO3-24 AnGap-11 [2177-1-3] 05:19AM BLOOD Glucose-113* UreaN-133* Creat-2.3* Na-140 K-4.6 Cl-109* HCO3-26 AnGap-10 [2177-1-2] 05:31AM BLOOD Glucose-106* UreaN-133* Creat-2.5* Na-139 K-4.6 Cl-110* HCO3-25 AnGap-9 [2177-1-1] 05:28AM BLOOD Glucose-121* UreaN-133* Creat-2.7* Na-140 K-5.0 Cl-110* HCO3-25 AnGap-10 [2176-12-17] 01:53AM BLOOD Glucose-160* UreaN-42* Creat-1.7* Na-144 K-3.7 Cl-108 HCO3-23 AnGap-17 [2176-12-16] 09:11PM BLOOD Glucose-159* UreaN-41* Creat-1.7* Na-143 K-4.8 Cl-108 HCO3-20* AnGap-20 [2176-12-16] 07:11PM BLOOD Glucose-167* UreaN-41* Creat-1.7* Na-143 K-5.0 Cl-110* HCO3-19* AnGap-19 [2177-1-5] 04:36PM BLOOD ALT-48* AST-109* LD(LDH)-507* CK(CPK)-149 AlkPhos-89 Amylase-36 TotBili-3.3* [2177-1-4] 09:31PM BLOOD ALT-19 AST-44* LD(LDH)-294* AlkPhos-72 Amylase-43 TotBili-1.6* [2177-1-4] 02:06AM BLOOD CK(CPK)-28* [2176-12-17] 01:53AM BLOOD ALT-15 AST-42* LD(LDH)-300* CK(CPK)-265* AlkPhos-44 Amylase-26 TotBili-3.5* [2176-12-16] 07:11PM BLOOD CK-MB-1 cTropnT-<0.01 [2176-12-18] 08:40AM BLOOD CK-MB-13* MB Indx-4.0 cTropnT-0.28* [2176-12-18] 03:40PM BLOOD CK-MB-10 MB Indx-4.2 cTropnT-0.32* [2176-12-30] 03:44AM BLOOD calTIBC-143* Ferritn-838* TRF-110* [2177-1-4] 10:20PM BLOOD Ammonia-379* [2177-1-4] 02:06AM BLOOD TSH-5.7* [2177-1-4] 02:06AM BLOOD T4-4.1* [2177-1-5] 06:13PM BLOOD Glucose-197* Lactate-7.9* [2177-1-5] 04:54PM BLOOD Glucose-181* Lactate-7.6* K-4.7 [2177-1-5] 04:02PM BLOOD Lactate-7.0* [2177-1-5] 01:54PM BLOOD Glucose-184* Lactate-5.3* K-4.7 [2176-12-20] 04:56PM BLOOD SEROTONIN RELEASE ASSAY- negative [2176-12-17] 01:17PM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative Brief Hospital Course: Patient was admitted on [2176-12-16] for repair of AAA. She underwent an endovascular repair with no intraoperative complications. She also had an inguinal hernia found at the time of her operation which ACS was consulted intraoperatively and stated she could undergo elective repair. Postoperatively she remained intubated and required neosynephrine to maintain her blood pressure. As her pressor requirement increased her postoperative labs revealed a Hct of 19 for which she received 3 units of PRBCs, 2 units of FFP and 2 units of cyro. With resuscitation she was able to be weaned off of vasopressors, made NPO, remained intubated and was transferred to the CVICU. POD 0 - Cordis was placed for further hemodynamic monitoring, 1 unit PRBC transfused POD 1 - Remained intubated, started on nitro gtt for blood pressure control POD 2 - Found to have increased troponin from 0.16 to 0.28, cardiology consulted who believed she underwent a NSTEMI and recommended ECHO, aggressive beta blockade and holding [Date Range ] initially considering her platelet count of < 75K. She was also started on hydralazine in addition to Metoprolol 10mg IV Q6 hours for blood pressure control. HITT panel sent for thrombocytopenia. Given lasix with no response. Passed SBT. POD 3 - Was extubated after meeting requirements. Swan removed. POD 4 - Started on oral intake, lopressor changed to 37.5mg [Hospital1 ] PO and started on Ciprofloxacin for GNR growing from sputum. POD 5 - Transferred to VICU from CVICU, cordis changed to triple lumen CVL, Metoprolol increased to 50mg [Hospital1 ], had minimal response to 20mg IV times 2 of lasix. Cr 2.7, given 5% albumin for decreased UOP. POD 6 - Aline and JP removed. Metoprolol 75mg [Hospital1 ]. POD 7 - Started on Levaquin for STENOTROPHOMONAS in sputum. NGT placed for vomiting. placed on MIVF. POD 8 - Started on Toprol 150mg daily, methylnaltrexone given, PT consult obtained and was able to get patient from out of bed to chair. POD 9 - NGT removed. POD 10 - Continued to have abdominal distention. Given one dose of methylnaltrexone. Cr decreased to 2.3. Started prn diuresis based on UOP. POD 11 - Abdomen found to be distended, had episode of emesis, NGT placed. Reglan started. POD 12 - Started on Day 1 TPN, continued to have nausea and emesis in AM. POD 13 - Made NPO and started on Day 1 TPN. Had one episode of emesis. KUB revealed air fluid levels. POD 14 - Fentanyl patch started, received two 500cc boluses for decreased UOP. Was evaluated by renal service who believed to ARF to be caused by hypovolemia. Levaquin stopped after 8 day course. Started on 100cc/hr of MIVF and changed to H2 blocker. POD 15 - CT scan obtained for persistent abdominal distention which revealed a possible early SBO versus ileus. Continued to have no abdominal pain. PICC placed. POD 16 - Had two bowel movements after suppository stimulation. TPN continued. POD 17 - Continued TPN, NGT remained, no bowel function. POD 18 - Patient became lethargic and minimally arousable. Fentanyl patch was removed. Overnight patient became more difficult to arouse and would not respond to deep sternal rub. A stat head CT was performed revealing no evidence of acute stroke. Narcan times two was administered to rule out narcotic overdose with no response. ABG was within normal limits, electrolytes and cbc were also within normal limits. An emergent neurology consult was obtained who recommended no further acute interventions. Reglan, famotidine and fentanyl patch were all discontinued. Began having epistaxis after narcan with elevated SBP in the 180. Lopressor, hydralazine and dilaudid were given with a decrease in SBP. POD 19 - NGT changed to Left nare. Began having epistaxis in the setting of hypertension with SBP in the 180s which was not response to hydralazine. Patient had nasal packing placed and ENT evaluated the patient who recommended continuation of the packing and Clindamycin while the packing was in place. Later in the evening it was noted that the patient began having jerking motions consistent with seizure activity. Patient was emergently transferred to the ICU and intubated and sedated on a midazolam drip. Neurology was called who believed this to be seizures and recommended continuation of the midazolam drip and correction of uremia given the possibility that this was encephalopathy secondary to uremia. She continued to have seizures and was then changed to dilantin however became bradycardic and the dilantin was stopped and Keppra started. The family was informed of these events and decided to make the patient DNR (able to continue vasopressor but no compressions.) She was also started on CVVHD to correct her uremia. A stat head CT revealed no acute intracranial processes. POD 20 - Placed on EEG monitoring. Patient continued to have seizures and was then changed to Propofol, Versed and Phenobarbital. She required the initiation of Dopamine and levophed to maintain her SBP. With the continued seizure activity refractory to medical therapy the family was called who decided to make the patient CMO. The family understood that with this action this would result in her death. The patient was made CMO at 19:04 and expired at 20:40 on [2177-1-5]. The family was at the bedside at the time of death. Medications on Admission: Toprol 100', LISINOPRIL 40', ISOSORBIDE MONONITRATE 30', Lasix 40", LANTUS 38u qHS, Protonix 40', GABAPENTIN 300 qHS, ALLOPURINOL 50' [Last Name (LF) 6089], [First Name3 (LF) ] 81, COLCHICINE 0.6', COMBIVENT 18 mcg-103 mcg (90 mcg)/Actuation 1-2 puffs", VB12 1,000 prn, EPOGEN 10,000 every other wk prn HCT <30, Calcium Carbonate-Vitamin D3 600 mg (1,500 mg)-200 unit', ENDOCET 5-325 [2-4] qHS prn, FERROUS GLUCONATE 325 [Month/Day (2) 6089], LORAZEPAM 1 qHS, MAGNESIUM GLUCONATE 12.5', NEURONTIN 100 qAM, KCL 20 mEq [Month/Day (2) 6089], SIMVASTATIN 10', VENTOLIN 90 mcg 1-2 puffs prn, NTG 0.4 prn, colace, senna Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Abdominal Aortic Aneurysm status post repair Cardiopulmonary arrest Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None	[ "V45.82", "998.11", "780.01", "583.81", "440.8", "496", "287.5", "440.20", "550.90", "349.82", "780.39", "276.52", "403.90", "585.3", "441.02", "278.00", "274.9", "E878.2", "357.2", "486", "414.01", "784.7", "V15.82", "997.1", "412", "428.32", "250.60", "440.1", "560.1", "410.71", "285.1", "272.4", "584.5", "250.40", "285.21", "V49.86", "997.49", "428.0" ]	icd9cm	[ [ [] ] ]	[ "39.79", "39.95", "39.71", "39.25", "99.15", "21.21", "39.29", "33.24", "96.71" ]	icd9pcs	[ [ [] ] ]	11500, 11509	5475, 10787	293, 743	11620, 11629	2662, 5452	11682, 11689	2242, 2367		11471, 11477		11530, 11599		10813, 11448			11653, 11659									2382, 2382																							250, 255						771, 1532								2397, 2643							1554, 1966	1982, 2226
27,545	103,561	23051	Discharge summary	report	Admission Date: [2128-9-14] Discharge Date: [2128-9-21] Date of Birth: [2070-5-11] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2597] Chief Complaint: PAD Major Surgical or Invasive Procedure: Aortobifemoral bypass with a 14 x 7 Dacron graft, right profundoplasty and lysis of adhesions History of Present Illness: This 58-year-old lady has severe peripheral vascular disease. She has previously had a left femoral- popliteal bypass that was made by me. She has also had bilateral iliac angioplasty and stenting. She has continued to smoke and developed re-stenosis in her iliac arteries. She was studied a couple of weeks ago and found to have extremely narrowed and diseased iliac vessels on the left and occluded external iliac artery on the right and a slightly aneurysmal severely diseased infrarenal aorta. Because of this combination of problems we decided to do an aortobifemoral graft. She also has bilateral significant renal artery stenosis Past Medical History: PMH: Hypertension, Hyperlipidemia, Borderline Diabetes (diet controlled), PVD, CAD, s/p MI in [2107], Prior CVA ([2124] or [2125]) -occasional residual memory issues PSH: Bilateral common iliac artery stenting, [2126-3-1] Left fem-[Doctor Last Name ] bypass, [2112]: Coronary stenting at the [Hospital3 2358], Cholecystectomy, Hysterectomy, Tonsillectomy Social History: smoker drinker Family History: n/c Physical Exam: a/o x3 nad crackles at bases rrr abd benign inc c/d/i RLE dop pt [Name (NI) ] palp dp/pt Pertinent Results: [2128-9-21] 05:21AM BLOOD WBC-9.3 RBC-3.37* Hgb-10.7* Hct-31.2* MCV-93 MCH-31.7 MCHC-34.2 RDW-14.0 Plt Ct-184 [2128-9-20] 02:19AM BLOOD PT-12.4 PTT-26.3 INR(PT)-1.1 [2128-9-21] 05:21AM BLOOD Glucose-92 UreaN-19 Creat-1.1 Na-133 K-3.4 Cl-100 HCO3-29 AnGap-7* [2128-9-21] 05:21AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.2 [2128-9-17] 5:46 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [2128-9-17]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH OROPHARYNGEAL FLORA. CHEST (PORTABLE AP) INDICATION: Status post line change. A single AP view of the chest is obtained, AP upright portable at 13:40 hours, and is compared with the prior study of [2128-9-16]. Patient has had placement of a right-sided IJ line with its tip projecting over the right atrium on the current examination. Small bilateral effusions are present, more marked on the left side with bibasilar atelectasis. IMPRESSION: Bilateral pleural effusions, more marked on the left side. Bibasilar atelectasis, more marked on the left side. Right IJ line with tip likely in the right atrium. [Hospital1 18] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.2 cm Left Ventricle - Fractional Shortening: 0.42 >= 0.29 Aorta - Ascending: 3.5 cm <= 3.4 cm Findings 58 years old female for infrarenal AAA. Has H/O MI and CHF in the past. Depressed LV systolic function with an EF 40-45%. There is apical hypokinesia and Basal portion of lateral wall akinesia. Cardiac output before the clamp with continuity equation is 3-3.5l/min. Prolong MPI 0.6. Vp before the clamp 48cm/sec. After the clamp it decreased to 20cm/sec and after the clamp came off it stayed 40cm/sec. E/E' ratio [9-24]. No valvular abnormalities. LEFT ATRIUM: Normal LA size. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mildly depressed LVEF. Transmitral Doppler E>A and TDI E/e' <8 suggesting normal diastolic function, and normal LV filling pressure (PCWP<12mmHg). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Mildly dilated descending aorta. Focal calcifications in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Conclusions The left atrium is normal in size. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). The calculated myocardial performance index was 0.65 (MPI . 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. There are simple atheroma in the ascending aorta. The descending thoracic aorta is mildly dilated. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. Brief Hospital Course: Mrs. [Known lastname 44356],[Known firstname ] was admitted on [2128-9-14] with severe b/l claudication. She agreed to have an elective surgery. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a Aortobifemoral bypass with a 14 x 7 Dacron graft, right profundoplasty and lysis of adhesions.. . She was prepped, and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the PACU for further stabilization and monitoring. She was then transferred to the VICU for further recovery. While in the VICU she recieved monitered care. When stable she was delined. Her diet was advanced. A PT consult was obtained. When she was stabalized from the acute setting of post operative care, she was transfered to floor status In the VICU she was SOB / Inhalers were started. Pt worked with PT. On DC her 02 SATS were back to baseline. On the floor, she remained hemodynamically stable with his pain controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. She was discharged homw with VNA services Medications on Admission: [Last Name (un) 1724]: lopressor 50 ", Plavix 75, asa 81, simvastatin 80, MVI, Lisiopril 20, Hctz 25, Nitroquick 0.4 Discharge Medications: 1. Medications lopressor 50 ", Plavix 75, asa 81, simvastatin 80, MVI, Lisiopril 20, Hctz 25, Nitroquick 0.4 2. Aspirin Sig: One (1) PO once a day. 3. Simvastatin Sig: One (1) PO once a day. 4. Lisinopril Sig: One (1) PO once a day. 5. Hydrochlorothiazide Sig: One (1) PO once a day. 6. Oxycodone Sig: [12-16] PO every six (6) hours as needed: prn. Disp:20 * Refills:0 7. Metoprolol Sig: One (1) PO three times a day. 8. multivitiamin Sig: One (1) once a day. 9. nitro quick Sig: One (1) three times a day: prn / if you experience chest pain please call your PCP or come to the Er immediatly. Discharge Disposition: Home with Service Discharge Diagnosis: Aortoiliac occlusive disease. Hypertension, Hyperlipidemia, Borderline Diabetes (diet controlled), PVD, CAD, s/p MI in [2107], Prior CVA ([2124] or [2125]) -occasional residual memory issues Discharge Condition: Good Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [1-17] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Call Dr [Last Name (STitle) ] office at [Telephone/Fax (1) 3121], schedule an appointment for one week Completed by:[2128-9-21]	[ "414.01", "412", "440.1", "272.4", "401.9", "440.21", "V45.82", "568.0", "V12.59", "444.0" ]	icd9cm	[ [ [] ] ]	[ "39.25", "54.59", "39.79" ]	icd9pcs	[ [ [] ] ]	7561, 7580	5335, 6747	318, 414	7828, 7835	1669, 2235	10679, 10821	1536, 1541		6918, 7538		7601, 7807		6773, 6895			7859, 10246	10272, 10656								1556, 1650										2270, 5312													275, 280						442, 1081															1103, 1488	1504, 1520
50,391	156,670	54426	Discharge summary	report	Admission Date: [2187-3-28] Discharge Date: [2187-4-10] Date of Birth: [2104-12-31] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 603] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right internal jugular line placement Debridement of sacral ulcer History of Present Illness: Mrs.[Known lastname ] is a 82 year old female with a PMHx significant for Alzheimer's dementia, diabetes mellitus type 2, hypertension, and multiple admissions for ascending cholangitis who was transferred from OSH for hypotension. The patient received bactrim for a UTI at her [Known lastname ]. On the day of admission, she had a fever with altered mental status. She was taken to an OSH and received levaquin. She was found to have a systolic BP in 70s, fluid responsive. CT head was negative. Of note, the patient has had several admissions over the last 3-4 months for ascending cholangitis s/p [Known lastname ] with sphincterotomy and CBD stent in [11-20], treated with 14 day course of Zosyn-->CTX, s/p percutaneous cholecystostomy on [2187-1-15], and repeat [Date Range ] wtih stent removal and sludge/stone extraction and double pigtail CBD stent placement on [2187-2-22], treated with 10 day course of CTX-->cefpodoxime and flagyl for C. Diff. Patient was planned to have a cholecystectomy this week. On the last admission, palliative care was consulted. She was made DNR/DNI and transitioned to hospice care. In the ED, VS were: T103, HR 106, 78/40, 16, 98% on 2L. Patient was lethargic, oriented to self only. She received CTX and also had a CT abdomen that showed possible cholangitis. Pt has had known chronic acalculous cholecystitis, s/p perc drainage. Surgery evaluated the patient and did not feel the gallbladder was the source of the sepsis. She also received Zosyn. She was also found to have a DVT and was started on heparin gtt. She was hypotensive to BP 70/41. A RIJ was placed. Currently, VS are BP 113/50 on levophed 0.06, HR 102, RR25, 100% on 2L. Pt received a total of 5L of NS. UOP of 750cc. Discussion between ED and family was that pt will be FULL CODE for now until further discussion. Past Medical History: Osteochondroma of L knee as a child Mitral Valve Prolapse Type II Diabetes Hypertension Alzheimer's disease Right ORIF of hip fracture at age 75 Sacral decubitous ulcer and bilateral heel deep tissue wounds History of C. difficile infection Social History: Not currently smoking, alcohol or illicit drug use. Lives in a nursing home. Full care for all of her activities of daily living. Daughter [Name (NI) 111407], ph: [Telephone/Fax (1) 111408]. Family History: Daughter with arthritis, father died of hepatitis C from a blood transfusion. Mother died at age 86 of a myocardial infarction. Son with hypertension. Physical Exam: Physical Examination GEN: NAD HEENT: PERRL, oral mucosa dry NECK: Right IJ central line, nontender, no erythema PULM: Clear anteriorly CARD: RR, nl S1, nl S2 ABD: Soft, NT, ND EXT: no C/C/E NEURO: Not oriented Pertinent Results: Admission Labs: [2187-3-27] 08:45PM BLOOD WBC-7.9 RBC-3.87* Hgb-10.5* Hct-34.3* MCV-89 MCH-27.2 MCHC-30.7* RDW-17.2* Plt Ct-291 [2187-3-27] 08:45PM BLOOD Neuts-91.2* Lymphs-4.4* Monos-3.2 Eos-1.0 Baso-0.3 [2187-3-27] 08:45PM BLOOD PT-15.0* PTT-27.1 INR(PT)-1.3* [2187-3-27] 08:45PM BLOOD Glucose-160* UreaN-11 Creat-1.0 Na-142 K-4.9 Cl-112* HCO3-22 [2187-3-27] 08:45PM BLOOD ALT-6 AST-14 CK(CPK)-77 AlkPhos-88 TotBili-0.4 [2187-3-27] 08:45PM BLOOD Lipase-18 [2187-3-27] 08:45PM BLOOD cTropnT-0.07* [2187-3-27] 08:45PM BLOOD Albumin-2.2* Calcium-7.7* Phos-2.5* Mg-1.6 [2187-3-27] 08:45PM BLOOD Cortsol-21.5* [2187-3-27] 08:45PM BLOOD CRP-66.8* [2187-3-27] 08:41PM BLOOD Lactate-1.6 [2187-3-27] 08:45PM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.010 [2187-3-27] 08:45PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD [2187-3-27] 08:45PM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE Epi-<1 Interim/Discharge Labs [2187-4-10] 06:10AM BLOOD WBC-5.6 RBC-3.46* Hgb-9.6* Hct-30.2* MCV-87 MCH-27.7 MCHC-31.8 RDW-18.0* Plt Ct-489* [2187-4-10] 06:10AM BLOOD PT-25.3* PTT-33.8 INR(PT)-2.5* [2187-4-9] 06:05AM BLOOD PT-25.9* PTT-33.4 INR(PT)-2.6* [2187-4-8] 06:45AM BLOOD PT-21.1* PTT-33.1 INR(PT)-2.0* [2187-4-10] 06:10AM BLOOD Glucose-61* UreaN-7 Creat-0.7 Na-144 K-4.0 Cl-114* HCO3-24 AnGap-10 [2187-4-9] 06:05AM BLOOD Glucose-93 UreaN-6 Creat-0.6 Na-143 K-3.8 Cl-115* HCO3-22 AnGap-10 [2187-3-30] 03:18AM BLOOD ALT-8 AST-18 LD(LDH)-223 AlkPhos-98 TotBili-0.3 [2187-4-10] 06:10AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.3 Microbiology: [2187-3-27] 8:35 pm BLOOD CULTURE #1. FINAL REPORT [2187-4-2] Blood Culture, Routine (Final [2187-4-2]): NO GROWTH. [2187-3-27] 8:45 pm BLOOD CULTURE #2. FINAL REPORT [2187-4-2] Blood Culture, Routine (Final [2187-4-2]): NO GROWTH. [2187-3-27] 8:45 pm URINE Site: CATHETER FINAL REPORT [2187-3-31] URINE CULTURE (Final [2187-3-31]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [2187-3-28] 4:11 am MRSA SCREEN Source: Nasal swab. FINAL REPORT [2187-3-30] MRSA SCREEN (Final [2187-3-30]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. Imaging: CXR [3-27]: IMPRESSION: Interval development of mild interstitial pulmonary edema and small left pleural effusion. Retrocardiac opacity likely represents a combination of hiatal hernia and adjacent atelectasis. CT abd/pelvis [3-27]: IMPRESSION: 1. Markedly abnormal appearance of the gallbladder with grossly abnormal contour and pericholecystic inflammatory changes. Findings are concerning for acute cholecystitis with likely gangrenous component, though no definite pericholecystic fluid collections are seen. 2. Deep venous thrombosis extending from the left common iliac vein into the left common femoral and superficial femoral vein, incompletely imaged distally. 3. Small fluid collection along the greater curvaure of the stomach is of unclear etiology. The sequela of prior pancreatitis is a possible, albeit unlikely, possibility. 4. Endplate irregularity at T12/L1 is likely secondary to degenerative changes. MRI can be pursued if there is concern for diskitis. 5. Small nodular lesion appearing to arise from the right ovary is incompletely evaluated. Ultrasound can be pursued if clinically indicated. 6. Small bilateral pleural effusions. Echo [3-28]: Conclusions The left atrium is dilated. LVEF >65%. There is mild symmetric left ventricular hypertrophy with normal cavity size. 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 are mildly thickened. There is moderate aortic valve stenosis (area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Diastolic dysfunction. Moderate aortic stenosis. Mild pulmonary artery systolic hypertension. [2187-3-30] CXR - Right internal jugular line tip is in mid SVC. The cardiomediastinal silhouette is unchanged, but there is interval improvement in pulmonary edema which is currently mild. Bibasilar opacities, left more than the right are still present and on the left are suspicious for at least partial atelectasis of the left lower lobe. Bilateral pleural effusions are small. No pneumothorax is seen. Brief Hospital Course: Mrs.[Known lastname ] is a 82 year old female with a PMHx significant for Alzheimer's disease, DM2, HTN, and multiple admissions for ascending cholangitis who was transferred from an OSH for hypotension and fevers. 1. Severe septic shock: The patient received agressive fluid resuscitation in the ED. Multiple sources were considered, including LLL infiltrate on CXR, possible cholecystitis/cholangitis on CT scan, positive U/A, and decubitus ulcers. She was given aggressive fluid resucitation in the ED in addition to central venous pressure monitoring and arterial blood pressure monitoring and admitted to the MICU with broad spectrum antibiotic coverage including vanco/zosyn/flagyl. She was also put onto levophed initially which was complicated by afib with RVR and subsequently placed on neosynephrine for blood pressure support. Surgery was consulted for cholecystitis but signed off from the case, being unable to offer the patient any surgery for her gallbladder at this time. GI consult was made and recommended that cholangitis unlikely to be source of sepsis; however, should consider cholecystitis as cause of sepsis and consider percutaneous chole drainage via IR. Ucx from admit [Known lastname 65] for GNR, likely source. In discussion with the family, the decision was made not to pursue surgery or percutaneous interventions for treatment of her biliary disease. She was continued on broad spectrum antibiotics for both cholecystitis as well as PNA. She was able to be weaned off pressor medications. She received 7 days of vancomycin and zosyn for HAP and an E. coli UTI with plans to continue flagyl for C. difficile for an additional 2 weeks thereafter (last dose [2187-4-18]). 2. Hypotension: Likely related to sepsis upon admission. An echo was done which was reassuring that no cardiogenic causes of hypotension existed. Random cortisol of 21 was also reassuring. BP improved with antibiotic treatment and she was weaned off pressors. 3. New onset atrial fibrillation: Likely in setting of sepsis, levophed, and high fevers. Upon admission to the MICU the patient went into atrial fibrillation with a heart rate up to the 200's while on levophed. She was then switched to neosynephrine for pressor support and started on a diltiazem gtt which she responded to appropriately as well as a heparin gtt for both atrial fibrilation and DVT treatment. As her pressors were weaned off, she was weaned off the diltiazem drip and eventually converted to normal sinus rhythm. She wsa started on anticoagulation as below. 4. Deep venous thrombosis / Anticoagulation: A DVT of the left common femoral was seen on CT scan of the abdomen during evaluation in the ED. On admission, the patient was not hypoxic, arguing against a PE, but she was initially hypotensive. The patient had brown, but guaiac positive stools. She was started on a heparin gtt in the ED and continued on heparin during her initial inpatient hospitalization. She had some bleeding through her sacral ulcer when her PTT was supratherapeutic and she required 2 units of PRBC transfusion. However, her hematocrit remained stable thereafter on appropriate doses of heparin and later coumadin. The family was advised regarding the risks and benefits of anticoagulation. The patient was started on coumadin in the days immediately prior to discharge and will need to have her INR monitored and coumadin dose adjusted accordingly. Of note, flagyl prolongs the INR, so her dose will have to be adjusted again when she completes the course of this medication. She should remain on coumadin for at least 3 months, at which time the need for anticoagulation should be reassessed. Her DVT is likely provoked by being bed bound. Depending upon the patient's goals of care when she has finished 3 months of treatment life-long anticoagulation vs. transitioning to subcutaneous heparin TID can be considered. Coumadin dose at discharge was 2mg daily and INR was therapeutic x 72 hours. 5. C. difficile colitis: There was no evidence for toxic megacolon on imaging. The patient was on a course of flagyl for a C. difficile infection on her prior admission. Stools were C. diff positive on this admission. Flagyl was continued and she should remain on this medication until two weeks following cessation of vancomycin and zosyn (until [2187-4-18]). Stools were more formed and diarrhea improved by time of discharge. 6. Decubitus ulcers: There was concern that the patient's sacral ulcer could become infected from her diarrhea from C. diff. Her wound was evaluated by a wound care nurse, recommendations were made for plastic surgery debridement, but overall the ulcer appeared without evidence of acute infection. After discussion with the family, plastic surgery was contact[Name (NI) ] and debrided the sacral ulcer. They recommended continued wound care and nutritional support for wound healing as well as a Clinitron bed and Q2H turning to minimize pressure. The patient will also require a chronic indwelling foley to keep her ulcer dry as she is incontinent. The risks of future UTIs as a result of this were discussed with the family. 7. Nongap metabolic acidosis: Likely from aggressive NS fluid resuscitation upon admission due to hypotension. This resolved over time and the patient's electrolytes were monitored and repleted as necessary during her hospital course. 8. Diabetes mellitus, type 2: The patient's home lantus dose was decreased to avoid hypoglycemia. She was maintained on a humalog insulin sliding scale as well to avoid extreme hyperglycemia and to promote wound healing. 9. History of Cholangitis: The surgical team was contact[Name (NI) ] at the time of discharge and does not currently feel that the patient is a candidate for cholecystectomy. If the patient developes cholangitis in the future, a percutaneous cholecystostomy tube could be considered. The [Name (NI) ] team was also contact[Name (NI) ] and stated that the patient should keep her appointment next month as her biliary stents will need to be replaced every 3 months or so to prevent them from becoming clogged and the patient from having repeated infections, though she may have repeated infections despite this measure. FEN: Regular; Diabetic/Consistent Carbohydrate Consistency: Pureed (dysphagia); Nectar prethickened liquids Supplement: Sugar free shake breakfast, lunch, dinner 1. PO intake of thin liquids and puree consistencies. 2. Pills crushed with puree. 3. Continue strict 1:1 supervision to assist with POs. 4. Q8 oral care. Multivitamin with minerals, zinc, and vitamin C to promote wound healing. CODE STATUS: The patient's family feels strongly that they should continue to actively pursue care for the patient. The patient was DNI, but not DNR, during her hospitalization. Medications on Admission: Flagyl 500 mg tid Roxanol 5-20 mg q1 hr prn Ativan 0.5-1mg q4 hr prn Compazine 25 mg q6 prn levsin 1 mg q2 prn increased secretions ASA 81 mg APAP 1000 mg tid Humalog ISS + lantus 22 units sc Trazadone 25 mg po qhs collagenese ointment to decubitus ulcers Colace prn Senna prn Discharge Medications: 1. Multivitamin,Tx-Minerals Tablet [Name (NI) ]: One (1) Tablet PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet [Name (NI) ]: One (1) Tablet PO BID (2 times a day). 3. Zinc Sulfate 220 mg Capsule [Name (NI) ]: One (1) Capsule PO DAILY (Daily). 4. Psyllium 1.7 g Wafer [Name (NI) ]: One (1) Wafer PO BID (2 times a day). 5. Acetaminophen 500 mg Tablet [Name (NI) ]: Two (2) Tablet PO every eight (8) hours as needed for pain. 6. Insulin Glargine 100 unit/mL Solution [Name (NI) ]: Ten (10) units Subcutaneous QPM. 7. Insulin Lispro 100 unit/mL Solution [Name (NI) ]: as directed per sliding scale Subcutaneous QIDACHS. 8. Flagyl 500 mg Tablet [Name (NI) ]: One (1) Tablet PO every eight (8) hours: Through [2187-4-18]. 9. Warfarin 2 mg Tablet [Month/Day/Year ]: One (1) Tablet PO Once Daily at 4 PM: Please monitor INR frequently and adjust dose until stable. 10. Psyllium Packet [Month/Day/Year ]: One (1) Packet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Location (un) 931] House Nursing & Rehabilitation Center - [Location (un) 932] Discharge Diagnosis: Primary Diagnoses: 1. Hospital acquired pneumonia 2. E. coli urinary tract infection 3. Deep venous thromboses 4. Sacral decubitous ulcer 5. Bilateral heel ulcers 6. Clostridium difficile infection Secondary Diagnoses: 1. Alzheimer's dementia 2. Diabetes mellitus, type 2 Discharge Condition: Vital signs stable, afebrile, diarrhea improved. Discharge Instructions: You were transfered to the hospital for evaluation of fevers and low blood pressure. You were treated for pneumonia and a urinary tract infection. You have finished antibiotic treatment for these, but will need to continue taking metronidazole (flagyl) for a C. difficile infection through [2187-4-18]. You were also started on a medication called warfarin (coumadin) to thin your blood because you were noted to have blood clots in your legs. The level of this medication in your blood will need to be checked often until it becomes stable. You will need to continue this medication for at least 3 months and then may be able to transition to subcutaneous heparin three times daily. The following changes were made to your medications. 1. Please take warfarin 2 mg daily to dissolve/prevent blood clots. Your INR will need to be monitored and the dose of this medication adjusted. You will likely need to stop this medication before your [Month/Day/Year ]. Please check with the gastroenterologists first. 2. Please take a multivitamin with minerals, vitamin C, and zinc to help promote wound healing. 3. Your insulin glargine (lantus) dose was reduced to 10 units at night to prevent hypoglycemia. Your dose may need to be further adjusted depending upon your diet. 4. Please take a psyllium wafer twice daily as needed to add bulk to your stools. 5. Please take metronidazole (flagyl) 500 mg every 8 hours through [2187-4-18] to treat your C. difficile infection. 6. You did not have any significant pain requiring narcotics so your roxanol was stopped. 7. You did not seem to be anxious so your lorazepam (ativan) was stopped. 8. You did not have nausea and do not currently need compazine. Please call your physician or return to the hospital if you have fevers or other concerning symptoms. Followup Instructions: Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2187-5-3] 9:00 Provider: [Name10 (NameIs) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2187-5-3] 9:00	[ "599.0", "331.0", "276.2", "424.0", "427.31", "008.45", "275.3", "575.10", "575.0", "041.4", "707.24", "294.10", "250.00", "707.22", "995.92", "038.9", "707.03", "707.07", "486", "453.41", "401.9", "275.2", "785.52", "275.41" ]	icd9cm	[ [ [] ] ]	[ "38.91", "86.28", "38.93", "99.04" ]	icd9pcs	[ [ [] ] ]	17036, 17150	8840, 15692	327, 395	17467, 17518	3190, 3190	19385, 19616	2791, 2944		16019, 17013		17171, 17370		15718, 15996			17542, 19362									2959, 3171			17391, 17446																				276, 289						423, 2293					3206, 8817										2315, 2557	2573, 2775
45,176	185,463	9214+56016	Discharge summary	report+addendum	Admission Date: [2118-12-30] Discharge Date: [2119-1-1] Date of Birth: [2055-5-23] Sex: M Service: MEDICINE Allergies: Egg Attending:[First Name3 (LF) 12174] Chief Complaint: BRBPR/Dark Stools . Major Surgical or Invasive Procedure: EGD History of Present Illness: 63 yo M h/o NASH cirrhosis with varices/GAVE (just banded last week), multiple admissions for GI bleeds in setting of asa/plavix for CAD who presents with BRBPR and dark stools x one day. States he had four bowel movements yesterday and four more this AM. He states he normally has [1-29] bowel movements daily and this is not more than his normal pattern. He noted some dyspnea and chest tightness yesterday evening, but has not had any since. He denies abdominal pain/vomiting/nausea/hematemasis. Patient also notes a 12-lb weight gain in the past few days. He does note increased abdominal distension. No changes in his appetite. Denies dietary indiscretion and states he takes all of his medications. . Of note the patient had an EGD [12-23] and 2 cords of grade II varices were seen in the GE junction. The varices were not bleeding. 2 bands were successfully placed. 2 cords of grade I varices were seen in the Mid-esophagus. The varices were not bleeding at that time. . In the ED, initial VS were: 97.4 70 140/47 18 100%. Rectal exam showed maroon guaiac positive stool. NG lavage was negative. Hct 23.0 (from 28.9 [2118-12-20]). Cr stable at 1.2. Started on octreotide and pantoprazole gtts and given a dose of ceftriaxone. Liver was [Month/Day/Year 653] in the [Name (NI) ]. EKG: NSR rate of 74, no ischemic changes. Has 18G PIVs x 3, VS prior to transfer: 66 18 109/51 99% RA. . On arrival to the MICU, patient feels well without complaints. Past Medical History: - CAD: CABG [2103], stenting in [2106], [2110] DES, cath in [2114] all grafts and stents patent. Cards Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7389], NEBH. Recently discontinue Plavix due to multiple GI bleeds. - NASH cirrhosis: followed by Dr [Last Name (STitle) ], c/w distant h/o ascites, encephalopathy, Grade 2 esophogeal varices, s/p banding [2118-12-23]. - H/O obscure GI Bleed: gastric antral vascular ectasia (GAVE) noted on EGD and AVMs noted on capsule, varices, diverticulosis, and rectal varices - DM II on insulin with frequent episodes of hypoglycemia in the past - TIA [1-6] followed by Dr [Last Name (STitle) ] - Squamous cell carcinoma - HTN - HL Social History: He works as a plumber for [Company 31653]. Smoked 3.5-4 packs per day for over thirty years and quit in [2099]. He has not drunk in many years. He says he was a heavy drinker as a teenager, but not since that time. No illicit drug use. He is married Family History: Brother with asthma. Mom with diabetes and breast cancer, sister who had a heart attack in stroke in her 50s and father who died of stomach cancer at age 63. Physical Exam: ADMISSION EXAM Vitals: T:98.6 BP:111/49 P: 65 R: 16 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, mildly distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace edema in BLE. Rectal: Guaiac positive brown stool Neuro: NO focal deficits DISCHARGE EXAM VS: 98.2,67, 116/49 (116/49-129/61), 100 % RA GENERAL: Well appearing M who appears stated age. Comfortable, appropriate and in good humor HEENT: Sclera icteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft, non-tender to palpation. Dullness to percussion. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. no peripheral edema NEURO: CN II-XII intact, strength 5/5 bilaterally, sensation in tact to light touch. Pertinent Results: Admission Labs: [2118-12-30] 03:00PM BLOOD WBC-5.8 RBC-2.36* Hgb-7.2# Hct-23.0 MCV-98 MCH-30.6 MCHC-31.3 RDW-16.3* Plt Ct-142* [2118-12-30] 03:00PM BLOOD Neuts-69.2 Lymphs-14.4* Monos-6.8 Eos-9.1* Baso-0.6 [2118-12-30] 03:00PM BLOOD PT-12.0 PTT-25.8 INR(PT)-1.1 [2118-12-30] 03:00PM BLOOD Glucose-139* UreaN-23* Creat-1.2 Na-131* K-4.7 Cl-103 HCO3-21* AnGap-12 [2118-12-30] 03:00PM BLOOD ALT-37 AST-46* CK(CPK)-103 AlkPhos-82 TotBili-0.5 [2118-12-31] 04:42AM BLOOD Albumin-2.6* Calcium-7.4* Phos-4.0 Mg-2.2 . Discharge Labs [2119-1-1] 06:20AM BLOOD WBC-3.9* RBC-2.77* Hgb-8.5* Hct-26.1* MCV-94 MCH-30.6 MCHC-32.5 RDW-16.2* Plt Ct-119* [2119-1-1] 06:20AM BLOOD Glucose-186* UreaN-14 Creat-1.0 Na-134 K-4.3 Cl-107 HCO3-20* AnGap-11 [2119-1-1] 06:20AM BLOOD ALT-28 AST-36 AlkPhos-66 TotBili-0.5 [2118-12-30] 03:00PM BLOOD CK-MB-3 cTropnT-<0.01 [2118-12-30] 11:11PM BLOOD CK-MB-3 cTropnT-<0.01 [2118-12-31] 04:42AM BLOOD CK-MB-3 cTropnT-<0.01 [2119-1-1] 06:20AM BLOOD PT-12.9* PTT-27.6 INR(PT)-1.2* EGD: Varices at the middle third of the esophagus and lower third of the esophagus Two sites of recent banding visualized at the GE junction, with one band still in place. Small overlying ulcer seen without active bleeding. Erythema, and petechiae noted in the antrum consistent with known GAVE. in the stomach Otherwise normal EGD to second part of the duodenum RUQ US 1. Known non-occlusive thrombus in the main portal vein within the hepatic hilum is not visualized, possibly due to technical factors. Intrahepatic portal veins, hepatic veins, and hepatic arterial system are patent. 2. Shrunken nodular liver consistent with cirrhosis. No focal hepatic lesions. 3. Mild gallbladder wall thickening likely related to chronic liver disease. Known gallstones are not well seen, however, there are no signs of acute cholecystitis. 4. Unchanged splenomegaly measuring 14 cm. 5. No intra- or extra-hepatic biliary dilatation. 6. Stable moderate ascites. Brief Hospital Course: Assessment and Plan: 63 yo M h/o NASH cirrhosis, recurrent GI bleeds, CAD presenting with BRBPR and dark stools and a six point Hct drop in 11 days. . ACTIVE ISSUES . # GI bleed: Given patients recent esophageal banding presentation was most concerning for misplacement of the bands or an ulcer around the recent bands. Differential also included bleeding from AVMs, GAVE, esophageal varices (all seen on recent EGD) as well as lower sources including diverticulosis and rectal varices. Patient had a negative NG lavage. HCT was noted to be 23 on admission from a baseline of around 30. The patient was transfused 2 units PRBCs with appropriate increase in his HCT. He underwent EGD which demonstrated an small ulcer at the site of recent variceal banding in addition to extensive gastropathy. It was ultimately felt that bleeding was likely resultant from the patient's GAVE. Patient may require laser ablation at a later date. Octreotide was discontinued and the patient was transitioned to PO protonix. The patients HCT remained stable and he was transferred to the floor where he was noted to have a brown non bloody stool. The patient was able to tolerate a regular diet. HCT was 26.1 at the time of discharge. . # Weight Gain: patient notes weight gain in past few days. Weight on admission 211.4 lbs and was noted to be 201 on [2118-12-20]. Differential includes worsening portal hypertension/cirrhosis, Congestive heart failure or renal failure. Synthetic function and LFTs were stable. Normal biventricular function in echo in [2116] and Cr was at baseline. RUQ US showed patent intrahepatic portal veins, hepatic veins, and hepatic arteries. [Month (only) 116] be reflective of increased ascites burden. The patient was restarted on his home diuretics at the time of discharge. He will follow-up with Dr. [Last Name (STitle) ] regarding up-titration of these medications. . # NASH Cirrhosis: Patient is followed by Dr. [Last Name (STitle) ] in the outpatient. Not on transplant list at present. As above home furosemide/spironolactone/nadolol was held in the acute setting and restarted at the time of discharge. . # Hyponatremia: Patients sodium was 131 on admission. This was felt to likely be secondary to hypervolemic hyponatremia. Sodium normalized and was 134 at the time of discharge. . STABLE ISSUES . # CAD: The patient was chest pain free throughout admission. He does have a significant history of coronary artery disease requiring a CABG and stenting. The patient recently stopped plavix in early [Month (only) 404] due to recurrent GI bleeds. His home ASA 81 mg was held on admission. Patient will restart this medication 2 days after discharge. He was continued on his home atorvastatin and zetia. . # Hyperlipidemia: Patient was continued on his home atorvastatin and zetia. . # Hypertension: Patients home lisinopril was held in the setting of a GI bleed. This medications was restarted at the time of discharge. . TRANSITIONAL ISSUES - Patient will follow-up with Dr. [Last Name (STitle) ] - Patient was full code throughout this admission Medications on Admission: 1. rifaximin 550 mg Tablet PO BID 2. atorvastatin 20 mg PO DAILY 3. ezetimibe 10 mg Tablet PO DAILY 4. folic acid 1 mg PO DAILY 5. furosemide 20 mg PO once a day. 6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day) as needed for < 3BMs per day: titrate to [1-29] BMs daily. 7. nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One Patch 24 hr Transdermal Q24H 8. Protonix 40 mg Tablet PO twice a day. 9. spironolactone 50 mg Tablet PO DAILY 10. aspirin 81 mg One PO DAILY 11. coenzyme Q10 50 mg Capsule Sig: One (1) Capsule PO once a day. 12. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. nadolol 20 mg PO DAILY 15. Lisinopril 2.5 mg daily 16. Lantus 35 units qhs 17. Novolog sliding scale Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Upper GI bleed Gastric antral vascular ectasia (GAVE) Esophageal Ulcer Secondary Diagnosis Non alcoholic steatohepatitis Diabetes Hyperlipidemia Coronary Artery diease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname ], It was a pleasure participating in your care while you were admitted to [Hospital1 ] Center. As you know you were admitted because you had blood in your stool that was concerning for a GI bleed. You blood counts were noted to be low and you were given a blood transfusion. An endoscopy was performed that showed a small ulcer where one of your varices had been banded in addition to dilated vessels in your stomach which were likely the source of the bleed. You blood counts were monitored closely and remained stable. You were also started on antibiotics to prevent infection. You will need to continue these for 3 more days. We made the following changes to your medications 1. START ciprofloxacin 500 mg daily for 3 more days 2. START Sucralfate 1 gram three times a day 3. STOP you aspirin for the next 2 days. You can restart this medication on [2119-1-3] You should continue to take all other medications as instructed. Please feel free to call with any questions or concerns. Followup Instructions: * You should [Hospital6 733] at [Telephone/Fax (1) 250] call on Monday to make an appointment to be seen by Dr. [Last Name (STitle) ] in the next 1-2 weeks . Department: LIVER CENTER When: TUESDAY [2119-1-10] at 9:30 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage * You should call on monday to have this appointment moved up Department: DERMATOLOGY AND LASER When: THURSDAY [2119-1-12] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2308], MD [Telephone/Fax (1) 3965] Building: [Location (un) 3966] ([Location (un) 55], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: PODIATRY When: TUESDAY [2119-2-21] at 11:20 AM With: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM [Telephone/Fax (1) 543] Building: Ba [Hospital Unit Name 723] ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Name: [Known lastname ],[Known firstname ] J Unit No: [Numeric Identifier 5519] Admission Date: [2118-12-30] Discharge Date: [2119-1-1] Date of Birth: [2055-5-23] Sex: M Service: MEDICINE Allergies: Egg Attending:[First Name3 (LF) 5520] Addendum: . Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 8. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 9. coenzyme Q10 50 mg Capsule Sig: One (1) Capsule PO once a day. 10. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO once a day. 11. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Lantus 100 unit/mL Solution Sig: Thirty Five (35) Subcutaneous at bedtime. 14. Novolog 100 unit/mL Solution Sig: per sliding scale Subcutaneous three times a day. 15. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 16. nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One (1) Transdermal once a day. 17. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: please hold for the next 2 days and restart on [2118-12-28]. Discharge Disposition: Home [Name6 (MD) ] [Last Name (NamePattern4) 5521] MD [MD Number(2) 5522] Completed by:[2119-1-3]	[ "401.9", "537.83", "V58.67", "530.20", "250.00", "571.5", "276.1", "789.59", "V45.81", "272.4", "456.21", "571.8" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	14874, 15018	6443, 9548	286, 291	10673, 10673	4414, 4414	11871, 13431	2834, 2993		13454, 14851		10463, 10652		9574, 10413			10824, 11848									3008, 4395																							226, 248						319, 1794					4431, 6420				10688, 10800						1816, 2543	2559, 2818
68,736	119,689	20821	Discharge summary	report	Admission Date: [2113-12-7] Discharge Date: [2113-12-14] Date of Birth: [2055-3-12] Sex: M Service: MEDICINE Allergies: Actos / Tricor / Toprol XL / Zetia / Iodine-Iodine Containing Attending:[First Name3 (LF) 9160] Chief Complaint: R heel cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: 58M with ALS on BiPAP at home, DM2 with neuropathy who developed fever (to 101.8) and chills one day prior to admission and his wife noticed R heel discoloration and yellow drainage from heel pressure ulcer. The patient denies trauma to that foot and has never had diabetic foot ulcers in the past. The patient did not have pain or foot numbness, nor did he have migrating erythema, swelling, or joint involvement. He needs help with his ADLs and with transfers, but denies pressure sores. In the ED, the patient's VS were HR 86, 24, 146/61, 100% Bipap. He received vancomycin and unasyn for polymicrobial and MRSA coverage. A foot Xray was done. Podiatry was consulted who could not probe to bone. The patient was admitted to the MICU due to BiPap requirement [1-4] ALS and diaphragn weakness. In the ICU, his initial vitals were 91, 152/ 53, 97% BiPap 20/10. Past Medical History: - Diabetes - complicated by retinopathy s/p laser tx, neuropathy, nephropathy - CAD - underwent cath for tx of lesions in the LCX and RCA detected on stress testing; no hx angina (90% mid left circumflex stenosis, a 70% mid RCA stenosis, 60% proximal posterior descending artery stenosis). s/p DES at LCX, RCA in '[09] - HTN - OSA on CPAP at home - s/p carotid endarterectomy on [7-9] - Anemia - Gout - Carotid atherosclerosis: Mr. [Known lastname 55486] is status post left CEA. - Possible drug-induced myopathy (elevaated CPK for past several months) -Possible diastolic dysfunction. No recent echo, but noted on cath last year - ALS CKD Neurogenic bladder HTN DM2 Gout CAD HL Social History: Mr. [Known lastname 55486] is married with a 30-year-old son and 29-year-old daughter. The entire family, works for Mr. [Known lastname 55487] small business, which is a produce supply company. His business has been slow because of the economy. Tobacco: None. Alcohol: Rare use. Drugs: None. Mr. [Known lastname 55486] is not currently sexually active. Family History: Father and brother with CAD. Another brother died suddenly, possibly of MI or CVA. Mother is alive and well. Two maternal uncles and maternal grandfather with diabetes. Physical Exam: Admission exam Vitals: T: 101 BP: 152/53 P: 85 R: 18 O2: 98% General: Alert, oriented, no acute distress, on BiPap 20/10 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: Clear to auscultation bilaterally listened anteriorly, some upper airway ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, slight bruising from insulin GU: no foley Ext: RLE slightly more swollen than LLE, slightly warmer, nontender, dopplerable dorsalis and PT pulses, R heel with 5x5cm open ulcer with slight drainage, no sinus tracts, sensation slightly decreased Neuro: Chronic weakness, sensation intact, tongue fasciculations Discharge exam Vitals: T: 98.8 BP: 140/80 P: 70 R: 20 O2: 98% on BiPap 20/10 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, EOMI, 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 listened anteriorly, some upper airway ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, slight bruising from insulin GU: no foley Ext: Right heel with 5x5cm open ulcer with no drainage, sensation slightly decreased. 1+ pitting edema bilaterally Neuro: Chronic weakness, sensation intact, tongue fasciculations Pertinent Results: Admission labs [2113-12-7] 05:00PM BLOOD WBC-21.6# RBC-3.41 Hgb-11.0* Hct-32.4* MCV-95 MCH-32.4* MCHC-34.0 RDW-14.2 Plt Ct-251 [2113-12-7] 05:00PM BLOOD Neuts-84* Bands-0 Lymphs-7* Monos-7 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [2113-12-7] 05:00PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [2113-12-8] 03:56AM BLOOD ESR-120* [2113-12-7] 05:00PM BLOOD Glucose-339* UreaN-33* Creat-1.1 Na-133 K-5.3* Cl-93* HCO3-30 AnGap-15 [2113-12-8] 03:56AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 [2113-12-8] 03:56AM BLOOD CRP-236.5* Discharge labs [2113-12-13] 05:30AM BLOOD WBC-14.9* RBC-3.41* Hgb-10.8* Hct-32.1* MCV-94 MCH-31.8 MCHC-33.7 RDW-14.5 Plt Ct-287 [2113-12-13] 05:30AM BLOOD Glucose-102* UreaN-25* Creat-0.9 Na-138 K-3.4 Cl-98 HCO3-30 AnGap-13 [2113-12-13] 05:30AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9 Studies: Foot XR [2113-12-7]: Vascular calcifications are widespread. There are second through fourth hammertoes. Soft tissues about the heel appears swollen, but there is no evidence for bone destruction. There is patchy demineralization and degenerative change about the tarsometatarsal joints, which is worrisome for sequelae of neuropathy including chronic-appearing bone destruction and sclerosis of the middle cuneiform. There is no evidence for recent fracture. IMPRESSION: No evidence for osteomyelitis involving the calcaneus. Findings suggesting neuropathic changes at the tarsometatarsal joints. Foot MR [2112-12-8]: FINDINGS: Multiplanar images of the right ankle were performed before and after the administration of intravenous contrast. There is minimal irregularity of the posterior skin at the heel. Mild edema within the subcutaneous soft tissues is seen. There is minimal if any enhancement within the soft tissues about the heel. The adjacent calcaneus demonstrates normal marrow signal. No osteomyelitis or focal fluid collection is identified. The Achilles tendon is intact. There is some edema at its distal insertion and to the calcaneal tuberosity. There is some edema and mild enhancement surrounding the flexor hallucis longus tendon more distally, consistent with tenosynovitis. No definite rupture is seen. There is no joint effusion. The sinus tarsi is preserved. There is no abnormal marrow edema or enhancement within the remainder of the hindfoot and midfoot. There is some thickening of the plantar fascia at its attachment to the posterior calcaneus. Mild edema within the inferior soft tissues is also seen. IMPRESSION: 1. Mild irregularity along the posterior heel consistent with known soft tissue ulcer. There is no MR evidence for osteomyelitis or abscess formation. 2. Minimal tenosynovitis involving the flexor hallucis longus tendon and at the distal insertion of the Achilles tendon. 3. Mild thickening of the plantar fascia with some mild surrounding edema. CT ABDOMEN/PELVIS: LUNG BASES: Lung bases are included and show minimal atelectasis in the left lower lung lobe. There are no suspicious pulmonary nodules or pleural effusions identified. ABDOMEN: The liver and spleen are normal in size. No focal hepatic lesions are seen. The gallbladder, pancreas, adrenals, and kidneys are unremarkable. There are no enlarged retroperitoneal or mesenteric lymph nodes. PELVIS: A small fat-containing umbilical hernia is seen. Subcutaneous stranding is identified in the anterior abdominal wall, most likely following subcutaneous injections. The urinary bladder is decompressed due to the presence of a Foley catheter. The seminal vesicles and prostate are normal in size for the age of the patient. The small and large bowel appear unremarkable. There is no evidence for diverticulitis. There is no pelvic or inguinal lymphadenopathy. Review of the images on bone window does not show any suspicious bony lesions. IMPRESSION: 1. No additional sources of infection are identified in the abdomen or pelvis. 2. Minimal subsegmental atelectasis in the left lower lung lobe. RIGHT LOWER EXTREMITY LENI FINDINGS: The left common femoral, superficial femoral and popliteal veins are patent with normal compressibility, color flow and spectral waveform analysis and response to augmentation. The calf veins are patent with normal compressibility and color flow. IMPRESSION: No left lower extremity DVT. CHEST X-RAY: FINDINGS: The lungs are clear with no evidence of consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette remains stably widened at the level of the carina. Osseous structures are grossly unremarkable. IMPRESSION: No acute cardiopulmonary process. Microbiology: WOUND CULTURE (Final [2113-12-9]): STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Blood Cultures times 4: NO GROWTH. (FINAL) CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2113-12-14]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). URINE CULTURE (Final [2113-12-9]): NO GROWTH. Brief Hospital Course: #Diabetic foot ulcer: Patient presented with a fever and a blister on his right heel. Given his history of diabetes complicated by peripheral neuropathy, there was concern that the patient may have an osteomyelitis versus cellulitis. Podiatry was consulted initially who recommended starting the patient on IV vancomycin and Unasyn. MRI of the right heel did not show evidence of osteomyelitis. The patient also was followed by wound care who suggested multipodius boots, adaptic dressings on the heel, covered by DSD daily. He also had daily wet to dry dressings over the heel. Blood cultures were drawn that returned negative. The patient remained afebrile initially after starting IV antibiotics. The patient was transitioned to oral clindamycin with cultures of the heel returning showing MSSA. However, he spiked a fever again initially after transitioning to oral clindamycin. The patient was continued on oral clindamycin despite the fever. Blood cultures drawn at the time of the spike returned no growth (final). The patient was discharged with instructions to continue the oral clindamycin to complete a full 7 day course. He also had follow-up with Podiatry and his primary care physician arranged upon discharge. # Leukocytosis: Because of a persistent leukocytosis, there was concern that the patient may have an absecess as his white count remained elevated despite appropriate antibiotic therapy. He underwent chest x-ray that did not show an infiltrate given concern of aspiration in a patient with ALS. A CT of the abdomen/pelvis did not show evidence of an abscess. #Hypertension: Patient's systolic blood pressures consistently ran in the 140s. His home Losartan and verapamil were continued through the admission. #ALS: Patient with weakness of his respiratory muscle as result of ALS requiring continuous BiPAP. BiPAP was continued through the admission on satble settings with respiratory therapy following the patient through his hospital course. The patient was discharged home on his admission BiPAP settings. Additionally, the patient was sent home with a prescription for a hospital bed as a result of impaired mobility secondary to ALS. #Diabetes mellitus, insulin dependent: Complicated by peripheral neuropathy. The patient was discharged home on his original insulin regimen of 40 units of lantus in the morning and 80units of lantus in the evening. He was also sent home with instructions to continue his insulin sliding scale as prescribed by his primary care physician. #Consipation: Patient had not had a bowel movement for close to a week while in the hospital. He was given an aggressive bowel regimen, and on day of discharge, the patient had a bowel movement. #Gout: Home allopurinol was continued through the admission. #Depression: Home Celexa, Seroquel, and Clonazepam were continued through the admission. #CAD: Patient had no cardiac complaints throug hte admission, consistently denying chest pain and shortness of breath. His home plavix dose was continued through the admission. #Lower extremity edema: Patient with 1+ pitting edema of the lower extremities through the hospitalization. His home bumetaninde was continued through the admission. Medications on Admission: Alphagan P 0.1 % Eye Drops, flomax 0.4', seroquel 50 qhs prn insomnia, plavix 75', celexa 40', tamiflu 75" x5 days, lumigan 0.03% eyedrops, lantus 40 units qam 80 units qpm, novolog sliding scale, advair diskus 250 mcg-50 mcg q puff inh", calcium carbonate 600 (1500)", nystatin [Numeric Identifier 4856] topical cream apply to rash", myamyc [Numeric Identifier 4856] unit/g topical powder apply to rash", asa81', allopurinol 400', klonopin 1 qhs prn insomnia, bumetanide 4", verapamil sr 120', cozaar 100', buproprion hcl sr 150", claritin 10' prn allergies, Rhinocort Aqua 32 mcg/Actuation Nasal Spray 2 sprays(s) each nostril' prn, miralax 17g oral powder packet Discharge Medications: 1. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 2. allopurinol 100 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 8. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q24H (every 24 hours). 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 10. bumetanide 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 12. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous qAM. 13. insulin glargine 100 unit/mL Solution Sig: Eighty (80) units Subcutaneous qPM. 14. insulin aspart 100 unit/mL Solution Sig: According to your home sliding scale units Subcutaneous qACHS. 15. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation once a day. 16. bupropion HCl 150 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 17. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 18. Rhinocort Aqua 32 mcg/Actuation Spray, Non-Aerosol Sig: Two (2) sprays Nasal once a day as needed: Administer into each nostril. 19. brimonidine 0.1 % Drops Sig: One (1) drop in the affected eye Ophthalmic three times a day. 20. Lumigan 0.03 % Drops Sig: One (1) drop in the eye Ophthalmic qPM. 21. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO once a day. 22. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 23. clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours) for 3 days. Disp:8 Capsule(s) Refills:0 24. [Hospital 485] hospital bed for ALS with gel overlay DX ALS Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Cellulitis ALS Hypertension Type 2 Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 55486], It was a pleasure taking care of your during your hospitalization at [Hospital1 69]. You were hospitalized with fevers/chills and a right heel foot ulcer. There was concern for osteomyelitis, so you were admitted to the hospital. An MRI of your right foot showed no evidence of osteomyelitis. You initially received IV anitibiotics and were transitioned to oral antibiotics. You are being discharged home with 3 more days of clindamycin to be taken every 8 hours. Please keep all follow-up appointments. They are listed below. Please note the following medication changes: NEW oral clindamycin 450mg every 8 hours for another 3 days. Followup Instructions: Department: [Hospital3 249] When: WEDNESDAY [2113-12-20] at 12:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], M.D. [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 9162]	[ "V45.82", "707.22", "250.62", "414.01", "041.11", "583.81", "403.90", "713.5", "362.01", "585.9", "250.42", "357.2", "327.23", "335.20", "518.83", "707.07", "682.7", "250.52", "564.09", "274.9", "285.9", "311", "596.54" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	15813, 15884	9708, 12911	341, 348	15972, 15972	4004, 9685	16853, 17253	2364, 2536		13635, 15790		15905, 15951		12937, 13612			16148, 16746									2551, 3985																				16766, 16830			284, 303						376, 1242									15987, 16124						1264, 1959	1975, 2348
11,066	107,863	9196+9197+56012	Discharge summary	report+report+addendum	Admission Date: [2104-1-30] Discharge Date: [2104-3-24] Date of Birth: [2029-8-6] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 74 year old female transferred from [Hospital 2523] Hospital with complaint of shortness of breath and chest pain. The patient was admitted to [Hospital 2523] Hospital for right lower extremity cellulitis and was started on Unasyn. During her admission there, she developed shortness of breath and substernal chest pain and desaturation on room air. The patient was then transferred to [Hospital6 256] for further evaluation and management. Upon admission, the patient appeared to have an acute myocardial infarction and unstable angina. PAST MEDICAL HISTORY: The patient is a 74 year old woman who, in [2089], underwent an aortic valve replacement and coronary bypass grafting. She subsequently developed unstable angina. Catheterization showed severe three vessel disease. EF of approximately 45%. The aortic valve prosthesis, which was a St. Jude's valve, was in good working order on admission. HOSPITAL COURSE: She was taken by Dr. [Last Name (STitle) ] to the Operating Room and underwent a redo coronary artery bypass graft x 3; left internal mammary artery to left anterior descending artery, saphenous vein to diagonal branch and saphenous vein graft to posterior descending coronary artery. The patient also was placed on an intra-aortic balloon pump by her femoral artery on [2104-2-5], by Dr. [Last Name (STitle) ]. Unfortunately, the patient has severe lower leg cellulitis requiring treatment prior to bypass surgery. She has a history of severe peripheral vascular disease and therefore, intra-aortic pump was not placed. The patient was taken to the Operating Room by Dr. [Last Name (STitle) ] on [2104-2-5], and underwent a redo coronary artery bypass grafting x 3 for left internal mammary artery to the left anterior descending, saphenous vein graft to diagonal branch and saphenous vein graft to posterior descending coronary artery. Postoperatively, she was placed on Vanco and levofloxacin for her cellulitis. On postoperative day #1, the patient had an intra-aortic balloon pump in place and was placed on pressor in the CSRU. On postoperative day #2, the patient was reintubated for ventilatory difficulties. Subsequently, the patient also went into A fib and on postoperative day #4, the patient was cardioverted to sinus for A fib, unresponsive to Amiodarone. She was taken back to the cath lab where several grafts were foun occluded. She underwent PTCA and stenting of the LIMA graft and the LM artery.. Also, her postoperative course was complicated by renal failure. On [2-15], she had a Quinton dialysis catheter placed in the right groin. She tolerated the procedure well but subsequent dialysis was not required. Also, on [2-12], Infectious Disease recommended Flagyl for her diarrhea. Throughout her course, the patient was extubated on [2-7]. Subsequently, her course was complicated by fluid overload, PMVT arrest, bacteremia. The patient was extubated again on [2104-2-21], and Dobbhoff that was placed became clogged and was d/c'd. The patient failed speech and swallow study because of aspiration within liquids. The study was done on [2104-1-30]. Subsequently, the patient was recommended for percutaneous endoscopic gastrostomy placement and tracheostomy. Due to her recurrent failure of extubation, Dr. [Last Name (STitle) ] placed a percutaneous tracheostomy tube and flexible bronchoscopy on [2104-3-3]. The procedure went well. On the following day, [2104-3-4], the patient underwent a percutaneous gastrostomy tube placement in the Operating Room. After the placement of a percutaneous endoscopic gastrostomy, the patient was started on gastric feeds, and the patient appeared to be tolerating gastric feeds well. . And also throughout her course, she was placed on Plavix for her coronary artery stents and poor small vessels The patient is status post coronary artery bypass graft complicated by early graft closure and also had left main percutaneous transluminal coronary angioplasty stents, left internal mammary artery percutaneous transluminal coronary angioplasty stents and diagonal percutaneous transluminal coronary angioplasty stents postoperative. Her EF was less than 20%. Postoperative course was also complicated by arrhythmia and over time her renal status appeared to be improving and eventually her creatinine had come down to baseline of 1.5 and she began to make urine with Lasix. On [2104-2-20], the patient is status post stenting. Postoperative day #12, status post coronary artery bypass graft x 3 and stenting. The patient developed a rectus sheath hematoma and was required two units of transfusion. General Surgery was consulted. Apparently the bleeding appeared to be stable and it stopped on its own. The patient did not require operation at that time. Given the patient's frequent arrhythmia, the patient was taken by EP to have an AICD placed on [2104-2-22]. On the 27th, electrocardiogram showed she has a ventricular paced rhythm with 100% capturing. The patient developed VT arrest after trach. At the same time, the patient was on vancomycin and Flagyl for antibiotic coverage. The patient had a Portacath catheter placed on the [3-7]. The patient was also started on a Heparin drip for anticoagulation. The patient had AICD placed on [2104-3-12], and postoperative day #1 after AICD placement, the patient had an V tach and continued to have irregular rhythm. An echocardiogram was performed on the [3-14], which showed a thrombus at her St. Jude's valve. The patient underwent a TPA of thrombus. Post TPA echocardiogram showed mild to moderate aortic regurgitation; mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate mitral regurgitation and no pericardial effusion. The gradient across the aortic valve has appeared to be decreased to approximately 28 with intravenous TPA. At this time, the patient remained in the CSRU on trach and tolerating the percutaneous endoscopic gastrostomy tube and her AICD. She is being AV paced with AICD at heart rate of approximately 105. Post TPA, the patient course was complicated by hematoma at her AICD site over her left subclavian site. The patient underwent a hematoma evacuation on [2104-3-18]. Postoperatively, the patient did well. The patient was deemed ready for discharge at this time. Prior to her discharge, the patient was afebrile. Vital signs were stable. Chest was clear. Abdomen was soft, nontender, nondistended. The patient was tolerating percutaneous endoscopic gastrostomy feed and she is getting ProMod with fiber at full strength at 55 cc an hour. The patient's AICD was turned on by Cardiology of AV pacing to a rate of 90. The patient tolerated that for about a week and appeared to be tolerating that and stable on the current AICD settings. The patient is pending rehabilitation bed at this time. Please have the patient call the Electrophysiology Service, attending, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 284], for follow up appointments with AICD and upon her discharge from rehabilitation, please have her contact Dr. [Last Name (STitle) ] for follow up appointments. The patient had a tracheostomy #7 and per Respiratory Therapy, please always deflate cuff prior to placing the valve and monitor O2 sats and respiration while valve in place. Take the valve off while no one is supervising her. Do not allow the patient to sleep with the valve in place. PNB wean schedule is up to the discretion of the Nurse's and the Respiratory Therapist at rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass graft x 3. 2. Status post percutaneous endoscopic gastrostomy. 3. Status post trach. 4. Status post AICD placement. 5. TPA of thrombosed aortic valve. 6. Status post hematoma evacuation. 7. Coronary artery disease. 8. Acute renal failure. 9. Diabetes mellitus. 10. Hypertension. 11. Chronic respiratory insufficiency. 12. Mechanical ventilation dependency. DISCHARGE MEDICATIONS: The patient is to be discharged with: 1. Spironolactone 25 mg p.o. q d. 2. Lasix 80 mg intravenous t.i.d. 3. Amiodarone 400 mg p.o. q d. 4. Levothyroxine 25 mcg p.o. q d. 5. Ascorbic Acid 500 mg per nasogastric tube q d. 6. Multi-vitamin 5 mg per nasogastric tube q d. 7. Zinc Sulfate 220 mg per G tube q d. 8. Percocet Elixir 5 mg per G tube q 4 to 6 hours prn. 9. Glipizide 10 mg p.o. b.i.d. 10. Aspirin 325 mg per G tube q d. 11. Prevacid 30 mg per G tube q d. 12. Albuterol one to two puffs q 4 hours prn. 13. Coumadin 2 mg p.o. q hs. 14. Thyroxalin 5 mg p.o. q d. 15. The patient is to be discharged with ProMod with fiber at full strength at 55 cc an hour. DISCHARGE INSTRUCTIONS: Please check INR and adjust Coumadin level for a target range of INR of 3 for her prosthetic aortic valve. She had to finish a 30 day course of Plavix and will no longer be requiring Plavix per Cardiology. The patient is deemed ready for discharge. Dictated By:[Location (un) 31605] MEDQUIST36 D: [2104-3-20] 17:48 T: [2104-3-20] 19:00 JOB#: [Job Number 31606] Admission Date: [2104-1-30] Discharge Date: [2104-3-26] Date of Birth: [2029-8-6] Sex: F Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 74-year-old female patient who transferred to the [Hospital6 2018] from [Hospital 21145] Hospital on the night of [2104-1-29], with a chief complaint of shortness of breath and chest pain. She was actually admitted to Brochton History for right lower extremity cellulitis on [2104-1-22]. She was started on intravenous Unasyn; however, she developed shortness of breath and substernal chest pain and desaturated to 80%. She had an electrocardiogram at that time which showed new onset atrial fibrillation with a left bundle branch block. The patient was placed on oxygen, and she was treated with Morphine and intravenous diuretics at that time. Her oxygen saturation improved, and her atrial fibrillation rate was controlled with Metoprolol, and Digoxin was started. She was placed on intravenous Heparin. The patient was ultimately scheduled for cardiac catheterization; however, this was deferred secondary to bacteremia which was documented around [1-24] at [Hospital 21145] Hospital. It was found to be coag-negative staph for which she was placed on Unasyn. The patient has had some episodes at [Hospital 21145] Hospital of congestive heart failure, and she was ultimately transferred to the [Hospital6 256] for cardiac catheterization. PAST MEDICAL HISTORY: Atrial fibrillation of new onset during the admission at [Hospital 21145] Hospital. Hypertension. Aortic stenosis treated with an aortic valve replacement in [2092] with a mechanical valve. This was performed at [Hospital 14852], and the patient has been on Coumadin therapy for her mechanical aortic valve. Diabetes mellitus since [2100]. Hypercholesterolemia. She is status post right carotid endarterectomy. She is status post cardiac catheterization in [2093] with an angioplasty to an unknown vessel at the time. She is also status post coronary artery bypass grafting. She also has a history of depression. MEDICATIONS ON TRANSFER: Lopressor 100 mg b.i.d., Aspirin 325 mg q.d., Plavix 75 mg q.d., Zocor 40 mg q.d., Isosorbide Dinitrate 20 mg t.i.d., Digoxin 0.125 mg q.d., Glipizide 5 mg p.o. b.i.d., Vancomycin 1 g to be given p.r.n. dosing for a level of less than 15, Unasyn 3 g IV q.8 hours. PHYSICAL EXAMINATION: General: She was anxious appearing. She was alert and oriented times three. Vitals signs: Temperature 98.1??????, heart rate 85-120 in atrial fibrillation, blood pressure 118/70, respirations 32, oxygen saturation on 4 L nasal cannula ranged from 88-95%. Lungs: She had bibasilar crackles with expiratory wheezes. Heart: Irregular with no murmur noted. There was a mechanical S2. Abdomen: Soft, nontender, nondistended. Positive bowel sounds. Extremities: Her right lower extremity did have notable erythema with 2+ edema. She had palpable dorsalis pedis pulse on the left, and Doppler signal dorsalis pedis on the right. HOSPITAL COURSE: The patient was managed on the Medicine Service and ultimately taken to the Cardiac Catheterization Lab on [2104-2-1]. This revealed an 80% distal left main coronary artery occlusion, as well as two-vessel disease. She was also noted to have iliac artery atherosclerosis, marked systemic and pulmonary arterial desaturation, as well as elevated pulmonary artery wedge pressure. An intra-aortic balloon was deferred at that time due to significant history of peripheral vascular disease. Cardiothoracic Surgery consultation was obtained on [2104-2-1], by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. It was recommended that the patient receive continued intravenous antibiotic therapy for the thrombophlebitis in her leg, as well as two reverse her anticoagulation from her Coumadin usage with Vitamin K. The patient was ultimately taken to the Operating Room on [2104-2-5], where she underwent redo coronary artery bypass graft with a LIMA to the left anterior descending, saphenous vein to the diagonal, and saphenous vein to the posterior descending artery. She also had placement of an intra-aortic balloon pump. This was performed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Postoperatively the patient was transported to the Cardiac Surgery Recovery Unit. She was continued to be followed by the Infectious Disease Service, as well as Pulmonary Medicine. Postoperatively she was on Amiodarone, Dobutamine, Neo-Synephrine, Propofol, and Insulin intravenous infusion. Her cardiac index ranged from 1.5 to 2.3 during the first 24-48 hours, and this was treated with intravenous Dobutamine. Dobutamine was ultimately weaned off. She remained on Amiodarone. Nitroglycerin was added, and her balloon pump was weaned to [1-18], and she was started on diuretics on postoperative day #2. The patient remained on the ventilator but was weaning to CPAP with pressure support mode at that time. She was awake, alert and oriented and following commands appropriately. Later in the day on postoperative day #2, the patient was noted to have worsening ventilator parameters with periods of desaturation after extubation, and she was urgently reintubated. The patient also had some acidosis which was treated with Sodium Bicarbonate, and the patient was restarted on Dobutamine at 5 mcg/kg/min. She was placed on a Heparin infusion because of her mechanical aortic valve. She remained on Neo-Synephrine at this time, and Propofol and Amiodarone drips. Over the next 24-48 hours, the patient continued to have increasing need for pressors and inotropes. She had en echocardiogram which showed a diminished ejection fraction postoperatively, as well as some signs of fluid overload. She was in atrial fibrillation on [2-8] and 25, and unsuccessful attempts were made at cardioversion. The patient was ultimately taken to the Cardiac Catheterization Lab on [2-9] due to continued need for pressors and inotropes and decreased left ventricular ejection fraction by echocardiogram. In the catheterization lab on [2-9], she had PTCA with stent placement to the LIMA to the left anterior descending graft, and the patient was taken back to the Cardiac Surgery Recovery Unit. The patient remained somewhat tachycardiac on Dobutamine with a cardiac index of approximately 2. The patient was placed on Natrecor per the Heart Failure Service, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. She was also placed on Bumex with attempts to aggressively diurese her after her events over the previous two days, and she was changed from Levophed to Vasopressin. The patient remained in the Intensive Care Unit on pressors and inotropes over the course of the next few days; however, on [2-10], she was taken to the Cardiac Catheterization Lab for placement of an intra-aortic balloon pump due to continued need for support in the Intensive Care Unit. The patient was maintained in the Intensive Care Unit on Levophed, Milrinone, Natrecor and Propofol drips, as well as an intravenous Heparin drip. She was begun on tube feeds. Her creatinine had started to rise until she went into renal failure requiring CVVH treatment in the Intensive Care Unit. Renal consultation was obtained on [2104-2-13]. Their recommendation initially was to discontinue the Natrecor and the intra-aortic balloon pump which were both done without resolution of her renal failure. It was also their recommendation of the Heart Failure Service to initiate CVVH at this time; however, the Renal Service felt that the patient required more diuretics and requested that the diuretics be increased prior to initiation of CVVH for fluid overload. On [2104-2-18], an Electrophysiology consult was requested due to history of paroxysmal ventricular tachycardia, as well as atrial fibrillation. It was their recommendation to continue Amiodarone, as well as Lidocaine, as the patient had previously on [2-18] had ventricular tachycardia necessitating defibrillation. The Electrophysiology Service recommended continuing the Amiodarone IV drip, as well as to continue Lidocaine. On [2-19], the patient had recovered from her ventricular tachycardia arrest the previous day. She remained on Amiodarone and Dobutamine drips, as well as Heparin, Insulin, Lidocaine, and Neo-Synephrine. She was also maintained on Plavix. Over the next few days, the patient's intra-aortic balloon pump was discontinued with manual pressure placement on the groin for 40 min; however, the patient was noted on [2-20] to have developed a rectus sheath hematoma. At this time, her Heparin was held for a short period. On [2104-2-20], the patient was begun on CVVH due to the need to get fluid off of her, as well as continuing renal insufficiency. Her Neo-Synephrine was ultimately weaned off over the next couple of days. She began to make progress from a hemodynamic standpoint. She was maintained on Amiodarone; however, was not progressing with ventilator weaning. She developed bacteremia with gram-negative rods in her blood, as well as in her sputum. She also developed yeast in her urine for which she was placed on appropriate antibiotics. The patient was ultimately extubated and reintubated once again. She was reintubated on [2-25] due to increased work of breathing and respiratory failure. The patient underwent bronchoscopy at the time of reintubation or shortly thereafter which was ultimately clear with minimal secretions. On [2-27], the patient was attempted on a wean from the ventilator with hopes of extubating her again, which she failed. The following day on the 13th, she was weaned again from the ventilator and ultimately extubated. She remained extubated for approximately 48 hours, when she required urgent reintubation due to oxygen saturation of 80% and tachypnea and respiratory distress. The patient underwent tracheostomy on [3-2], and she underwent feeding tube placement on [3-4]. She had a PICC line placed on [3-7]. The patient continued, actually during the time of tracheostomy, with ventricular tachycardia which deteriorated to ventricular fibrillation requiring cardioversion. The Electrophysiology Service was reconsulted to assess whether it would be appropriate for the patient to have an AICD placed. The patient remained in the Cardiac Surgery Recovery Unit over the next few days on intravenous Heparin drip, as well as intravenous Neo-Synephrine drip for some hypotension. The patient's renal function did recover and was able to maintain appropriate fluid balance with the use of diuretics, and CVVH was discontinued. The patient was started on Caspofungin for blood cultures which were positive for yeast. The patient was taken to the Electrophysiology Lab where she underwent AICD placement on [3-11]. The patient tolerated the procedure well. She remained on Neo-Synephrine drip at that time. She had successful placement of an [Company 1543] defibrillator and was transported to the Cardiac Surgery Recovery Unit postprocedure, however, was hypotensive, having increasing Neo-Synephrine requirements and ultimately required transfusion of 2 U packed red blood cells postprocedure. The patient apparently had a significant intraoperative blood loss during her ICD placement. The patient was fluid resuscitated at that time, and on the morning of the 26th, she began to have significant episodes of ventricular tachycardia progressing to ventricular fibrillation requiring multiple defibrillation over the next 24 hours, occurring mostly of [2104-3-13]. She underwent an echocardiogram at that time which revealed fixed anterior leaflet of her prosthetic aortic valve which was immobile possibly due to thrombus, and this was a new finding since she had a transesophageal echocardiogram on [3-3]. This was treated in the Intensive Care Unit with TPA over the next 24 hours, and a repeat echocardiogram was performed on [3-14]. This showed a significant improvement with a significant decrease in her aortic valve peak and mean gradient, and the valve was thought to be functioning much more appropriately after being treated with the TPA infusion. On [2104-3-17], most likely as the result of her TPA infusion, the patient had an increasing hematoma in the pocket of the AICD in her left anterior chest for which she was taken to the Operating Room. After her valve was opened with the thrombolytics, her ventricular tachycardia abated. The patient remained in the Cardiac Surgery Recovery Unit with some decreased in ventilatory support. She was maintained on her goal of tube feeds, which she had been tolerating well. She was most of the time AV paced with her device that had been recently placed. The patient had begun trials with a trach mask and a Passy-Muir valve, which she was tolerating for short periods at a time well. She remained hemodynamically stable. On [3-20] and 7, the patient was noted to have an elevated white blood cell count which was felt to be pulmonary in origin, since she had a questionable new infiltrate on her chest x-ray. She required increased ventilatory support and increased FIO2; however, over the next 48 hours, she was decreased back to her baseline ventilator settings. She remains hemodynamically stable today [2104-3-24], and is ready to be discharged to a rehabilitation facility. CONDITION ON DISCHARGE: Heart rate 90, and she is AV paced. Blood pressure 94/40. She remains afebrile. White blood cell count today is 12.6. Her hematocrit is 27, and her platelet count is 216,000. The patient's prothrombin time is 14.6, INR 1.4, PTT 78.9 on intravenous Heparin drip. Her CHEM7 from today revealed a sodium of 140, potassium 3.9, chloride 96, CO2 34, BUN 63, creatinine 1.1, glucose 156. Her physical exam revealed coarse breath sounds bilaterally. Her incisions are clean, dry, and intact. Her abdomen is soft, nontender, nondistended at this time. She remains on tube feeds, Promote with fiber, at 55 cc/hr, which is her goal. DISCHARGE DIAGNOSIS: 1. Redo coronary artery bypass graft times three on [2104-2-5], with a LIMA to the left anterior descending, saphenous vein to the posterior descending artery, and saphenous vein to the diagonal. On [3-2], she underwent tracheostomy for respiratory failure and pneumonia. On [3-4], she underwent percutaneous endoscopically placed gastrostomy tube. On [3-11], she underwent automatic implantable cardiovascular defibrillator placement. On [3-17], she underwent surgical evacuation of an AICD hematoma. 2. Atrial fibrillation, ventricular fibrillation. 3. Hypertension. 4. Diabetes mellitus, type 2. 5. Right carotid endarterectomy. 6. Hypercholesterolemia. 7. Cellulitis. 8. Peripheral vascular disease. 9. Depression. 10. Thrombosis of prosthetic heart valve and thrombolysis with TPA. DISCHARGE MEDICATIONS: Aldactone 25 mg p.o. q.d., Lasix 80 b.i.d., Zaroxolyn 5 q.d., Amiodarone 400 q.d., Levothyroxine 25 q.d., this was started postoperatively and should be followed with appropriate lab values for continuing thyroid replacement therapy, Vitamin C 500 mg q.d., Multivitamin 1 q.d., Zinc 220 q.d., Aspirin 325 q.d., Coumadin 3 mg q.d. With a target INR of 3.0, and this is anticoagulation for a mechanical aortic valve, she remains on a Heparin IV infusion at 1050 U/hr with a target PTT of 60-80, until her INR is above 2.5, and then this Heparin may be discontinued when her Coumadin is dosed to give her an INR above 2.5, Albuterol 2 puffs q.6 hours, Lansoprazole 30 mg q.d., Glipizide 10 mg b.i.d., Santal ointment b.i.d. to her leg wound with saline wet-to-dry dressing to cleanse in between Santal, Percocet p.r.n., sliding scale regular Insulin coverage for blood glucose of 150-200 she receives 3 U subcutaneous regular Insulin, 201-250 6 U, 251-300 9 U. DISCHARGE INSTRUCTIONS: The patient's tube feeding through her PEG tube is Promote with Fiber at 55/hr which is her goal. She needs to have her coagulation parameters monitored very closely until she is on a stable Coumadin dose. FOLLOW-UP: The patient is to follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 284] in Electrophysiology here at [Hospital6 649] upon discharge from rehabilitation. She is also to follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] of the Cardiothoracic Surgery Service upon discharge from rehabilitation. Her cardiothoracic surgery office number is [Telephone/Fax (1) 170]. In addition, she should follow up with her referring PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 964] MEDQUIST36 D: [2104-3-24] 13:12 T: [2104-3-24] 13:30 JOB#: [Job Number 31607] Name: [Known lastname ], [Known firstname 2189] M Unit No: [Numeric Identifier 5497] Admission Date: [2104-1-30] Discharge Date: [2104-3-21] Date of Birth: [2029-8-6] Sex: F Service: ADDENDUM: For History of Present Illness, see previous dictation. The patient will be discharged on a heparin drip at 1050 units per hour, and her PTT today was 75. Her goal PTT is between 60 to 80. She will remain on a heparin drip until her INR is therapeutic. She will be discharged on Coumadin 5 mg p.o. q.d. Please check INR. Today, [2104-3-21], the patient had a slightly evaluated white blood cell count of 18; however, she did not have any fevers, and her physical condition appeared to be good. DISCHARGE DISPOSITION: She was to be discharged to a rehabilitation facility. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. Please check a complete blood count on [3-22] and see which way her white blood count has trended. Currently, she is not on antibiotics. 2. Additionally, please keep a pressure dressing over her left automatic internal cardioverter-defibrillator placement site. DR.[Last Name (STitle) ],[First Name3 (LF) ] 02-229 Dictated By:[Dictator Info 5498] MEDQUIST36 D: [2104-3-21] 09:09 T: [2104-3-21] 09:34 JOB#: [Job Number 5499]	[ "518.81", "410.71", "414.02", "276.2", "785.51", "427.1", "997.3", "998.12", "414.01" ]	icd9cm	[ [ [] ] ]	[ "37.94", "36.06", "96.6", "37.23", "36.01", "38.95", "39.95", "36.12", "39.61", "99.20", "88.56", "37.61", "31.1" ]	icd9pcs	[ [ [] ] ]	27340, 27396								24483, 25442		23640, 24459			12500, 22962		25467, 27316			27429, 27916																		11848, 12482																	9575, 10869														11560, 11825	10892, 11534		22987, 23619
518	106,955	44015	Discharge summary	report	Admission Date: [2109-4-12] Discharge Date: [2109-4-15] Date of Birth: [2062-9-18] Sex: M Service: MEDICINE Allergies: Clindamycin Attending:[First Name3 (LF) 3556] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Dialysis History of Present Illness: 46 y/o Ethiopian male hx T1DM, HIV, ESRD (secondary to nephrolithiasis, htn and T1DM) previously on HD since [7-14], has been on PD intermittently for several months, most recently started PD 3d PTA, last HD [4-8], removed 5kg) and peripheral neuropathy presents with dyspnea by EMS from dialysis (had PD overnight). Pt notes SOB since last night, + cough with clear sputum, + PND. No fever/chills/diarrhea/n/v/dysuria. + abd pain around PD stie with deep inspirationUsual SBP 150-180- baseline per OMR notes x 2 months. No recent diet or medication changes. . ED course: Temp 97.1, BP 215/95, HR 72, Sat 99% on 2l, started on nipride drip, titrated to 2mcg/kg/min, BP improved to 177/91. Initial K 7.5, hemolyzed, repeat K 5.0. Past Medical History: - Type 1 diabetes - HIV (boosted atazanavir, lamivudine, stavudine), dx'd [2096] - ESRD on HD, planned change to peritoneal dialysis in near future, on transplant list (clinical study for HIV/solid organ transplant) - Recent hospitalizations for Serratia bacteremia (presumed source AV graft) most recently treated with 6 week course meropenem - History of schistosomiasis - Restless leg syndrome - Peripheral neuropathy on gabapentin - S/p cholecystectomy Social History: Moved from [Country 4812] in [2091]. Lives with wife in [Location (un) 538]. Works in support services for a law firm. Denies any alcohol or IV drug use. Quit smoking last year; previous 30 pack-year history. Family History: Non-contributory. Physical Exam: T 97.2 HR 72 BP 188/84 RR 12 99% 2L NC General: appears to be more comfrtable, speaks in full sentences, NAD HEENT: anicteric, OP clear Neck: No LAD or difficult to see JV CV: RRR, Normal S1, S2 without m/r/g. Pulm: crackles [12-12] way up b/l, no wheezes Abd: LLQ with PD catheter appears clean, although no dressing in place, soft, ND, ND, no HSM Ext: 2+ edema nonpitting b/l, 2+ distal pulses Neuro: CNs II-XII grossly intact. A/O x 3. Skin: No rash Pertinent Results: [2109-4-12] 06:25AM WBC-4.6 RBC-2.90* HGB-10.6* HCT-31.7* MCV-109* MCH-36.6* MCHC-33.5 RDW-16.5* [2109-4-12] 06:25AM NEUTS-63.6 LYMPHS-21.8 MONOS-6.6 EOS-7.6* BASOS-0.3 [2109-4-12] 06:25AM CALCIUM-8.7 PHOSPHATE-5.8* MAGNESIUM-2.8* [2109-4-12] 06:25AM cTropnT-0.21* proBNP-[Numeric Identifier 94326]* [2109-4-12] 06:25AM GLUCOSE-92 UREA N-96* CREAT-13.2# SODIUM-137 POTASSIUM-7.5 CHLORIDE-97 TOTAL CO2-24 ANION GAP-24* . CT w/o contrast: CT OF THE CHEST: Compared to prior CT from [2109-3-26], there is almost mareked improvement in the diffuse bilateral peribronchiolar opacities. Since the last exam, there is interval developmen of a wedge-shaped area of consolidation within the left lung base, which may represent a pneumonia, however given its shape cannot exlude infarction. Again seen are small bilateral pleural effusions, not significantly changed. The heart and pericardium are unremarkable. Small mediastinal lymph nodes are seen which do not meet CT criteria for pathologic enlargement. The visualized upper abdomen is unremarkable. Bone windows demonstrate no suspicious lytic or sclerotic lesion. Surgical clips are seen adjacent to the right crus of the diaphragm. A right subclavian central venous catheter is seen with tip in the distal SVC. IMPRESSION: Compared to the prior CT from [2109-3-26], there is marked improvement of the previously noted peribronchiolar opacities within both lungs. However, there is development of a new wedge-shaped opacity within the left lower lobe concerning for pneumonia versus infarction. Stable bilateral small pleural effusions. . CTA [2109-4-14]: CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: 10-mm hypodense focus in the left thyroid lobe. No filling defects are noted within the main pulmonary artery and its branches. The previously described wedge-shaped opacity in the left lung base is not seen on the current study. A rounded small pleural- based opacity in the posterior aspect of the left lung base is seen and unchanged when compared to a study dated [2109-4-13]. The airways are patent to the segmental levels, bilaterally. Small mediastinal and axillary lymph nodes, not pathologically enlarged by CT criteria are again noted, unchanged. Heart and great vessels are unchanged. No evidence of pericardial effusions. Emphysematous changes are again seen. Diffuse mild bilateral ground-glass opacities are unchanged when compared to a prior study. The liver demonstrates two small hypodensities measuring 9 mm and 1.7 cm in segment V and VIII, respectively previously characterized as hemagioma. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Interval resolution of the left lower lobe wedge-shaped opacity. Brief Hospital Course: A&P: 46 yo M hx T1DM, HIV, ESRD p/w dyspnea, elevated BP, low grade fevers and cough. . # SOB and HTN: The patient presented to the ED with fluid overload and hypertensive urgency and was started on a nipride drip. On transition to the inpatient setting he was converted to a labetalol drip to avoid buildup of cyanide biproducts while he awaited hemodialysis. His dyspnea was well controlled on reaching the floor and remained well controlled throughout his hospital stay. His hypertension continued to be an issue following his first dialysis session, despite the removal of 5.2 L of fluid during that session. He was continued on labetalol drip to maintain SBP < 180 with 160 as target. Following his second dialysis treatment on hospital day 2, he weighed 57kg, which was considered his new dry weight. For improved BP control, he was started on 20 mg Lisinopril per recommendation of the renal team. He also continued his outpatient regimen of 160 diovan [Hospital1 ] and 50 atenolol QD. Although his pressure was better controlled, he still had breaks into the 180s and his pressure control will need to be optimized as an outpatient. . Renal: The patient had recently transitioned from hemodialysis to peritoneal dialysis, which was apparently insufficient, resulting in fluid overload, hypertension and admission. The patient was discharged with plans to resume hemodialysis at his previous hemodialysis center under the care of his outpatient nephrologist. His next hemodialysis treatment was scheduled for Wed. [4-17]. . HIV: The patient's HAART regimen was continued. . Anemia: Continue epogen at HD. . # Fevers: The patient briefly spiked a fever on [4-13] and underwent non-con CT of the chest. He had increasing cough as well. Sputum and blood cultures were negative. The patient's non-con Chest CT demonstrated a peripheral wedge shaped opacity, and the patient was started on vancomycin and zosyn, given his relative immunosuppression and his recent hospitalization with full course of levofloxacin. A follow-up CTA was done to rule out PE and showed complete resolution of the wedge shaped area, which presumably was simply atelectasis. However, the lung was not entirely clear, and it was felt prudent to continue an [7-19] day course of IV antibiotics. For this reason, the patient was dosed one gram of ceftazadine and one gram of vancomycin following his dialysis on [Last Name (LF) 766], [4-15] and he was written a prescription to receive one gram of vancomycin and one gram of ceftazadine after each of his dialysis sessions on [4-17] and [4-19]. (and then the course would end). On the day of discharge, the patient's nasal viral swab returned positive for parainfluenza virus. As discussed with ID, the patient's CT and clinical findings could all be explained by parainfluenza virus, but there was also a significant chance for bacterial superinfection. Thus, the antibiotic course was planned as described above. . He was also scheduled for followup with his infectious disease physicians on [4-23]. . Medications on Admission: Gabapentin 100 mg tid Atenolol 50 mg PO daily Valsartan 160mg [Hospital1 ] Compazine PRN Insulin (NPH 10 U [Hospital1 ] and Regular 5 U QAM) Tenofovir 300 mg PO QSAT Ritonavir 100 mg p.o. daily Atazanavir 300 mg p.o. daily Stavudine (Zerit) 20 mg PO QHD DAYS after HD Lamivudine (Epivir) 25 mg PO after HD on HD days Discharge Medications: 1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 6. Lamivudine 10 mg/mL Solution Sig: Twenty Five (25) mg PO DAILY (Daily): Take orally after hemodialysis on hemodialysis days. . 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Prochlorperazine 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Nausea. 11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 12. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:20 Capsule(s) Refills:2 13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: per regimen Subcutaneous twice a day. 14. Ceftazidime 1 g Recon Soln Sig: One (1) Intravenous at dialysis for 2 doses: Patient should receive 1 gram of ceftazadime administered at his dialysis center after dialysis on [4-17] and [4-19]. . Disp:2 doses Refills:0 15. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous at dialysis for 2 doses: 1 gram, to be given after dialysis at 5/9 and [4-19]. Disp:2 doses Refills:0 Discharge Disposition: Home Discharge Diagnosis: End stage renal disease requiring regular hemodialysis Parainfluenza viral infection HIV Hypertensive urgency Volume overload Discharge Condition: Good Discharge Instructions: You were admitted with elevated blood pressure and respiratory difficulty which improved with dialysis. However, your blood pressure continues to be elevated at times throughout the day. You will need to work with your clinic physicians to improve your blood pressure. Elevated blood pressures for a long period of time with increase your risk of stroke and heart disease. . You have a cough and imaging of your chest showed that you may have a small infection. For this you need to have IV antibiotics (ceftazadine and vancomycin) administered at your next two dialysis sessions on Wednesday [4-17] and Friday [4-19]. You have been given prescriptions for these two antibiotics and your physician at dialysis has been informed. . In addition, you should check your temperature on a daily basis and any time that you feel sick. If you have a temperature greater than 100.4 that does not resolve quickly, you should call your primary care physician. . You had testing for TB during this hospitalization which was negative. One of your tests is still pending. If this test is positive, you will be contact[Name (NI) ]. Your physicians at [Hospital3 ] also will have access to these results when you come in for appointments. . You will need regular dialysis. Your next dialysis [Hospital3 648] is scheduled for Wednesday, [4-17] at 6:45 AM. It is vital that you do not miss [First Name (Titles) ] [Last Name (Titles) 648]. . Please keep your other appointments listed in the appointments section. These doctors [Name5 (PTitle) ] help [Name5 (PTitle) ] with your blood pressure. . You have been started on a new blood pressure medication called lisinopril. You should take this medication as prescribed, and continued taking your other blood pressure medications. Followup Instructions: DIALYSIS at your regular dialysis center: Wednesday, [4-17] at 6:45 AM. . Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name 9406] Phone:[Telephone/Fax (1) 457] Date/Time:[2109-4-23] 10:00 . Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2109-5-14] 9:10 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560] Completed by:[2109-5-8]	[ "333.94", "356.9", "357.2", "486", "042", "250.61", "403.91", "428.0", "585.6" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	10155, 10161	5146, 8214	280, 291	10331, 10338	2315, 5123	12187, 12742	1803, 1822		8589, 10132		10182, 10310		8240, 8566			10362, 12164									1837, 2296																							233, 242						319, 1063															1085, 1548	1564, 1787
27,210	167,674	27254	Discharge summary	report	Admission Date: [2165-5-20] Discharge Date: [2165-5-23] Date of Birth: [2142-10-11] Sex: F Service: MEDICINE Allergies: Haldol / Oxycodone / Demerol / Ms Contin / Penicillins / Fentanyl Attending:[First Name3 (LF) 5119] Chief Complaint: diarrhea, abdominal pain, diabetic ketoacidosis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname ] is a 22 year old female with Type I DM complicated by gastroparesis, chronic abdominal pain thought secondary to chronic pancreatitis and severe personality disorder presenting with . Of note she has had numerous admission for abdominal pain, nausea and vomiting thought to be due to chronic pancreatitis/gastroparesis. These admissions have been complicated by narcotic seeking behaviors, refusal of po medications, insisting IV narcotics and threatening her care providers when she does not get IV mediations. Of note, she was recently terminated from her PCP practice because of failure to adhere to behavioral contract. . In the ED T98 BP 128/87 HR 122 RR 24 98% RA. She was found to be hyperglycemia with glucose of 440 on arrival. She had positive anion gap on admission, urine ketones negative. She was give 1L NS, 10 units regular insulin IV and started on an insulin gtt at 8 units per hour. When she was denied IV pain medications by the ED physicians she repeatedly turned off her IV fluids and refused treatment. Past Medical History: #. Type I DM (since age 12, c/b severe gastroparesis) #. Chronic pancreatitis #. Chronic abdominal pain - unclear etiology likely multifactorial [3-11] chr pancreatitis, gastroparesis and psychosocial factors - patient is on a strict pain regimen outlined in OMR #. H/o PUD secondary to H. pylori #. Gastritis #. Iron deficiency anemia #. Right adnexal cyst #. Status post cholecystectomy ([1-11]) #. Asthma #. Urinary retention (worsened by dephenhydramine and narcotics previously) #. H/o line infections #. Depression & borderline personality disorder; h/o cutting behavior and SA but none > 1 year. Multiple prior admissions Social History: The patient was born and raised in the [Country 13622] Republic. She was sent to the US at age 11-12 years due to onset of medical problems. She previously lived with her father until she was turned out prior to third psychiatric hospitalization. She has been homeless off and on and currently lives in group home. She has a legal/[Doctor Last Name ] guardian [Name (NI) 919] [Last Name (NamePattern1) ] Tobacco: Smokes one ppd ETOH: Reports none Illict: Reports none Family History: Non-contributory Physical Exam: T96.8 HR 102 BP 135/77 RR 17 97% RA Gen: A&0 x 3, tearful HEENT: nc at eomi perrla Neck: supple, no lad CV: rrr s1 s2 no appreciable murmur Abd: obese, soft, diffuse tenderness, no rebound or guarding, hypoactive bowel sounds Ext: warm, no pedal edema, dp's palpable Pertinent Results: Admission Labs: [2165-5-20] 09:15PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.031 [2165-5-20] 09:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2165-5-20] 09:15PM URINE RBC-[4-11]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[4-11] [2165-5-20] 09:02PM GLUCOSE-473* UREA N-16 CREAT-0.8 SODIUM-134 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-16* ANION GAP-25* [2165-5-20] 09:02PM estGFR-Using this [2165-5-20] 09:02PM ALT(SGPT)-95* AST(SGOT)-61* LD(LDH)-398* ALK PHOS-215* TOT BILI-0.4 [2165-5-20] 09:02PM LIPASE-23 [2165-5-20] 09:02PM ALBUMIN-4.8 PHOSPHATE-3.5 MAGNESIUM-2.0 [2165-5-20] 09:02PM OSMOLAL-308 [2165-5-20] 09:02PM WBC-10.0 RBC-4.63 HGB-15.5 HCT-43.2 MCV-93 MCH-33.6* MCHC-36.0* RDW-13.5 [2165-5-20] 09:02PM NEUTS-73.7* LYMPHS-21.8 MONOS-3.1 EOS-0.6 BASOS-0.7 [2165-5-20] 09:02PM PLT COUNT-346 [2165-5-20] 08:59PM GLUCOSE-440* LACTATE-4.0* NA+-138 K+-4.9 . Discharge Labs: Imaging: CXR: SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: Heart size, mediastinal and hilar contours are normal and unchanged. There is no focal parenchymal opacification. There is no pleural effusion or pneumothorax. Pulmonary vasculature is normal. Osseous structures are grossly unremarkable. A tubular structure is partly visualized at the inferior aspect of the film. IMPRESSION: No acute cardiopulmonary process . RUQ Ultrasound: Grayscale and color Doppler son[Name (NI) 493] images were obtained which demonstrates the liver to be of normal echotexture and echogenicity. No focal hepatic lesion is seen. There is no ascites. Main portal venous flow is hepatopetal. There is no intra- or extra-hepatic bile duct dilatation with the common bile duct measuring 3 mm. The patient is status post cholecystectomy. The gallbladder is not visualized. The visualized right kidney is normal. IMPRESSION: 1. No intra- or extra-hepatic bile duct dilatation. 2. No ascites. 3. Status post cholecystectomy . MICRO: Blood 4/14: NGTD urine [5-21]: NGTD MRSA [5-21]: NGTD Brief Hospital Course: Ms. [Known lastname ] is a 22 year old female with Type I DM complicated by gastroparesis, chronic abdominal pain thought secondary to chronic pancreatitis and severe personality disorder admitted with diabetic ketoacidosis. Her hospital course is as follows: . DKA: The patient was admitted with an anion gap of 20 in DKA. Blood and urine cultures were drawn, but the cause was thought to be due to medication non-adherence. She was aggressively volume resuscitated and started on an insuling drip and admitted to the MICU. Her anion gap corrected quickly. [Last Name (un) ] was consulted and recommended resuming her NPH at 30units [Hospital1 ] as well as a HISS. She was tolerating small POs. Her blood sugars were stable in the low 200s on transfer from the MICU. On the floor she was generally non-compliant with her fingersticks and her diet. Whenn they were checked they were in the 200s range. . Chronic Abdominal Pain: The patient has not receiving opiates from her outpatient physician because of drug seeking behavior. She has broken pain contracts in the past and is trying to find a PCP that id willing to prescribe her medication. LFTs were mildly abnormal but RUQ was unremarkable. She was initially treated in the ICU with her PO dilaudid 2mg PO q6prn as well as diazepam 5mg PO q6prn. The patient would benefit from detox placement but she declined. She often complained that 2mg was not touching her pain and she needed more. After speaking with the patient's guardian, the decision was made not to continue her pain medications further. We feel that the pain meds is causing her more harm than good. The patient was not given any pain meds at discharge and I would recommend that she not be given any in the future unless any significant pathology is found. The patient was given reglan to help with nausea symptoms that she may experience with withdrawal. She was encouraged to take her diazepam as well. . Depression: Her seroquel and diazepam were continued with good effect. . Asthma: Stable on her outpatient regimen . Dispo: The patient was discharged to her group [Last Name (un) ] ein stable conodition. Medications on Admission: Quetiapine 200 mg Tablet Sustained Release PO QHS Zolpidem 10 mg Tablet PO HS Albuterol One Puff Inhalation Q6H as needed Fluticasone-Salmeterol 250-50 mcg One Inhalation [Hospital1 ] Gabapentin 300 mg PO HS Diazepam 5 mg PO Q6H as needed for anxiety. Multivitamin PO DAILY Docusate Sodium 50 mg/5 mL Ten (10) ml PO BID NPH 42 units qam and 40 units qpm Humalog sliding scale Protonix 40 mg Tablet daily Hydromorphone 1 mg/mL Liquid Sig: (2) mg PO q6 h prn pain Discharge Medications: 1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:30 Tablet(s) Refills:0 3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 9. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty Two (42) units Subcutaneous qam. 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty (40) units Subcutaneous qpm. 12. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: AS DIR Subcutaneous AS DIR: AS PER SLIDING SCALE. Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Discharge Condition: Fair Discharge Instructions: Your were admitted for diabetic ketoacidosis. You need to take your insulin as prescribed and follow a diabetic diet. You are high risk for becoming acidotic again ir you do not. Acidosis can be lifethreatening and result in coma or death. . -We strongly encourage you to pursue detox placement for your addiction to narcotics. -We will not be giving you narcotics. We will give you medications that will help with the signs/symptoms of opiate withdrawal. -We recommend following up with your PCP even through they will not give you pain medications. Followup Instructions: Provider: [First Name4 (NamePattern1) 1386] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2165-6-11] 9:45 Provider: [Name10 (NameIs) 6122] WEST OUTPATIENT RADIOLOGY Phone:[Telephone/Fax (1) 8243] Date/Time:[2165-7-16] 9:30 [First Name7 (NamePattern1) 1569] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 5122] Completed by:[2165-5-23]	[ "305.1", "301.9", "493.90", "V58.67", "250.13", "311", "577.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9059, 9065	5096, 7261	375, 381	9131, 9138	2963, 2963	9741, 10192	2642, 2660		7778, 9036		9086, 9110		7287, 7755			9162, 9718				3999, 5073					2675, 2944																							288, 337						409, 1464					2979, 3982										1486, 2124	2140, 2626
5,503	117,578	10896	Discharge summary	report	Admission Date: [2168-12-14] Discharge Date: [2168-12-19] Date of Birth: [2114-1-5] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 28989] is a pleasant, 54-year-old male with a known history of coronary artery disease with a catheterization in [Month (only) 205] of this year which showed 3-vessel coronary artery disease. However, the patient was ultimately referred to outpatient medical therapy because he denied permission for a coronary artery bypass graft. His symptoms persisted with angina on exertion and had a positive stress test approximately one month ago. Ultimately, he agreed to a coronary artery bypass graft and was transferred from the [Hospital3 15174] where he was recently admitted for substernal chest pressure and a rule out myocardial infarction protocol. PAST MEDICAL HISTORY: The patient's past medical history is significant for cardiac risk factors of hypercholesterolemia, positive family history, as well as hypertension. He did have a non-Q-wave myocardial infarction in [2168-7-10]. He has had low back pain chronically requiring narcotics to treat. He did fracture his right foot 10 years ago. PAST SURGICAL HISTORY: His past surgical history included tonsillectomy. He has had a lymph node removed from his neck 35 years ago, and a hair implant 20 years ago. REVIEW OF SYSTEMS: Review of systems was notable just for exertional substernal chest pain relived with nitroglycerin. He had no respiratory complaints. MEDICATIONS ON ADMISSION: His medications on admission were atenolol 12.5 mg p.o. q.d., aspirin, Lipitor, nitroglycerin. ALLERGIES: He has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: His examination was notable for a blood pressure of 100/70, heart rate of 60, in no acute distress. His head, ears, nose, eyes and throat examination revealed pupils were equal, round, and reactive to light and accommodation. Mucous membranes were moist. His trachea was midline. No bruit. Heart had a regular rate and rhythm with no murmurs. Lungs were clear to auscultation bilaterally. His abdomen was soft, nontender, and nondistended, with no bruit. His extremities were normal. There were normal palpable posterior tibialis and dorsalis pedis pulses bilaterally. LABORATORY DATA ON PRESENTATION: His admission laboratories were notable for white blood cell count [Pager number ], hematocrit 39, platelets 84,000. Chemistries were sodium of 137, potassium 4.4, chloride 100, bicarbonate 27, blood urea nitrogen 18, creatinine 1.2, glucose 101. PT and INR were within normal limits. HOSPITAL COURSE: He was therefore admitted on [12-14] to the Cardiothoracic Surgery Service to have his coronary artery bypass graft to be completed on [2168-12-16]. Additional information about the admission workup included a chest x-ray that was negative. A urinalysis that was also negative. The patient went to the operating theater on [2168-12-16] with Dr. [Last Name (STitle) 1537], where he underwent a 4-vessel coronary artery bypass graft. He received grafts including left internal mammary artery to the left anterior descending artery, left radial graft to the PL, as well as saphenous vein graft to the first obtuse marginal, sequential to the diagonal. Postoperatively, he was transferred to the Intensive Care Unit where he was on nitroglycerin, propofol, and Neo-Synephrine. On postoperative day one the patient was taken off of Pressonex. His Neo-Synephrine was weaned to off. He was placed on a cardiac diet. He was started on Lopressor, Lasix, and aspirin. His postoperative hematocrit was 26, white count of 15,000. Platelets were 319. Blood urea nitrogen and creatinine of 15 and 0.8. Ultimately, he was transferred to the floor on postoperative day one. His postoperative course was complicated only by high pain requirement. The patient ultimately had an Acute Pain consultation and was placed on oxycodone 10 mg to 20 mg p.o. q.4h. p.r.n. as well as Tylenol 650 mg p.o. q.4-6h. p.r.n. On postoperative day three, his temperature was noted to be 101.5. He was cultured times two. Additionally, he got a chest x-ray that showed a new left retrocardiac density since surgery which was suspicious for a possible pneumonia. Urinalysis was negative. Blood cultures did not grow out anything during his hospital course. He was empirically started on Levaquin and Flagyl to treat presumed pneumonia. His temperature curve quickly defervesced once he was started on the empiric therapy. His pain was well controlled. He was ambulating and voiding spontaneously. Portable chest x-ray showed no evidence of pneumothorax, just small bilateral effusions, right greater than left. Additionally, the aforementioned retrocardiac densities were present on the left side. By postoperative day four, the patient was ambulating a level V and had completed stairs. His discharge laboratories were notable for a hematocrit of 23, a white blood cell count of 13,000, as well as blood urea nitrogen of 16, and creatinine of 0.8. His discharge examination was notable for a temperature of 98, pulse 87, blood pressure 115/70, respiratory rate 20, 92% on 2 liters, in no acute distress. His sternum was stable. There was no drainage. No was no erythema. The staples were intact. His heart was regular with no murmur. His lungs were clear to auscultation except for decreased breath sounds, left greater than right. No crackles were present, however. His abdomen was benign. His lower extremities were warm and well perfused with palpable dorsalis pedis and posterior tibialis pulses bilaterally. MEDICATIONS ON DISCHARGE: (The patient's discharged medications included the following) 1. Lopressor 25 mg p.o. b.i.d. 2. Lasix 20 mg p.o. q.d. times seven days. 3. K-Dur 20 mEq p.o. q.d. times seven days. 4. Colace 100 mg p.o. b.i.d. while he is taking oxycodone. 5. Oxycodone 10 mg to 20 mg p.o. q.4h. p.r.n. 6. Zantac 150 mg p.o. b.i.d. 7. Aspirin 325 mg p.o. q.d. 8. Tylenol 650 mg p.o. q.4-6h. p.r.n. 9. Levaquin 500 mg p.o. q.d. for a total course of seven days (to be completed by [2168-12-26]). 10. Flagyl 500 mg p.o. t.i.d. (to be completed by [2168-12-26]). DISCHARGE FOLLOWUP: The patient's follow up will include being seen by Dr. [Last Name (STitle) 1537] in one month from the time of discharge. He will require no home services with [Hospital6 3429]. He was to be seen in the Wound Care Clinic one week from the time of this discharge. DISCHARGE STATUS: The patient's disposition was to home. CONDITION AT DISCHARGE: Condition on discharge was stable, afebrile. DISCHARGE DIAGNOSES: Status post 4-vessel coronary artery bypass graft for unstable angina. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern4) 3204] MEDQUIST36 D: [2168-12-20] 17:27 T: [2168-12-20] 16:54 JOB#: [Job Number 35452]	[ "413.9", "486", "997.3", "401.9", "412", "414.01", "V15.82", "272.0" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.19", "36.12" ]	icd9pcs	[ [ [] ] ]								6754, 7109				5735, 6305	1578, 2661	2680, 5708										1251, 1396														6685, 6731					1416, 1551								6327, 6670			185, 870															893, 1226
60,575	103,019	18149	Discharge summary	report	Admission Date: [2113-3-12] Discharge Date: [2113-3-19] Date of Birth: [2036-4-12] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Tape / Lipitor Attending:[First Name3 (LF) 1505] Chief Complaint: Fatigue/Dyspnea on exertion Major Surgical or Invasive Procedure: [2113-3-14] Coronary artery bypass graft x 1, aortic valve replacement with [Street Address(2) 6158]. [Male First Name (un) 923] porcine valve [2113-3-14] Right axillary 8 mm Dacron conduit. History of Present Illness: 76 year old female with history of paroxysmal SVT including paroxysmal atrial fibrillation and flutter, high degree AVB s/p dual chamber pacemaker and coronary artery disease with prior LAD stenting who has been followed by serial echaocardiograms for worsening aortic insufficiency. Over the past year, she has noticed a significant decline in her exercise tolerance. She has gone from being able to walk 30minutes on a treadmill to now experiencing significant dyspnea climbing stairs or walking up a [Doctor Last Name ]. She underewent a cardiac catheterization in [2112-10-2] which revealed recurrent left anterior descending artery disease and mild right coronary artery disease. Given the progression of her symptoms and her worsening aortic insufficiency, she has been referred for surgical evaluation. Past Medical History: -history of paroxysmal SVT including paroxysmal atrial fibrillation/flutter (27% of the time, up from 14% on recent Holter) -Coronary Artery Disease s/p prior LAD stenting [6-2] -Hypertension -Hyperlipidemia -Hypothyroidism -glaucoma s/p laser therapy -Hx of Meniere's (not currently a problem) -Breast CA [2070] s/p left radical mastectomy and chest radiation with persistent left arm lymphedema and recurrent cellulitis in left arm -Tracheobronchomalacia (Mild) and Pulmonary nodules on right (mild) -moderate aortic stenosis and mitral regurgitation, moderate pulmonary hypertension -Anemia -Hiatal hernia -Glaucoma s/p laser therapy -Susceptible to pneumonia Past Surgical History: -s/p dual chamber pacemaker for high degree AVB [2104], generator change [10-10] -s/p left radical mastectomy [2070] with radiation -s/p thyroidectomy for benign thyroid nodule -s/p bilateral cataract surgery -s/p left eye [Last Name (un) ] surgery -s/p cataract surgery Social History: Lives in [Location ] alone, goes to [State 108] in the winter. -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mother had heart surgery in her 80's. Physical Exam: Pulse: 70 Resp: 16 O2 sat: 100% B/P Right: 123/59 Left: - mastectomy side Height: 5'5" Weight: 161 lbs General: Well-devloped, well-nourished elderly female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR, High picthed III/VI SEM radiating to left carotid Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema: Left arm lymph edema noted. No peripheral edema of LE's. Varicosities: some bilateral, GSV appeared suitable on previous exam in [Month (only) 956]. 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 Transmitted vs bruit bilaterally Pertinent Results: [3-14] Echo: PRE-BYPASS: The left atrium is moderately dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the body of the right atrium. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. There is severe thickening of the mitral valve chordae. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Preserved [Hospital1 ]-ventricular systolic function. 2. Bioprosthetic valve in aortc position. Well seated, stable and has good leaflet excursion. 3. No AI, Peak gradient = 18 mm Hg. 4. MR is now trace to mild. 5. Intact aorta and no other change. [2113-3-19] 05:25AM BLOOD WBC-6.7 RBC-3.13* Hgb-9.1* Hct-27.3* MCV-87 MCH-29.1 MCHC-33.4 RDW-15.4 Plt Ct-243 [2113-3-19] 05:25AM BLOOD PT-19.2* PTT-28.7 INR(PT)-1.8* [2113-3-18] 04:40AM BLOOD Plt Ct-187# [2113-3-19] 05:25AM BLOOD Plt Ct-243 [2113-3-18] 04:40AM BLOOD PT-17.2* INR(PT)-1.5* [2113-3-18] 04:40AM BLOOD Glucose-112* UreaN-15 Creat-0.7 Na-138 K-3.9 Cl-104 HCO3-27 AnGap-11 [2113-3-18] 04:40AM BLOOD WBC-7.7 RBC-3.16* Hgb-9.2* Hct-27.3* MCV-87 MCH-29.1 MCHC-33.6 RDW-15.5 Plt Ct-187# Brief Hospital Course: Ms. [Known lastname 50183] was admitted to the [Hospital1 18] on [2113-3-12] for surgical management of her cardiac disease. She was placed on heparin as she had been off Coumadin in preparation for surgery. She was worked-up in the usual preoperative manner. On [2113-3-14], she was taken to the operating room where she underwent right axillary artery cannulation with and aortic valve replacement and coronary artery bypass grafting to one vessel. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next 24 hours, she awoke neurologically intact and was extubated. She was weaned from all vasoactive medications. The EP service interrogated her pacemaker without changing any settings. She was later transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. Chest tubes and pacing wires were removed per cardiac surgery protocol. Coumadin was resumed for her chronic atrial fibrillation and she is to have an INR drawn on [3-20] with results called to the [Hospital 197] Clinic. She was receiving her home dose of 3 mg po daily. The physical therapy service worked with her daily to increase strength and endurance. On post operative day 5 she was tolerating a full oral diet, ambulating without difficulty and her incisions were healing well. It was felt that she was safe for discharge home with visiting nurse services at this time. Medications on Admission: Coumadin 4mg Fridays and 3mg all other days ([Hospital 197] clinic with Dr. [Last Name (STitle) ]- LAST DOSE [2113-3-9] Proair HFA 90mcg 1-2puffs every 4 hours prn Cephalexin 2grams 1 hour prior to dental work and 1gram 6 hours after. Lasix 40mg daily Synthroid 112mcg daily Mastectomy bra Metoprolol succinate 100mg daily Ramipril 10mg daily Zocor 40mg daily Aspirin 81mg daily Calcium 500 + D 500mg (1250mg)-200U twice daily Systane eye drops Fibercon 625mg daily Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 9. 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 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 12. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 1 Refills:0 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed daily for INR goal 2.0-2.5. Disp:30 Tablet(s) Refills:0 16. Multivitamin with Iron-Mineral Tablet Sig: One (1) Tablet PO once a day: Take at a separtate time from Synthroid. Disp:30 Tablet(s) Refills:1 17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 1 Aortic insufficiency s/p aortic valve replacement Past medical history: -history of paroxysmal SVT including paroxysmal atrial fibrillation/flutter (27% of the time, up from 14% on recent Holter) -Coronary Artery Disease s/p prior LAD stenting [6-2] -Hypertension -Hyperlipidemia -Hypothyroidism -glaucoma s/p laser therapy -Hx of Meniere's (not currently a problem) -Breast CA [2070] s/p left radical mastectomy and chest radiation with persistent left arm lymphedema and recurrent cellulitis in left arm -Tracheobronchomalacia (Mild) and Pulmonary nodules on right (mild) -moderate aortic stenosis and mitral regurgitation, moderate pulmonary hypertension -Anemia -Hiatal hernia -Glaucoma s/p laser therapy -Susceptible to pneumonia Past Surgical History: -s/p dual chamber pacemaker for high degree AVB [2104], generator change [10-10] -s/p left radical mastectomy [2070] with radiation -s/p thyroidectomy for benign thyroid nodule -s/p bilateral cataract surgery -s/p left eye [Last Name (un) ] surgery -s/p cataract surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [12-3] weeks ([Telephone/Fax (1) 1300] Cardiologist Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in [12-3] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Coumadin management postop with Dr. [Last Name (STitle) ]. Goal INR 2.0-2.5. Please have blood drawn (INR) on [2113-3-20] with results called to [Hospital 197] Clinic. Completed by:[2113-3-19]	[ "416.8", "427.32", "414.2", "V58.61", "V10.3", "519.19", "272.4", "414.01", "401.9", "428.0", "424.1", "428.30", "244.0", "V53.31", "424.0", "457.0", "V15.3", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.11", "35.21" ]	icd9pcs	[ [ [] ] ]	9595, 9653	5508, 7003	323, 531	10810, 10905	3593, 4695	11529, 12194	2550, 2704		7531, 9572		9674, 9785		7029, 7508			10929, 11506								10501, 10789	2719, 3574																							256, 285						559, 1378															9807, 10478	2398, 2534						4705, 5485
5,589	101,081	28390	Discharge summary	report	Admission Date: [2166-10-9] Discharge Date: [2166-10-29] Date of Birth: [2090-4-24] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x3 (off pump)(Left internal mammary artery -> left anterior descending artery, saphenous vein graft -> obtuse marginal, saphenous vein graft -> posterior descending artery) History of Present Illness: 75 year old male underwent routine stress test that was positive and underwent cardiac catherization [2166-10-9] at OSH which showed three vessel coronary artery disease and was transferred for surgical evaluation Past Medical History: Kidney Disease Coronary Artery Disease Gastroesophageal reflux disease benign prostatic hypertrophy Hypertension Elevated Cholesterol Gout Hypothyroid Social History: Married and lives with wife denies tobacco occasional ETOH Family History: non contributory Physical Exam: Admission General: well appearing, no acute distress Vitals: HR 56 SR, B/P 139/56, RR 14, RA sat 100% Wt 83.5kg Neuro: alert and oriented x3 PERRLA, EOMI, grip strengths and plantar flexion equal bilterally CV: RRR, no rub/murmur Resp: lungs clear bilaterally anterior GI: + bowel sounds, soft, nontender, nondistended, no masses Ext: warm, well perfused, no varicosities Pulses: palpable, no carotid bruit Discharge General: well appearing, no acute distress Vitals: Temp 99 HR 70 SR, B/P 125/60, RR 18, RA sat 95% Wt 83.6kg Neuro: alert and oriented x3 PERRLA, EOMI, R=L strength CV: RRR, no rub/murmur/gallop Resp: lungs clear bilaterally anterior and posterior GI: + bowel sounds, soft, nontender, nondistended, no masses Ext: warm, well perfused, pulses palpable - Left big toe warm edematous Inc: Sternal - stable no drainage, no erythema; Left leg endovascular harvest with steristrips no erythema or drainage Pertinent Results: [2166-10-9] 09:15PM PT-11.7 PTT-27.8 INR(PT)-1.0 [2166-10-9] 09:15PM PLT COUNT-128* [2166-10-9] 09:15PM WBC-7.7 RBC-4.52* HGB-13.9* HCT-41.2 MCV-91 MCH-30.7 MCHC-33.6 RDW-14.2 [2166-10-9] 09:15PM TSH-2.8 [2166-10-9] 09:15PM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [2166-10-9] 09:15PM ALT(SGPT)-10 AST(SGOT)-14 ALK PHOS-79 AMYLASE-75 TOT BILI-0.3 [2166-10-9] 09:15PM LIPASE-104* [2166-10-9] 09:15PM ALBUMIN-3.6 MAGNESIUM-2.0 [2166-10-9] 09:15PM GLUCOSE-99 UREA N-40* CREAT-2.3* SODIUM-144 POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-28 ANION GAP-12 [2166-10-29] 06:10AM BLOOD WBC-8.4 RBC-3.22* Hgb-9.8* Hct-29.4* MCV-91 MCH-30.3 MCHC-33.2 RDW-13.8 Plt Ct-205 [2166-10-29] 06:10AM BLOOD Plt Ct-205 [2166-10-17] 12:46PM BLOOD Eos Ct-470* [2166-10-29] 06:10AM BLOOD Glucose-96 UreaN-89* Creat-4.7* Na-138 K-4.7 Cl-104 HCO3-23 AnGap-16 [2166-10-26] 03:22AM BLOOD Glucose-102 UreaN-86* Creat-5.0* Na-138 K-4.0 Cl-106 HCO3-22 AnGap-14 [2166-10-24] 04:00AM BLOOD UreaN-75* Creat-5.3* Na-137 K-4.3 Cl-104 HCO3-23 AnGap-14 [2166-10-23] 01:36AM BLOOD Glucose-164* UreaN-64* Creat-4.7* Na-139 K-4.9 Cl-105 HCO3-25 AnGap-14 [2166-10-22] 12:00PM BLOOD Glucose-136* UreaN-55* Creat-3.8* Na-143 K-5.0 Cl-112* HCO3-22 AnGap-14 [2166-10-21] 11:30AM BLOOD Glucose-164* UreaN-51* Creat-2.7# Na-144 K-4.9 Cl-115 HCO3-19* AnGap-15 [2166-10-19] 04:50AM BLOOD Glucose-82 UreaN-64* Creat-3.8* Na-140 K-5.0 Cl-110* HCO3-20* AnGap-15 [2166-10-16] 06:20AM BLOOD Glucose-98 UreaN-57* Creat-2.9* Na-141 K-4.8 Cl-108 HCO3-22 AnGap-16 [2166-10-12] 04:45AM BLOOD Glucose-95 UreaN-60* Creat-3.1* Na-140 K-4.7 Cl-107 HCO3-24 AnGap-14 [2166-10-28] 06:00AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0 UricAcd-10.0* [2166-10-17] 05:35AM BLOOD calTIBC-224* Ferritn-260 TRF-172* [2166-10-16] 06:20AM BLOOD PTH-156* [2166-10-17] 05:35AM BLOOD C3-124 C4-34 [Last Name (un) ] DUP EXTEXT BIL (MAP/DVT) Reason: bilat upper extremity vein mapping for future AV fistula [Hospital 93] MEDICAL CONDITION: 76 year old man with REASON FOR THIS EXAMINATION: bilat upper extremity vein mapping for future AV fistula VENOUS DUPLEX UPPER EXTREMITY. REASON: Chronic kidney disease in need of placement of fistula. FINDINGS: Duplex evaluation was performed of both upper extremity venous systems. Both subclavian veins are patent and phasic. Both brachial arteries are patent with triphasic waveforms. Both cephalic veins show significant thrombophlebitis, right greater than left without evidence of extension into the deep system. Both basilic veins are patent. On the right, the diameter ranges from 0.30-0.57 cm and on the left 0.22-0.32 cm. IMPRESSION: Patent bilateral subclavian veins and bilateral brachial arteries. Patent bilateral basilic veins with diameters as noted. Thrombophlebitis in both cephalic veins, right greater than left as described above. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] ECHO MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 5 mm Hg Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A Ratio: 1.50 INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Complex (mobile) atheroma in the aortic arch. Normal descending aorta diameter. Complex (mobile) atheroma in the descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic 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 patient was under general anesthesia throughout the procedure. Suboptimal image quality. The patient appears to be in sinus the patient. Conclusions: 1. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 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%). Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are complex (mobile) atheroma in the aortic arch. There are complex (mobile) atheroma in the descending aorta. 5.The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). 7.There is a trivial/physiologic pericardial effusion. 8. Post revascularization LV and RV systolic function are unchanged. Electronically signed by [Name6 (MD) 1509] [Name8 (MD) 1510], MD on [2166-10-21] 16: RENAL U.S.; -59 DISTINCT PROCEDURAL SERVIC Reason: duplex to assess for renal artery stenosis//flow [Hospital 93] MEDICAL CONDITION: 76 year old man with CRI pre-op CABG REASON FOR THIS EXAMINATION: duplex to assess for renal artery stenosis//flow INDICATIONS: Chronic renal insufficiency. Three coronary artery bypass. Assess artery stenosis. RENAL ULTRASOUND: Comparison is made to [2166-10-10]. The study is limited by the patient's breath-holding ability for the Doppler portion. There is a discrepancy in renal size with the right kidney measuring 7.6 cm, and the left measuring 11.8 cm. There is no hydronephrosis or renal mass. Doppler assessment of blood flow to both kidneys was severely limited on the right, but there is a suggestion of a parvus tardus waveform. The peak velocity within the artery was 12.5 cm. The renal vein is patent. The left kidney was better evaluated, and the upstrokes appear more brisk with higher peak velocities. IMPRESSION: Small right kidney with findings most consistent with chronic right renal artery stenosis. MRI/MRA may be performed if there is unresponsive hypertension. CAROTID SERIES COMPLETE [2166-10-15] 8:50 AM CAROTID SERIES COMPLETE Reason: bruit [Hospital 93] MEDICAL CONDITION: 76 year old man with CAD REASON FOR THIS EXAMINATION: bruit CAROTID STUDY HISTORY: Coronary artery disease and a bruit. FINDINGS: Minimal plaque involving the ICA on the left only. The peak systolic velocities bilaterally are normal as are the ICA to CCA ratios. There is normal antegrade flow involving both vertebral arteries. IMPRESSION: Widely patent common and internal carotid arteries bilaterally. DR. [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6888] Approved: WED [2166-10-22] 9:00 AM Brief Hospital Course: Mr. [Known lastname 2026] was admitted from OSH for cardiac surgery evaluation. In preoperative evaluation he had renal consult that worked him up for increased creatinine. His creatinine continued to be elevated and wa closely monitored. On [10-21] he was transferred to the operating room for off pump coronary artery bypass graft surgery, please see operative report for further details. Surgery was uncomplicated and he was brought to the CSRU for invasive monitoring. He was weaned from sedation and and awoke neurologically intact. On posterative day 1 he was extubated without incident. He remained in the CSRU for close hemodynamic monitoring, respiratory management, and renal function. Nephrology continued to follow. He continued to progress physically but with elevated creatinine. He was transferred to [Hospital Ward Name ] 2 on postoperative day 6. His creatinine remained elevated with adequate urine output, allopurinol was restarted for elevated uric acid. On postoperative day 8 he was ready for discharge home with VNA services with follow up by own Nephrologist Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Medications on Admission: Nadolol, synthroid, lisinopril, proscar, prilosec, lipitor, ASA, allopurinol, folate Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. 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 10. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Outpatient Lab Work Uric Acid level qweekly please call results to Dr [Last Name (STitle) 68884] [Name (STitle) 745] ([Telephone/Fax (1) 68885]) and Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 53192]) 12. Outpatient Lab Work Lab work: SMA 7 twice weekly and as needed please call results to Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 53192]) and Dr [Last Name (STitle) 68884] [Name (STitle) 745] ([Telephone/Fax (1) 68885]) and Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 11763]. 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 14. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: s/p Coronary Artery Bypass Graft x3 (off pump) Non oliguric acute tubular necrosis Acute Gout Chronic Kidney Disease Coronary Artery Disease Gastroesophageal reflux disease benign prostatic hypertrophy Hypertension Elevated Cholesterol 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 [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) 68884] [Name (STitle) 745] in 1 week ([Telephone/Fax (1) 68885]) please call for appointment Dr [Last Name (STitle) 29070] in [2-14] weeks ([Telephone/Fax (1) 37284]) please call for appointment Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 1 week ([Telephone/Fax (1) 53192]) please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3633]) Nephrologist Dr [Last Name (STitle) ] for follow with lab results for renal function Completed by:[2166-11-4]	[ "244.9", "584.5", "414.01", "V70.7", "530.81", "997.5", "440.0", "250.00", "285.9", "276.50", "585.9", "403.90", "600.00", "412", "451.82", "411.1" ]	icd9cm	[ [ [] ] ]	[ "99.04", "36.12", "99.07", "36.15", "88.72", "99.05" ]	icd9pcs	[ [ [] ] ]	13475, 13509	10213, 11390	342, 550	13789, 13796	2034, 4062	14263, 14974	1063, 1081		11525, 13452	9631, 9656	13530, 13768		11416, 11502			13820, 14240									1096, 2015																							283, 304	9685, 10190					578, 797															819, 971	987, 1047
81,630	147,738	40919	Discharge summary	report	Admission Date: [2105-9-4] Discharge Date: [2105-9-10] Date of Birth: [2041-1-19] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2105-9-4] Aortic valve replacement with a 25-mm On-X mechanical valve; Pericardial reconstruction using the core matrix pericardial History of Present Illness: 64 year old male who has been followed by serial echocardiograms for several years because possibility of bicuspid aortic valve disease. In the fall of [2104] he began having symptoms of dyspnea on exertion. He decreased his activity and his symptoms have subsequently decreased. However when he over-exerts himself, such as mowing his lawn, he significant develops dyspnea on exertion. He denies chest pain, syncope, orthopnea, PND and pedal edema. His most recent echocardiogram in [2104-11-14] showed a trileaflet aortic valve with severe aortic stenosis. He was advised to undergo aortic valve replacement in [2105-2-14] but because of personal situations he delayed his surgery. Past Medical History: Aortic stenosis Diabetes Mellitus Hypercholesterolemia Hypertension Dyspepsia Benign prostatic hypertrophy Osteoarthritis Tobacco dependence Obesity Colonic adenoma Metatarsal fracture Polypectomy Left Wrist Fracture requiring surgery Social History: Lives with: Wife Occupation: Retired HVAC mechanic Tobacco: 40 PYH, Quit 2 months ago ETOH: Denies Family History: Father died of rheumatic heart disease at age 58. Mother died of cancer/lymphoma. Physical Exam: Pulse: 86 Resp: 17 O2 sat: 98% B/P Right: 138/88 Left: 135/90 General: WDWN male in no acute distress. Patient obese. Skin: Dry [x] intact [x]. There is a rash noted on his right antecubital region with central scale/flaking. The rash radiates out into a papular, erythematous rash. This was an attepmted site of his cardiac catheterization. HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 4/6 systolic ejection murmur radiating to carotids and precordium Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 1 Left: 1 DP Right: 1 Left: 1 PT [Name (NI) 167]: 1 Left: 1 Radial Right: 1 Left: 1 Carotid Bruit: transmitted murmurs bilaterally Pertinent Results: [2105-9-4] Intraop TEE PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([2-15]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: Preserved biventricular systolic function. LVEF 55%. There is a bimetallic prosthesis seen at the native aortic position, stable and f unctioning well. Residual mean gradient is 12 mm of Hg. Intact thoracic aorta. Discharge Labs: [2105-9-10] 02:52AM BLOOD WBC-8.9 RBC-3.18* Hgb-10.2* Hct-28.6* MCV-90 MCH-32.1* MCHC-35.6* RDW-14.0 Plt Ct-201# [2105-9-7] 04:07AM BLOOD WBC-10.7 RBC-3.35* Hgb-10.9* Hct-29.6* MCV-88 MCH-32.7* MCHC-37.0* RDW-14.0 Plt Ct-108* [2105-9-6] 06:20AM BLOOD WBC-14.9* RBC-3.65* Hgb-11.8* Hct-33.5* MCV-92 MCH-32.3* MCHC-35.2* RDW-14.0 Plt Ct-132* [2105-9-10] 02:52AM BLOOD PT-22.2* PTT-60.2* INR(PT)-2.1* [2105-9-9] 04:03AM BLOOD PT-15.7* PTT-32.4 INR(PT)-1.4* [2105-9-8] 05:26AM BLOOD PT-12.3 PTT-28.6 INR(PT)-1.0 [2105-9-7] 05:22AM BLOOD PT-12.7 INR(PT)-1.1 [2105-9-6] 06:20AM BLOOD PT-13.0 PTT-26.4 INR(PT)-1.1 [2105-9-10] 02:52AM BLOOD Glucose-142* UreaN-17 Creat-1.0 Na-139 K-4.0 Cl-102 HCO3-28 AnGap-13 [2105-9-7] 04:07AM BLOOD Glucose-167* UreaN-15 Creat-0.9 Na-138 K-3.8 Cl-99 HCO3-31 AnGap-12 [2105-9-6] 06:20AM BLOOD Glucose-192* UreaN-15 Creat-1.0 Na-136 K-4.3 Cl-100 HCO3-26 AnGap-14 [2105-9-5] 03:18AM BLOOD Glucose-134* UreaN-14 Creat-0.9 Na-137 K-4.9 Cl-106 HCO3-26 AnGap-10 [2105-9-7] 04:07AM BLOOD Mg-2.0 Brief Hospital Course: Admitted [2105-9-4] and underwent surgery with Dr. [Last Name (STitle) 914]. For surgical details, please see operative note. Following surgery, he was transferred to the CVICU in stable condition on titrated propofol and phenylephrine drips. Extubated later that day and transferred to the floor on POD #1 to begin increasing his activity level. Beta blockade slowly initiated and Warfarin started on POD #2 for mechanical aortic valve. He was bridged with IV heparin until therapeutic. INR was monitored daily and Warfarin was dosed for a goal INR between 2.0 - 2.5. Chest tubes and pacing wires removed per protocol. Over several days, he continued to make clinical improvements with diuresis and was cleared for discharge to home on postoperative day six when his INR rose over 2.0. Prior to discharge, arrangements were made with Dr. [Last Name (STitle) 89337] and the [Hospital1 ] Coumadin Clinc to monitor Warfarin as an outpatient. At discharge, he was in a normal sinus rhythm with 1+ pedal edema and oxygen saturations of 97% on room air. All wounds were clean, dry and intact. Medications on Admission: Simvastatin 20mg dialy Lisinopril 5mg daily Metformin 1000mg [Hospital1 ] Glipizide 2.5mg daily Aspirin 81mg daily Multivitamin daily Trazadone 100mg qhs Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 5. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 6. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Rel 24 hr(s) Refills:2 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed by [Hospital 197] Clinic. Daily dose may vary according to INR. tTitrate for goal INR between 2.5 - 3.0. Disp:60 Tablet(s) Refills:2 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 12. Potassium Chloride 20 meq daily for 7 days Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Aortic stenosis s/p mechanical AVR Diabetes Mellitus type 2 Hypercholesterolemia Hypertension Dyspepsia Benign prostatic hypertrophy Osteoarthritis Tobacco dependence Obesity Colonic adenoma Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - 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 4) 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 5) No lifting more than 10 pounds for 10 weeks 6) 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 Labs: PT/INR for Coumadin ?????? indication mechanical AVR Goal INR: 2.5 - 3.0 First draw day after discharge [2105-9-11] Please call results to [Hospital1 ] [Hospital 197] Clinic phone numbers [Telephone/Fax (1) 31020] or [Telephone/Fax (1) 82719]. Fax number is [Telephone/Fax (1) 31021] Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) 914] [Name (STitle) ] [9-29] @ 1:15 pm Cardiologist: Dr [Last Name (STitle) 6512] [10-9] @ 11:10 AM [Location (un) 1468] office Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) ] in [5-19] weeks [Telephone/Fax (1) 31019] 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 mechanical AVR Goal INR: 2.5 - 3.0 First draw day after discharge [2105-9-11] Please call results to [Hospital1 ] [Hospital 197] Clinic phone numbers [Telephone/Fax (1) 31020] or [Telephone/Fax (1) 82719]. Fax number is [Telephone/Fax (1) 31021] Completed by:[2105-9-10]	[ "305.1", "600.00", "746.4", "429.3", "401.9", "424.1", "V58.61", "272.0", "427.31", "278.00", "250.00" ]	icd9cm	[ [ [] ] ]	[ "39.61", "37.49", "35.22" ]	icd9pcs	[ [ [] ] ]	7555, 7630	4782, 5887	297, 437	7865, 8039	2575, 3675	9211, 10093	1553, 1637		6096, 7532		7651, 7844		5913, 6073			8063, 9188				3691, 4759					1652, 2556																							237, 259						465, 1162															1184, 1420	1436, 1537
27,808	166,072	34591	Discharge summary	report	Admission Date: [2103-9-26] Discharge Date: [2103-10-3] Date of Birth: [2031-7-26] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Streptokinase Attending:[First Name3 (LF) 1505] Chief Complaint: sternal click with coughing Major Surgical or Invasive Procedure: [2103-9-27] Replating of the sternum and bilateral pectoralis flaps History of Present Illness: 72 y/o female s/p CABG x 4 on [2103-9-17] who had uncomplicated post-op course and was discharged on [9-21]. She now returns with sternal pain and clicking when coughing. Past Medical History: Coronary Artery Diease s/p Myocardial infarction, s/p PCI to RCA, s/p CABGx3 [2103-9-17], Hyperlipidemia, Hiatal hernia, Depression, Subarachnoid hemorrhage secondary to streptokinase [2088], Hypertension, Gastritis, Reactive airway disease, s/p PPM placement for 2nd degree AV block Social History: History of smoking having quit in [2088] with a 35-40 pack year history. Family History: Strong family history of premature coronary artery disease. Physical Exam: VS: 97.5 78 128/80 18 94RA Chest: CTAB, Incis c/d/i +click, no erythem or drainage Cardiac: RRR Abd: Soft NT/ND Ext: Mild edema Pertinent Results: [2103-9-27] 07:00AM BLOOD WBC-10.0 RBC-3.83* Hgb-11.6* Hct-35.0* MCV-91 MCH-30.4 MCHC-33.2 RDW-13.9 Plt Ct-566* [2103-9-26] 05:10PM BLOOD Glucose-155* UreaN-21* Creat-0.8 Na-136 K-3.5 Cl-91* HCO3-35* AnGap-14 [Known lastname ],[Known firstname ] C [Medical Record Number 79396] F 72 [2031-7-26] Radiology Report CT CHEST W/CONTRAST Study Date of [2103-9-26] 6:39 PM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG FA6A [2103-9-26] SCHED CT CHEST W/CONTRAST Clip # [Clip Number (Radiology) 79397] Reason: R/o mediastinitis Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 72 year old woman with erythema and sternal click s/p CABG REASON FOR THIS EXAMINATION: R/o mediastinitis CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: JKPe WED [2103-9-26] 8:35 PM sternal dehiscence with malpositioned wires but no wire fx. large partial rim enhacing fluid collection in retro/parasternal space approx 4 x 14cm on sagital reformations (401b:7), infection can not be excluded. No distructive osseous changes to suggest osteo, but this may still be present and radiographically occult. small pericardial effusion and collection of fluid in right cardiophrenic space. connection b/w retrosternal collection and pericardial collection can not be excluded. patchy ground glass peripheral opacities may be infectious or inflammatory. Wet Read Audit # 1 JKPe WED [2103-9-26] 7:38 PM sternal dehiscence with malpositioned wires but no wire fx. large partial rim enhacing fluid collection in retro/parasternal space approx 4 x 14cm on sagital reformations (401b:7), infection can not be excluded. No distructive osseous changes to suggest osteo, but this may still be present and radiographically occult. small pericardial effusion and collection of fluid in right cardiophrenic space. patchy ground glass peripheral opacities may be infectious or inflammatory. no findings to suggest active middle meadiastinitis with mild post-sx changes. Preliminary Report !! WET READ !! sternal dehiscence with malpositioned wires but no wire fx. large partial rim enhacing fluid collection in retro/parasternal space approx 4 x 14cm on sagital reformations (401b:7), infection can not be excluded. No distructive osseous changes to suggest osteo, but this may still be present and radiographically occult. small pericardial effusion and collection of fluid in right cardiophrenic space. connection b/w retrosternal collection and pericardial collection can not be excluded. patchy ground glass peripheral opacities may be infectious or inflammatory. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] Wet read entered: WED [2103-9-26] 8:35 PM Imaging Lab Brief Hospital Course: Mrs. [Known lastname 79393] was admitted with presumed unstable and dehisced sternum. Chest x-ray revealed dislocated sternal wires and she then [Known lastname 1834] a chest CT. CT showed sternal dehiscence associated with retro/parasternal fluid collection for which infection can not be excluded. She was started on antibiotics and Plastic surgery was consulted. Patient was brought to the operating room on [9-27] where she [Month/Day (4) 1834] replating of the sternum and bilateral pectoralis flaps. Following surgery she was transferred to the CVICU in stable condition. Later on op day she was weaned from sedation, awoke neurologically intact and extubated. She remained in the CVICU d/t confusion and hallucinations and was eventually discharged to telemetry floor on post-op day four. She continued to slowly improve while receiving medical management, including antibiotics, and was followed by plastic surgery during her complete post-op course. She worked with physical therapy for strength and mobility. On post-op day six she appeared to be doing well and was discharged to rehab with the appropriate follow-up appointments. Medications on Admission: Aspirin, Lipitor, Lopressor, Colace, Protonix, Zetia, Synthroid, Wellbutrin, Venlafaxine, Tramadol, Albuterol Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 8. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO QAM (once a day (in the morning)). 12. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: for surgical wound. Disp:7 Tablet(s) Refills:0 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Doctor Last Name ] [Doctor Last Name ] hospital Discharge Diagnosis: Sternal wire dislocation/dehisscence PMH: s/p CABGx3 [2103-9-17], Hyperlipidemia, Hiatal hernia, Depression, Myocardial infarction Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 4 weeks. ([Telephone/Fax (1) 1504] Please follow-up with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 79398] in [2-25] weeks. [Telephone/Fax (1) 7401] Please follow-up with Dr. [First Name (STitle) ] in 1 week ([Telephone/Fax (1) 57417] Follow JP drainage and record daily Completed by:[2103-10-3]	[ "493.90", "V45.81", "E878.2", "V45.01", "599.7", "553.3", "535.50", "401.9", "414.00", "272.4", "998.59", "998.31", "244.9", "311" ]	icd9cm	[ [ [] ] ]	[ "78.51", "34.03", "83.82", "34.79", "86.74", "38.93" ]	icd9pcs	[ [ [] ] ]	6797, 6880	4121, 5279	322, 395	7058, 7066	1252, 1849	7808, 8203	1028, 1089		5439, 6774	1889, 1948	6901, 7037		5305, 5416			7090, 7785									1104, 1233																							255, 284	1980, 4098					423, 603															625, 918	934, 1012
12,413	144,198	21617	Discharge summary	report	Admission Date: [2178-1-26] Discharge Date: [2178-2-5] Date of Birth: [2098-2-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 7539] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization x 3 with PCI stenting Intubation Intra-aortic balloon pump placement History of Present Illness: Mr. [Known lastname 56898] is a 79 year old male with history of hypertension, hyperlipidemia, paroxysmal Afib, and PVD who was sent to ED by his nephrologist as she noticed he was SOB with O2 sat 84% on RA with pursed lip breathing. Recently admitted to [Hospital1 18] [Date range (1) 56899] with NSTEMI which was medically managed (on asa, metoprolol, simvastatin, and nitro) [2-25] to acute on chronic RF. He was d/c'ed to rehab and since had been living with his daughter. [Name (NI) ] states that his SOB started about 1-2 weeks ago and has been progressing such that he is now SOB at rest. He also notes increased swelling of LE bilat. Denies CP/palpitations/nausea/dizziness. No cough/abd pain. No f/c/ns. He claims that he has been compliant with medications and that he cannot swallow foods (for months) so drinks high energy shakes. Was sent by ambulance from clinic. Oxygen saturation was 100% on NRB on arrival, and 98% on 2L via NC. Pt given 80 IV lasix in ED with much symptomatic improvement. I/O even in ED b/c was maintained on IVF from ambulance. (I/O=500cc/500cc) Past Medical History: 1. CAD??silent MI in the past 2. COPD 3. paroxysmal Afib 4. hypercholesterolemia 5. bilateral CEA about 20y ago 6. PVD s/p angioplasty LLE about 10y ago 7. neck CA s/p XRT 7y ago Social History: denies tobacco/ETOH Family History: MI in father at 65yo Physical Exam: T 97.5, BP 90-110/50-60, P68, 94% on RA Gen-very pleasant elderly gentleman, comfortable lying in bed, in no pain/distress, +NC on 6L O2 HEENT-anicteric, oral mucosa dry, OP- pink/dry - no lesions; neck supple JVD + 10cm CVS-HS - distant, rrr, no murmur resp: CTA with bibasilar crackles ABD: soft, nt/nd, +BS ext-2+ pitting edema to knees bilat.; no c/c; spont movt of all 4 ext. neuro-A+Ox3, move all 4 limbs symmetrically, no facial asymmetry; CN 2-12 grossly intact; 5/5 strength of biceps/tricps/knee flex/ext. sensation to light touch intact throughout. Pertinent Results: [2178-1-26] WBC-5.2 RBC-4.41* Hgb-12.0* Hct-38.2* MCV-87 MCH-27.3 MCHC-31.5 RDW-17.3* Plt Ct-229 [2178-2-5] WBC-5.3 RBC-3.10* Hgb-8.3* Hct-26.0* MCV-84 MCH-26.7* MCHC-31.8 RDW-18.0* Plt Ct-37* [2178-1-26] Neuts-73.3* Bands-0 Lymphs-20.9 Monos-5.3 Eos-0.1 Baso-0.3 [2178-2-1] Neuts-74.4* Bands-0 Lymphs-19.3 Monos-5.6 Eos-0.3 Baso-0.4 [2178-1-27] PT-13.4 PTT-30.4 INR(PT)-1.1 [2178-2-5] Plt Ct-37* [2178-2-2] Fibrino-357 [2178-2-5] Fibrino-546# [2178-2-5] FDP-10-40 [2178-1-26] Glucose-91 UreaN-54 Creat-2.5# Na-135 K-4.7 Cl-103 HCO3-24 [2178-2-5] Glucose-116 UreaN-52* Creat-3.2* Na-136 K-3.3 Cl-99 HCO3-27 [2178-1-26] 05:00PM BLOOD CK(CPK)-65 cTropnT-0.02* [2178-1-27] 06:58AM BLOOD CK(CPK)-44 cTropnT-0.04* [2178-1-29] 05:35AM BLOOD CK(CPK)-26* CK-MB-4 cTropnT-0.03* [2178-2-3] 10:37PM BLOOD CK(CPK)-683* CK-MB-11* MB Indx-1.6 [2178-2-4] 10:06PM BLOOD CK(CPK)-788* CK-MB-66* MB Indx-8.4* [2178-1-28] ALT-18 AST-15 AlkPhos-69 Amylase-45 TotBili-0.5 [2178-2-1] ALT-36 AST-90* LD(LDH)-697* CK(CPK)-130 AlkPhos-99 TotBili-0.6 [2178-2-2] 02:55AM BLOOD LD(LDH)-311* CK(CPK)-60 TotBili-0.5 DirBili-0.2 IndBili-0.3 [2178-2-5] 09:30AM BLOOD LD(LDH)-847* [2178-1-28] Calcium-8.2* Phos-3.8 Mg-1.9 [2178-2-1] Albumin-3.1* Calcium-8.4 Phos-3.8 Mg-1.9 [2178-1-28] Iron-32* calTIBC-286 Ferritn-36 TRF-220 [2178-2-2] Hapto-132 [2178-1-28] PTH-102* [2178-2-5] 04:22PM BLOOD Cortsol-37.3* [2178-2-5] HEPARIN DEPENDENT ANTIBODIES NEGATIVE CXR [2178-1-26]: 1) Interval development of moderate sized bilateral pleural effusions with associated atelectatic changes. 2) Mild interstitial edema. EKG [2178-1-26]: Sinus rhythm. Borderline P-R interval prolongation. Low limb lead voltage. Late R wave progression. ST-T wave abnormality. Since the previous tracing of [2177-12-11] sinus rhythm is now present and the Q-T interval is longer. Cardiac Cath [2178-1-28]: COMMENTS: 1. Selective coronary angiography revealed a right-dominant system. The LMCA had an ostial 95% lesion. The LAD had diffuse irregularities with a 90% mid D2 lesion. The LCx had sequential 80% mid-vessel lesions. The RCA had sequential 90% mid-vessel lesions. 2. The left and right-sided filling pressures were both moderately elevated (RA mean 10mmHg, RVEDP 10mmHg, PA mean 31mmHg, PCWP mean 21mmHg). The estimated cardiac output was 3.81 l/min. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate diastolic ventricular dysfunction. Carotid Duplex [2178-1-30]: Inhomogenous mostly Isoechoic plaque involving the carotid arteries bilaterally with post- surgical changes and intimal hyperplasia. This represents moderaltely severe (60-69%) stenosis on the right and less than 40% hemodynamic effect on the left. RLE US [2178-1-31]: IMPRESSION: Nonocclussive right common femoral deep venous thrombosis. EKG [2178-1-31]: Probable atrial fibrillation with a rapid ventricular response. Since the previous tracing of [2178-1-27] atrial fibrillation is new. ST-T wave abnormalities may be more prominent. CXR [2178-2-1]: 1) Interval improvement in bilateral pleural effusions, most dramatically on the left. 2) Left apical linear density most likely representing a skin fold. Repeat imaging is recommended for further evaluation. 3) Nasogastric tube withdrawals within the body of stomach, and tip is ascending to the level of the gastroesophageal junction. Cardiac Cath [2178-2-1]: COMMENTS: 1. Selective coronary arteriography of this right dominant system revealed 3 vessel coronary artery disease. The LMCA had a 99% ostial lesion. The LAD had moderate diffuse disease with a 80% distal lesion as well as a 80% lesion in the D1. The LCX had a 80% lesion. The RCA was heavily calcified with diffuse disease throughout its course and a 80% mid and 90% distal lesion. 2. Hemodynamic evaluation revealed marked elevation of the right and left sided filling pressures with a RA of 10mmHg and mean PCWP of 38mmHg with significant "V" waves. There was evidence of moderate pulmonary HTM with a PAP of 50/32mmHg. The calculated cardiac index by Fick using a O2 consumption of 125 ml/min revealed a cardiac index of 4.8 Lt/min/M2 on 100% FiO2 and 20 mcg/kg/min of Dopamine. 3. Distal aortography revealed a totally occlusive 8F 40CC IABP in the right common iliac artery. The LCIA had seral 80% lesions at to the LCFA. The LSFA was totally occluded and reconstituted via collaterals at the level of te adductor cannal. 4. Successful PTCA/stenting of the LMCA with a 3.0x13mm Cypher [Name Prefix (Prefixes) ] [Last Name (Prefixes) 7930] with a 3.5x13mm balloon. Final angiography revealed no residual stenosis, no dissection and TIMI-3 flow (see PTCA comments). 5. Successful Atherectomy, stenting of the Left CIA/CFA with a 9.0x56mm and a 8.0x80mm Danalik sefl expandable stents. Final angiography revealed no residual stenosis, no dissection and TIMI-3 flow (see PTCA comments). 6. Successful removal of a 8F 40cc IABP from the right common femoral artery resulting in restoration of arterial flow. 7. Successful placement of a 8F 40cc IABP in the left common femoral artery. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Elevated right and left heart filling pressure. 3. Pulmonary HTN. 4. Peripheral vascular disease. 5. PCI of the LMCA. 6. PCI of the left CIA/CFA. 7. IABP placement. Transthoracic echo [2178-2-2]: Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis (EF ~30%) that becomes severely depressed (<20%) with the IABP off. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No definite aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild [1+] mitral regurgitation is seen with the IABP "off" with trivial mitral regurgitation with the IABP "on." There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There are prominent bilateral pleural effusions. Cardiac cath [2178-2-3]: COMMENTS: 1. Limited coronary angiography demonstrated a right dominant system with no significant disease in the recently placed LMCA stent as well as severe diffuse calcified 90% disease in the proximal and mid-RCA. 2. Limited resting hemodynamics revealed mean arterial pressure of 82 mmHg on a previously placed IABP via the left femoral artery as well as neosynephrine. 3. Successful placement of five overlapping stents in the RCA. The sizes from the ostium listed to the distal vessel included 3.0 x 18 mm Zeta, 3.0 x 38 mm Zeta, 2.5 x 28 mm Pixel, 2.5 x 28 mm Pixel, and 2.5 x 28 mm Pixel. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 4. Successful placement of 7.0 x 40 mm Absolute self-expanding stent in right iliac artery postdilated with a 6.0 mm balloon. Final angiography demonstrated minimal residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). FINAL DIAGNOSIS: 1. Planned intervention of single vessel coronary artery disease. 2. Cardiogenic shock on IABP and pressores with MAP 82 mmHg. 3. Successful placement of 5 stents in RCA. 4. Successful placement of self-expanding stent in right iliac artery. CXR [2178-2-4]: 1) Interval dramatic improvement in bilateral pulmonary edema. Moderate right sided and small left-sided pleural effusions persist. EKG [2178-2-5]: Sinus rhythm. Low limb lead voltage. S1, S2, S3 pattern. Persistent S wave to lead V6. ST-T wave abnormalities. Probable Q-T interval prolongation. The Q-T interval is difficult to calculate due to low voltage, artifact and probable positive U waves. Since the previous tracing of [2178-2-4] the Q-T interval prolongation is more apparent but probably was present and less appreciated in the previous tracing. MICRO: URINE CULTURE (Final [2178-1-27]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. AEROBIC BOTTLE (Final [2178-2-8]): NO GROWTH. ANAEROBIC BOTTLE (Final [2178-2-8]): NO GROWTH. URINE CULTURE (Final [2178-2-3]): NO GROWTH. BLOOD AEROBIC BOTTLE (Final [2178-2-5]): REPORTED BY PHONE TO [First Name9 (NamePattern2) 56900] [Doctor Last Name ] @ 0318 ON [2178-2-3]. ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS \| AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 0.5 S PENICILLIN------------ 4 S VANCOMYCIN------------ <=1 S ANAEROBIC BOTTLE (Final [2178-2-8]): NO GROWTH. AEROBIC BOTTLE (Final [2178-2-9]): NO GROWTH. ANAEROBIC BOTTLE (Final [2178-2-9]): NO GROWTH. SPUTUM GRAM STAIN (Final [2178-2-5]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2178-2-10]): MODERATE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. GRAM NEGATIVE ROD #2. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| STENOTROPHOMONAS (XANTHOMONAS) MALTOPH \| \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 I OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R TRIMETHOPRIM/SULFA---- <=20 S Brief Hospital Course: A/P: Mr. [Known lastname 56898] was a 79 yo gentleman with h/o hypertension, hyperlipidemia, PAfib PVD, CRI, and recent NSTEMI, who presented from PCP with CHF exacerbation. 1. CHF exacerbation: The patient was thought to be having a CHF exacerbation of unclear etiology. On admission, he was put on 1.5L fluid restriction and started on lasix, 40mg IV BID, to which he responded well with symptomatic improvement. Lasix was stopped on [1-28] for cardiac cath (performed secondary to concern that his symptoms were related to cardiac ischemia) and because BP remained low with SBP in 80's-100 range. Cardiac cath was done on [1-28] with results as in pertinent results section - significant 3 vessel disease with a severe L main lesion. Given these results, it was thought unlikely that Mr. [Known lastname 56901] CHF would improve without further intervention, ie CABG. However, given his pulmonary/renal status, there was much discussion as to whether Mr. [Known lastname 56898] was surgical candidate. He had one episode of shortness of breath on the night of [1-31] which responded to lasix and rate control, as he was noted to be in atrial fibrillation. The following night, however he had an episode of dyspnea unresponsive to lasix. His SBP was 130s, HR 70s in NSR. He eventually required a 100% NRB. An ABG showed hypoxia at 7.41/39/63, and he was intubated and transferred to the CCU where an intra-aortic balloon pump was placed at the bedside, and he was placed on pressors for hypotension, presumed secondary to cardiogenic shock. Upon review of his catheterization report, it was felt that the patient's recurrent SOB and acute pulmonary edema was likely related to ischemia, and it was decided to take the patient to the cath lab for a second time, for stenting of his left main coronary artery. During cath he underwent stenting of the LMCA with a 3.0 x 13 mm Cypher drug-eluting stent as well as stenting of the left iliac artery and common femoral artery with 9.0 x 56 mm, 8.0 x 80 mm, and 8.0 x 56 mm Dynalink stents all postdilated with a 8.0 mm balloon. Unfortunately, post-cath his hemodynamic status did not improve, and he was highly dependent on the balloon pump, and unable to be extubated. It was decided that as one last effort, the patient would have planned intervention of the heavily calcified RCA with planned rotational atherectomy, which he underwent on [2178-2-3] with placement of 5 stents in the RCA. After this catheterization the patient was weaned off the balloon pump, however remained on levophed for blood pressure support. His urine output was poor, therefore nesiritide was attempted however this caused him to become hypotensive. It was felt that there may have been a component of septic shock as well, with 1 bottle positive for enterococcus on [2-4]. He was started on ampicillin. Unfortunately, the patient's poor hemodynamic status, combined with his acute on chronic renal failure (likely secondary to poor perfusion secondary to CHF and hypotension as well as multiple die loads and resultant ATN), a dopping platelet count, poor oxygenation, and enterococcal blood infection, all proved to be too much for him, and he was pronounced dead on [2178-2-5] at 6:27 p.m. The patient was not on anticoagulation at the time secondary to concerns for HIT, and it is also possible that he had a pulmonary embolus, as he had non-occlussive thrombus in his right common femoral deep venous system on [1-31]. 2. CAD: As above. We continued his simvastatin, asa, lisinopril, and metoprolol. 3. Atrial fibrillation: He had a history of paroxysmal atrial fibrillation, and had been on coumadin in the past, however this had been discontinued during a previous admission for a GI bleed. He was controlled on amiodarone and metoprolol, but did flip in and out of atrial fibrillation during his hospitalization. 4. Acute on chronic renal failure: Followed by Dr. [Last Name (STitle) 1860] as an outpatient; creatinine 2.5 on admission, however rose to 3.6 on [2-4] after his second catheterization, likely a combination of poor perfusion as well as ATN from multiple contrast loads. 5. Enterococcal bacteremia: As above, the patient was found to have 1 blood culture bottle positive for enterococcus from [2-2]. He was started on ampicillin, however was only 2 days into treatment when he died. 6. Thrombocytopenia: His platelets were noted to be trending down on [2-1] just after his second catheterization and balloon pump placement. His platelets nadired at 37 on the day of his death. PT and PTT were both mildly elevated as well, however fibrinogen was within normal limits. HIT antibody was negative. Nevertheless, all heparin products were discontinued, and his balloon pump was removed as it was heparin coated. It is unclear what caused his thrombocytopenia. It could still have been HIT despite the negative antibody test. Medications on Admission: Toprol Colace Sennokot MVI Zocor Prevacid Trazodone Iron Combivent Procrit Dulcolax Allopurinol Nephrocaps Amiodarone Plavix Discharge Medications: Patient deceased. Discharge Disposition: Expired Discharge Diagnosis: Congestive Heart Failure Coronary artery disease Cardiogenic shock Thrombocytopenia Enterococcal bacteremia Acute on chronic renal failure Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A	[ "428.0", "410.72", "496", "280.9", "453.42", "038.0", "287.5", "427.31", "518.81", "403.91", "414.01", "276.7", "272.0", "443.9", "584.9", "785.51", "V10.89", "995.92", "785.52" ]	icd9cm	[ [ [] ] ]	[ "39.90", "37.23", "96.72", "39.50", "38.93", "96.04", "36.01", "37.22", "96.6", "36.07", "97.44", "89.64", "36.06", "00.13", "88.56", "37.61", "37.78" ]	icd9pcs	[ [ [] ] ]	18275, 18284	13098, 18058	342, 436	18466, 18476	2445, 4905	18528, 18534	1826, 1848		18233, 18252		18305, 18445		18084, 18210		9790, 13075	18500, 18505									1863, 2426																							283, 304						464, 1571															1593, 1773	1789, 1810
48,397	131,741	4354	Discharge summary	report	Admission Date: [2200-4-14] Discharge Date: [2200-4-21] Date of Birth: [2150-6-10] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: Morbid Obesity Major Surgical or Invasive Procedure: [2200-4-14] 1. Laparoscopic converted to open approach. 2. Roux-en-Y gastric bypass. 3. Repair of colotomy (transverse colon). 4. Repair of ventral hernias x2. [2200-4-15] 1. Exploratory laparotomy. 2. Endoscopy with clot evacuation. History of Present Illness: [Known firstname ] has class III morbid obesity with weight of 278.4 pounds as of [2200-2-25] (his initial screen weight on [2200-2-3] was 282.8 pounds), height 66 inches and BMI of 44.9. His previous weight loss efforts has included most recently HMR for 26 weeks in [2198] losing 35 pounds that he is still maintaining. He lost 120 pounds with 38 weeks of HMR in [2192] that he kept off for 15 months plus multiple other diets but has not been able to maintain the weight loss. Past Medical History: PMH 1. hypertension 2. paroxysmal atrial fibrillation for about 10 years 3. obstructive sleep apnea on CPAP 4. hyperlipidemia 5. fatty liver by ultrasound PSH none Social History: tobacco: none alcohol at least two cocktails one to two times a week He is employed in the insurance business as a claims adjuster. He has no children and lives with his spouse age 52. Family History: father deceased age 71 of cancer, heart disease and obesity. Physical Exam: Blood pressure was 162/94, pulse 82, respirations 16 and O2 saturation 96% on room air. On physical examination [Known firstname ] was casually dressed, pleasant and in no distress. His skin was warm, dry with no rashes, and there were a few follicular lesions on trunk and benign cherry hemangiomas. Sclerae were anicteric, conjunctiva clear, pupils were equal round and reactive to light, fundi were normal, mucous membranes were moist, tongue was pink and the oropharynx was without exudates or hyperemia. Trachea was in the midline and the neck was supple with no adenopathy, thyromegaly, carotid bruits or JVD. Chest was symmetric and the lungs were clear to auscultation bilaterally with good air movement. Cardiac exam was regular rate and rhythm with normal S1 and S2, no murmurs, rubs or gallops. The abdomen was obese but soft and non-tender, non-distended with positive bowel sounds and no appreciable masses or incision scars, there was a moderate sized ventral hernia that was reducible. There was no spinal tenderness or flank pain. Lower extremities were without edema, venous insufficiency or clubbing, perfusion was good, pulses were intact. There was no evidence of joint swelling or inflammation of the joints. There were no focal neurological deficits and his gait was normal. Pertinent Results: [2200-2-25] Abdominal US : 1. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. No evidence of cholelithiasis. [2200-4-14] 12:15PM WBC-13.9# RBC-4.87 HGB-14.2 HCT-41.7 MCV-86 MCH-29.1 MCHC-34.0 RDW-14.2 [2200-4-14] 07:40PM WBC-19.4 RBC-4.03* HGB-11.5* HCT-33.8* MCV-84 MCH-28.5 MCHC-34.0 RDW-13.6 [2200-4-14] 11:30PM WBC-19.6* RBC-3.35* HGB-9.8* HCT-28.3* MCV-85 MCH-29.3 MCHC-34.7 RDW-13.7 HCT [4-19]: 34.4 Brief Hospital Course: Mr. [Known lastname 18799] was admitted to the hospital and taken to the Operating Room where he underwent a laparoscopic gastric bypass, repair of a colotomy in the transverse colon and hernia repair. ( See formal operative note for details ) He tolerated the procedure well and returned to the PACU in stable condition. On the evening of surgery he gradually became tachycardic and pale. His pre op hematocrit was 41 and post op drifted to 28. Based on his symptoms and decreasing hematocrit he was taken back to the Operating Room for exploration. No active bleeding was identified so he then underwent endoscopy which revealed adherent clot at the GJ anastomosis. ( See formal Operative Note for details ) He was transfused both intra and post op and always maintained stable hemodynamics. His tachycardia resolved. Following exploration he was transferred to the SICU for close monitoring. He developed paroxysmal atrial fibrillation on post op day #1 and was treated with IV Lopressor. Over the next 48 hours he continued to have bursts of PAF eventually controlled with a Diltiazem drip and repletion of electrolytes. PAF has been a pre op problem but so infrequent that he was not on any medications for rate control. He was evaluated by the Cardiology service who recommended Lopressor 25 mg PO BID and titrate up as needed for rate control while the Diltiazem was weaned off. Eventually he was controlled with 50mg PO TID. Following transfer to the surgical floor he continued to make good progress. He started a stage 1 diet and over a 48 hour period was advanced to stage 3. He developed some gas and bloating on stage 3 and was eventually switched to a soy based diet which he tolerated much better. He was up and walking independently and his hematocrit remained stable. His surgical sites were healing well and after a prolonged hospital course he was discharged to home and will follow up with Dr. [Last Name (STitle) ] with in 2 weeks. At that time his staples will be removed. Medications on Admission: 1. aspirin 81 mg daily 2. vitamin C 1000 mg daily 3. vitamin B complex daily 4. Biotin 300 mg daily 5. vitamin D 1000 units daily 6. folic acid 0.4 mg daily 7. glucosamine 1500 mg daily 8. Garlic one tablet daily 9. iron 18 mg daily 10. magnesium 400 mg daily 11. potassium gluconate 595 mg daily 12. MVI 1 tab daily 13. Omega-3 fatty acids 1000 mg 200 mg daily Discharge Medications: 1. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 2. Roxicet 5-325 mg/5 mL Solution Sig: [4-14] ml PO every four (4) hours as needed for pain. Disp:500 ml Refills:0 3. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day. Disp:250 ml Refills:2 4. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. Potassium Gluconate 595 (99) mg Tablet Sig: One (1) Tablet PO once a day: please crush. 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day: Please crush. 7. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day: Empty capsule in waater and mix. Disp:60 Capsule(s) Refills:4 8. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day. Disp:250 Refills:2 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Hypertension. 2. Morbid obesity. 3. Obstructive sleep apnea. 4. Hyperlipidemia 5. Acute blood loss anemia 6. paroxysmal atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: * Please follow-up with your PCP or Cardiologist regarding starting Metoprolol for Paroxysmal A-Fib. Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 3. You will be taking Zantac liquid 150 mg twice daily for one month. This medicine prevents gastric reflux. 4. You will be taking Actigall 300 mg twice daily for 6 months. This medicine prevents you from having problems with your gallbladder. 5. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 6. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items [9-19] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 18800], RD Phone:[Telephone/Fax (1) 305] Date/Time:[2200-5-1] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9325], MD Phone:[Telephone/Fax (1) 305] Date/Time:[2200-5-1] 3:30 Completed by:[2200-4-21]	[ "553.29", "338.18", "E878.2", "E870.0", "401.9", "285.1", "276.6", "427.31", "V85.4", "272.4", "997.4", "998.2", "785.0", "571.8", "998.12", "V65.3", "278.01", "327.23", "560.1", "V64.41" ]	icd9cm	[ [ [] ] ]	[ "46.75", "53.59", "45.11", "54.12", "44.39" ]	icd9pcs	[ [ [] ] ]	6869, 6875	3534, 5552	329, 573	7062, 7062	2922, 3511	9468, 9831	1512, 1574		5965, 6846		6896, 7041		5578, 5942			7237, 7803									1589, 2903																							275, 291					9111, 9445	601, 1105							7828, 9099		7077, 7189						1127, 1293	1309, 1496
40,798	129,002	15271+56629	Discharge summary	report+addendum	Admission Date: [2186-7-15] Discharge Date: [2186-8-2] Date of Birth: [2121-7-27] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 473] Chief Complaint: Acute pancreatitis, transferred from [Location (un) 620] ICU. Major Surgical or Invasive Procedure: Exploratory Laporatomy [2186-8-2] History of Present Illness: 64 years old gentleman p/w epigastric pain irradiating to the back, started on Friday morning with increasing intensity over the day, no other symptoms associated. Denies fever, nausea, vomiting, or any other GI symptom. He presented to [Location (un) 620] ED at 8 pm. His labs workup showed Lipase of 15.000, LFT's had minimal abnormalities, AST:48 ALT: 50 Aphos:98 Tbili: 0.87 LDH: 292; WBC 16.1, glucose 212, Calcium 7.5, TRIG 71. CT scan showed diffuse inflammation of the head of pancreas, free fluid in the lesser sac and in both colic gutters. No hepatobiliary abnormality with normal gallbladder and non dilated CBD. He was admitted to the medical ICU for treatment of acute pancreatitis. He was given IV fluids 4L of NS and 3L 1/2 NS. In spite of fluid resuscitation he continue to have u/o of 40 cc per hour and HCT of 54.5. He has been transfer to TSICU of [Hospital1 18] to continue management. Past Medical History: 1. Gout. 2. Hypertension. 3. Hyperlipidemia. 4. GERD 5. Migraine 6. Obstructive sleep apnea in CPAP 7. BPH. 8. Colon polyps. 9. History of psoriatic arthritis. 10. Rosacea. 11. Seborrheic dermatitis. 12. Recent diagnosis of basal cell carcinoma. 13. Severe spinal stenosis in the cervical and lumbar s/p surgery at C4-C5 in [2181] and lumbar surgery in [2184]. Social History: He is an attorney, married with 3 children. Smoked 1 PPD for 20 years, quit on [2164] Drinks 3 - 6 onz of Vodka every night, on w/e drinks extra glass of wine or [Doctor Last Name ]. Family History: Grandfather with Pancreatic ca. Uncle with hx of Colonorectal Ca Physical Exam: On Admission: T 97.3 P 83 BP 159/99 R 18 SaO2 97% RA Gen: no acute distress HEENT: Dry mucosas, no icteric Lungs: Clear BLT Heart: Regular rate and rhythm ABD: BS (+) very distent ed, no tender at palpation, of note he's with Dilaudid PCA for pain management. No mass palpated. Extrem: no edema On Discharge: Gen: Patient deceased. CV: No heart beat, no pulse Pertinent Results: [2186-7-15] 06:46PM BLOOD WBC-15.8# RBC-5.48 Hgb-18.3 Hct-54.3* MCV-99* MCH-33.5* MCHC-33.8 RDW-13.5 Plt Ct-159 [2186-7-15] 06:42PM BLOOD PT-13.7* PTT-26.9 INR(PT)-1.2* [2186-7-15] 06:46PM BLOOD Glucose-288* UreaN-30* Creat-1.1 Na-136 K-6.3* Cl-113* HCO3-17* AnGap-12 [2186-7-15] 06:46PM BLOOD Lipase-1850* [2186-7-15] 06:46PM BLOOD Calcium-7.5* Phos-3.4 Mg-1.7 [2186-7-15] 10:43PM BLOOD Triglyc-49 [2186-7-15] 06:54PM BLOOD Type-CENTRAL VE Temp-36.3 O2 Flow-2 pO2-121* pCO2-43 pH-7.29* calTCO2-22 Base XS--5 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2186-7-15] 06:54PM BLOOD Lactate-3.2* [2186-7-20] 6:45 am SPUTUM Source: Endotracheal. RESPIRATORY CULTURE (Final [2186-7-22]): MODERATE GROWTH Commensal Respiratory Flora. KLEBSIELLA OXYTOCA. MODERATE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA \| AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2186-7-20] 8:22 am BRONCHOALVEOLAR LAVAGE LLL. RESPIRATORY CULTURE (Final [2186-7-22]): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). ~3000/ML. FURTHER WORKUP ON REQUEST ONLY. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [2186-7-24] 10:44 am Mini-BAL RESPIRATORY CULTURE (Final [2186-7-27]): Commensal Respiratory Flora Absent. KLEBSIELLA OXYTOCA. ~1000/ML. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 44420] ([2186-7-20]). YEAST. ~5000/ML [2186-7-28] 12:26 pm STOOL CONSISTENCY: FORMED Source: Stool. FINAL REPORT [2186-7-29] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2186-7-29]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [7-15]: RIGHT UPPER QUADRANT ULTRASOUND: The pancreas is completely obscured by intervening bowel gas but there is no evidence of intra-abdominal fluid collection. The liver is normal in echotexture without focal lesions.There is no intrahepatic or extrahepatic biliary ductal dilatation. The normal CBD measures 4 mm in diameter. The gallbladder is normal without stones. There is normal hepatopetal portal venous flow. The partially assessed right kidney measures 11.6 cm, with a 4.1 cm cyst in the upper pole. No hydronephrosis is noted. A right pleural effusion is noted, likely small. [7-16]: The liver is normal in contour and homogenous in signal intensity. There is no loss of signal on opposed phase T1-weighted images to suggest the presence of fatty change. No intrahepatic or extrahepatic biliary duct dilatation. The main portal vein and hepatic veins are patent. The splenic vein is not seen to opacify on the contrast-enhanced images. Unfortunately, the patient was not able to breath hold, so assessment is somewhat limited, nonetheless, it appears that the splenic vein is occluded (7a:12). There is narrowing of the proximal portal vein at the level of the confluence of SMV and splenic veins (3:35). The pancreas is diffusely swollen with induration of the surrounding fat, consistent with the patient's known pancreatitis. The pancreas is hypoenhancing without a focal region of apparent sclerosis. No pseudocyst is appreciated. Evaluation of vascular tree is limited by the non-breath holding technique. There is a moderate amount of intra-abdominal ascites. Small bilateral pleural effusions with associated compressive atelectasis. The spleen is not enlarged measuring 12.5 cm. There is a 4.4 cm cyst in the upper pole of the right kidney. The gallbladder is unremarkable, no gallstone seen; however, gallbladder wall is edematous likely secondary to the abdominal inflammation. The visualized bone marrow is unremarkable [7-21] CT ABD w/o contrast: IMPRESSION: 1. Pancreatitis with extensive peripancreatic stranding and fluid. No focal collections seen. Assessment of pancreatic necrosis is limited in the abscence of contrast, as is follow up assessment of splenic vein thrombosis described on recent MRCP. 2. Small-moderate volume simple ascites. 3. Bilateral pleural effusions, the left could be slightly hemorrhagic given layering debris. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 36901] 4. Focal areas of large bowel thickening, likely reactive to adjacent pancreatic inflammation. [7-29] CT OF ABDOMEN w/ contrast: There has been some decrease in volume of the bilateral pleural effusions since the prior study. There is persistent basal atelectasis. No pericardial fluid. There is new perihepatic free fluid. Further increase volume of free fluid is noted in the left anterior pararenal space, left paracolic gutter, right paracolic gutter and pelvis. The CT attenuation volume of fluid remains consistent with simple fluid. There is extensive stranding of the mesenteric fat throughout the upper abdomen. This has progressed significantly since prior study. The stranding extends to involve the transverse colon wherer there is extensive mural thickening and mucosal hyperenhancement involving the transverse and ascending colon .Findings are in keeping with an inflammatory colitis. Again these findings have progressed since the prior study. The pancreas is markedly edematous with surrounding mesenteric stranding. Some enhancing pancreatic tissue is seen in the pancreatic head and uncinate process . The area of enhancement measures approximately 4.0 x 2.5 x 5.4 cm and is centered on the posterior portion of the pancreatic head and uncinate process.The remainder of the pancreatic head, body and tail, however, demonstrate no enhancement on the post-contrast images, in keeping with necrosis. The splenic vein remains markedly attenuated but remains patent. The main portal vein and SMV are patent. The stomach and duodenum are within normal limits. There are no discrete walled off fluid collections at this time. Both kidneys enhance symmetrically. Normal appearance of both adrenal glands. Note is made of a 4.4 x 4.3 cm simple cyst arising from the upper pole of the right kidney. More inferiorly, there is a 1.3 x 2.1 hyperdense lesion arising from the lower pole of the right kidneyin keeping with a hyperdense cyst. Normal appearance of the left kidney. CT OF PELVIS: There is an increase in volume of the free fluid in the pelvis. Again the attenuation value is consistent with simple fluid. Normal appearance of the rectum and sigmoid colon. No enlarged pelvic sidewall or inguinal lymph node. Prostate size is within normal limits. OSSEOUS STRUCTURES: Degenerative changes are seen involving the lower thoracic and mid lumbar spine with anterior bridging osteophytes. Vertebral body height is maintained, however. No destructive lytic or sclerotic bone lesions are identified. IMPRESSION: 1. Significant ( >90% ) pancreatic necrosis with a small area of residual enhancing pancreatic tissue noted posteriorly within the uncinate process and pancreatic head. 2. Extensive stranding of the mesenteric fat with thickening of the adjacent transverse colon in keeping with an inflammatory colitis. 3. Perihepatic paracolic gutter and pelvic free fluid as described. 4. No focal pancreatic pseudocysts or wall enhancing fluid collections are identified. Brief Hospital Course: On [7-15], the patient was transferred from [Hospital1 18] [Location (un) 620] ICU to the TSICU. He presented 20 hrs prior with epigastric pain and elevated lipase. He had a 6L fluid resuscitation at [Hospital1 18] [Location (un) 620] upon transfer. The patient was conversational, had a normal mental status, and was responding to IVF resucitation. A CVL line was placed for CVP monitoring. Due to the patient's complicated hospital course, I will describe his hospital course with regards to organ systems. Neuro: Initially, the patient was mentating. Pain was controlled with a Dilaudid PCA. However, on HD2, the patient was more aggitated and became obtunded. He was intubated in order to be transported for MRCP. He remained on sedation, with intermittent Versed and fentanyl gtt. On HD3, the patient had increasing bladder pressures and increasing PIP. He was paralyzed with Cisatracurium with improvement in abdominal tension and bladder pressures. Paralysis was eventually weaned as his abdominal exam improved. He was also given intermittent haldol for agitation. Once the patient was on a CPAP vent setting, he was sedated with Precedex with good results. On [7-27], the patient was extubated and was verbal, but confused. However, on [7-28] (36 hrs later), the patient was reintubated for respiratory fatigue. He again received IV fentanyl for sedation. Propofol was not used due to concerns for hypotension. Cardiovascular: On transfer to the TSICU, the patient was responding to fluid resuscitation with LR and IV fluid bolus to keep his CVP 14-16 and urine output greater than 30 cc/hr. On HD 2, the patient became oliguric and CVVHD was started on HD3. As a result of the CVVHD, the patient became hypotensive with SBP 70s. He was intially started on norepinephrine for BP support. A bedside ECHO showed depressed LV fucntion. Bedside CO and CI monitoring was initiated. As a result, dobutamine was started with minimal improvement in LV function. However, the dobutamine caused atrial fibrialation with a RVR. The dobutamine was stopped, the patient was cardioverted twice to no response, had IV esmolol, IV digoxin, and eventually was placed on an amiodarone gtt. The patient responded well to the amiodarone with a HR in the low 100s. Norepinephrine was then used for blood pressure support. Vasporessin was the used as a second pressor. The patient was weaned off pressors by the second week and had stable BP in the 110-120's once extubated. Atrial fibrillation was controlled with intermittent digoxin and intermittent IV amidarone. After being reintubated, the patient was restarted on vasopressin and then neosynephrine was added for further support. Respiratory: The patient was transferred in no respiratory distress. However, on the morning of HD2, the patient was agitated and was intubated for transport to MRCP. On the evening of HD2, the patient was receiving boluses of IVF and albumin. However with the resulting oliguria, his CXR was becoming increasing fluid overloaded. On HD3, there was concern for early signs of ARDS and the patient was started on an ARDSnet ventilatory protocol. Once CVVHD was started and the patient tolerated fluid removal, vent settings were weaned to CPAP. The patient was extubated on [7-27] for 36 hrs. However, he experienced respiratory fatigue and was reintubated. GI: The patient was transerred from [Hospital1 18] [Location (un) 620] with acute pancreatits. In 48 hours his [Last Name (un) ] score was 7. CT ABD at [Location (un) 620] was consistent with acute pancreatitis without any fluid collections. At [Hospital1 18], a RUQ u/s was performed which did not show any gallstones or CBD dilatation. On HD2, the patient had a total bilirubin of 9.1, ultimately maximizing to 17.1 on [7-28]. GI was consulted for possible ERCP, but since there was no CBD dilatation, MRCP was recommended. MRCP showed a normal biliary tree and evidence of acute pancreatitis. Due to the rising bilirubin, hepatology was consulted, which felt the patient had fulminant alcoholic hepatitis. Throughout his admission, the hepatology service did not feel the need to treat the patient with steroids. MRCP - MRCP: suboptimal study, nl biliary tree, splenic vein not visualized - [7-17]: insulin gtt, worsening metabolic acidosis, rising lactate, rising creatinine, CPAP 15/5 to CMV 600x20 15. T&S sent. Anuric at 0500 - Maintain pCO2 40-50 (permissive hypercapnia): - Place esophageal balloon to titrate PEEP - trend ABGs w/ any changes [7-16] 2100 7.36/30/84/18/-6 .5 CPAP 15/5 [7-16] 2300 7.35/34/84/20/-5 .5 CPAP 15/5 [7-17] 0200 7.29/39/84/20/16 .5 CPAP 15/5 [7-17] 0700 7.27/41/96/20/-7 Gastrointestinal / Abdomen: 1. Acute pancreatitis: GSP v. EtOH (no GS seen on imaging) [Last Name (un) ] admit = 3 [Age >55; WBC 16.1@OSH; FSBG>200] [Last Name (un) ] 48 hr = 4 [Hct down>10%; BUN up>5; Base def>4; IVF seq>6L] [Last Name (un) ] total = 7 : >= 40% mortality 2. + Grey [Doctor Last Name ] sign 3. MRCP [7-16]: suboptimal study, nl biliary tree, splenic vein not visualized - likely thrombosis 4. isolated elv Tbil (0.8 to 12.2/24hr) ?EtOH hepatitis 5. MELD score ([7-17]): 30 6. Bladder pressures: 22-26 (9 after paralysis) - trend LFT/lipase - cont NGT: hold TF in setting of elevated intra-abdominal pressure - resuscitation (LR/Albumin), now oliguric, down titrate (elevated intra-abdominal pressure) - Hepatology recs: r/o viral hepatitis, likely EtOH hepatitis, consider TF (currently none) - consider repeat CTa/p to characterize evolution of pancreatitis ?necrosis --> not now, reconsider in future Nutrition: NPO - no TF presently Renal: 1. [Doctor First Name 48] [7-17] (1.1-3.2-3.5) with oliguria, now anuric (baseline Cr 1.0-1.2, admission 1.1) 2. Fluid balance: # L/d // # /LOS 3. FENa: 0.55 UOP o/n: 801 (34) [0-13cc/hr] 4. Resuscitation overnight: [Albumin: 2x12.5mg 25%/ 2x25mg 5%; Bolus: 3500; IVF: 3200] - Foley for urine output monitoring - Monitoring CVP, however in setting of elevated intra-abd pressure, is not accurate - Replete electrolytes PRN - will start CVVH - needs dialysis line Hematology: - HSQ - Daily Hct Endocrine: 1. No h/o DM/Thyroid dysfunction - insulin gtt for FSBG>250 Infectious Disease: 1. No active issues (afebrile, hemodynamically stable) - monitor fever curve, WBC - maintain high index of suspicion for infection, b/c pancreatitis can mimic sepsis Lines / Tubes / Drains: PIV, RIJ CVL ([7-15]), Foley ([7-15]); LEFT radial A-line ([7-15]) -Prophylaxis: - DVT: Boots; SQH - Stress ulcer: Protonix [Hospital1 ] - VAP bundle: - Comments: Communication: Patient; [Doctor First Name 5627] [Wife]: ([Telephone/Fax (1) 44421] ICU Consent: complete Code status: CMO On [2186-8-2] Patient was taken to OR for Ex-Lap for suspected abdominal compartment syndrome. No surgical intervention was possible at that time. Discussion with family - decided to put patient CMO. Patient expired at 14:31 with withdrawal of pressors and extubation. Medications on Admission: 1. Prednisone for the last 9 days: 5 days 40', 2days 20' 2 days with 10' (last dose on [7-15]) for treatment of Gout. He uses prednisone as often as twice per day to treat gout fares. 2. Fluticasone 2 sprays twice a day. 3. Testosterone intramuscularly every week. 4. Prevacid 30 mg daily. 5. Flomax 0.4 mg daily. 6. Bupropion SR 150 mg 2 tablets daily. 7. Aspirin 81 mg daily. 8. Lipitor 80 mg daily. 9. Lisinopril 20 mg daily. 10. Trazodone 50 mg at bedtime for sleep. 11. Doxycycline 100 mg 2 tablets twice a day for the past 6 months 12. Provigil 200 mg daily. 13. Aleve 220 mg as needed. Discharge Disposition: Expired Discharge Diagnosis: Multi-system Organ Failure secondary to Acute Alcohol Induced Pancreatitis Discharge Condition: Deceased Discharge Instructions: Name: [Known lastname ],[Known firstname 8124] Unit No: [Numeric Identifier 8125] Admission Date: [2186-7-15] Discharge Date: [2186-8-2] Date of Birth: [2121-7-27] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4987] Addendum: On [7-15], the patient was transferred from [Hospital1 8] [Location (un) 407] ICU to the TSICU. He presented 20 hrs prior with epigastric pain and elevated lipase. He had a 6L fluid resuscitation at [Hospital1 8] [Location (un) 407] upon transfer. The patient was conversational, had a normal mental status, and was responding to IVF resuscitation. A CVL line was placed for CVP monitoring. Due to the patient's complicated hospital course, I will describe his hospital course with regards to organ systems. Neuro: Initially, the patient was mentating. Pain was controlled with a Dilaudid PCA. However, on HD2, the patient was more agitated and became obtunded. He was intubated in order to be transported for MRCP. He remained on sedation, with intermittent Versed and fentanyl gtt. On HD3, the patient had increasing bladder pressures and increasing PIP. He was paralyzed with Cisatracurium with improvement in abdominal tension and bladder pressures. Paralysis was eventually weaned as his abdominal exam improved. He was also given intermittent Haldol for agitation. Once the patient was on a CPAP vent setting, he was sedated with Precedex with good results. On [7-27], the patient was extubated and was verbal, but confused. However, on [7-28] (36 hrs later), the patient was reintubated for respiratory fatigue. He again received IV fentanyl for sedation. Propofol was not used due to concerns for hypotension. Cardiovascular: On transfer to the TSICU, the patient was responding to fluid resuscitation with LR and IV fluid bolus to keep his CVP 14-16 and urine output greater than 30 cc/hr. On HD 2, the patient became oliguric and CVVH was started on HD3. As a result of the CVVH, the patient became hypotensive with SBP 70s. He was initially started on norepinephrine for BP support. A bedside ECHO showed depressed LV function. Bedside CO and CI monitoring was initiated. As a result, dobutamine was started with minimal improvement in LV function. However, the dobutamine caused atrial fibrillation with a RVR. The dobutamine was stopped, the patient was cardioverted twice to no response, had IV esmolol, IV digoxin, and eventually was placed on an amiodarone gtt. The patient responded well to the amiodarone with a HR in the low 100s. Norepinephrine was then used for blood pressure support. Vasopressin was the used as a second pressor. The patient was weaned off pressors by the second week and had stable BP in the 110-120's once extubated. Atrial fibrillation was controlled with intermittent digoxin and intermittent IV amiodarone. Repeat ECHO showed improved ventricular function. After being reintubated, the patient was restarted on vasopressin and then neosynephrine was added for further support. His pressor requirements increased on [8-1] and [8-2]. Respiratory: The patient was transferred in no respiratory distress. However, on the morning of HD2, the patient was agitated and was intubated for transport to MRCP. On the evening of HD2, the patient was receiving boluses of IVF and albumin. However with the resulting oliguria, his CXR was becoming increasingly consistent with fluid overload. On HD3, there was concern for early signs of ARDS and the patient was started on an ARDS net ventilatory protocol. Once CVVH was started and the patient tolerated fluid removal, vent settings were weaned to CPAP. The patient was extubated on [7-27] for 36 hrs. However, he experienced respiratory fatigue and was reintubated. Discussion regarding placing a trach was started after the second intubation. However, the patient became increasingly unstable with a worsening respiratory acidosis during the week of [7-31]. He was made CMO on [8-2]. GI: The patient was transferred from [Hospital1 8] [Location (un) 407] with acute pancreatitis. In 48 hours his [Last Name (un) 8126] score was 7. CT ABD at [Location (un) 407] was consistent with acute pancreatitis without any fluid collections. At [Hospital1 8], a RUQ u/s was performed which did not show any gallstones or CBD dilatation. On HD2, the patient had a total bilirubin of 9.1, ultimately maximizing to 17.1 on [7-28]. GI was consulted for possible ERCP, but since there was no CBD dilatation, MRCP was recommended. MRCP showed a normal biliary tree and evidence of acute pancreatitis. Due to the rising bilirubin, hepatology was consulted, which felt the patient had fulminant alcoholic hepatitis. Throughout his admission, the hepatology service did not feel the need to treat the patient with steroids. The total and direct bilirubin remained elevated during this admission. On [7-21], CT ABD without contrast was performed due to elevated WBCs and fever spikes. There was no evidence of pancreatic fluid collections. Repeat CT ABD with contrast on [7-29] was consistent with pancreatic hypotentuation, but no fluid collections or air/fluid levels. On HD3, the patient had increasing bladder pressures and PIP. The pancreatic surgery service, under Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1099], was consulted for possible intervention. Since these signs of abdominal compartment syndrome resolved with paralysis, a decompressive laparotomy was not warranted. On HD4, the patient's care was transferred to the pancreatic surgery service, who co-managed the patient along the with ICU team. On the last day of admission, the patient had rising WBCs and lactate. He was brought to the OR on [8-2] for exploratory laparotomy. However, no obvious abdominal pathology was revealed. However, a large amount of ascites was drained. FEN: The patient was initially started on TF early in the admission once the pressor requirement was improved. However, the TF were intermittently held for increased residuals, possibly due to bowel ileus. The patient was started on TPN for nutritional support. ID: Initially, the patient was treated supportively with IVF since there was no evidence of pancreatic necrosis on the first CT ABD. However, during the first few days, the patient had an increasing pressor requirement and had fever spikes. Urine and blood cultures have come back negative. Sputum cultures were eventually positive for Klebsiella pneumonia. On [7-23], the patient was started on empiric Zosyn. On [7-24], vancomycin and Tobramycin were also started for a VAP protocol. He continued on broad spectrum antibiotic coverage throughout the admission. There was no evidence of necrotizing pancreatitis. C Diff. toxin A and B remained negative. GU: The patient responded well to fluid resuscitation with regards to urine output and CVP. However, on HD2, he began to have decreased urine output that did not respond to IVF boluses and albumin. On the evening of HD3, his Cr rose from 1.1 to 3.5. Nephrology was consulted and the patient was begun on CVVH. Initially, he was kept in even fluid balance. As his hemodynamics stabilized, more fluid was aggressively removed with interval improvement in anasarca. However, the patient did not regain renal function throughout this admission. Heme: The patient presented from [Hospital1 8] [Location (un) 407] hemoconcentrated. His hematocrit decreased as fluid became mobilized. He had an initial 2u PRBCs early in his admission and another 3u PRBCs en route to the OR on [8-2]. He had a slight coagulopathy during the end of his admission. He had venodyne boots and Heparin SQ for DVT prophylaxis. ENDO: From early in his admission, the patient required an insulin drip to maintain a normal blood glucose level. In addition, the patient had a cortisol stimulation test which showed normal adrenal function. Dispo: Due to the patient's multi-organ failure from this episode of severe acute pancreatitis, he remained in critical condition. Because of rising WBCs, lactates, and respiratory acidosis, he was taken to the OR on the morning of [8-2]. Although a large amount of ascites was drained, there was no obvious pathology. After a family discussion, the patient was made CMO and expired in the afternoon of [8-2]. Brief Hospital Course: O Discharge Disposition: Expired [Name6 (MD) 116] [Last Name (NamePattern4) 4988] MD [MD Number(1) 4989] Completed by:[2186-8-3]	[ "274.9", "572.8", "038.9", "585.6", "780.52", "729.73", "272.4", "427.31", "518.81", "276.2", "276.1", "311", "997.31", "327.23", "530.81", "577.0", "427.89", "995.92", "427.32", "403.91", "789.59", "571.1", "558.9", "276.3", "785.52", "276.7", "303.91", "584.5" ]	icd9cm	[ [ [] ] ]	[ "54.11", "38.95", "96.6", "38.93", "99.15", "96.72", "96.08", "99.62", "38.91", "96.04", "39.95", "96.71", "33.24" ]	icd9pcs	[ [ [] ] ]	26973, 27123	26947, 26950	369, 409	18421, 18432	2531, 4304		2063, 2130				18322, 18399		17549, 18269			18460, 26924									2145, 2145								4337, 10420						2459, 2512									262, 330						437, 1358								2159, 2445							1380, 1838	1854, 2047
21,448	174,986	45776	Discharge summary	report	Admission Date: [2126-8-29] Discharge Date: [2126-8-31] Date of Birth: [2069-5-31] Sex: M Service: MEDICINE Allergies: Penicillins / Enalapril Attending:[First Name3 (LF) 3256] Chief Complaint: ETOH withdrawal and chest pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 57M with history of EtOH abuse, MI, cardiomyopathy, Afib, HTN, hepatitis B/C states that one hour prior to arrival he started having left sided chest pain. The patient is homeless and was cold, wet, and sleeping on a bench when he felt a sudden onset substernal pressure as well as left arm numbness. He took nitroglycerin, and that did not immediately relieve the pain. There was associated shortness of breath. States that he is taking a total of one quart of Listerine daily, with the last intake the morning of admission. Past Medical History: Atrial fibrillation Tachycardia induced cardiomyopathy (since resolved) ETOH abuse with cirrhosis Hypertension 2.5-cm cystic lesion in pancreatic tail ([2121]) Colonic polyposis s/p knee replacement Hepatitis B/C/ETOH, grade 3 fibrosis Social History: Homeless, lives on the street in [Location (un) ] Corner. Smokes 2ppd for 44yrs. Drinks listerine, 1 medium bottle per day for the past 4-5 years. Denies current IVDU. Previously did IV cocaine in the remote past. Denies taking painkillers. Family History: Positive for coronary artery disease (details unknown) and hypertension. His father had an aortic aneurysm. There is a history of cancer of the brain and the breast. Physical Exam: On Admission to the ICU 114, 161/100, 18, 98 General Appearance: Awake. Tremulous. NAD. Disheveled w body odor. HEENT: PERRL, no nystagmus Cardiovascular: Normal S1 S2, no m/r/g, JVP non-elevated Respiratory: CTAB, no rhales, rhonci, or wheezes Abdominal: Soft, Non-tender, Bowel sounds present Extremities: 2+ pulses through out, no edema Neurologic: CN II-XII intact, Good strength in upper extremities, patient reports difficulty moving lower extremities [12-19] prior injuries SKIN: No rash or tenderness to percussion over thorax Pertinent Results: [2126-8-31] 06:11AM BLOOD WBC-4.2 RBC-3.34* Hgb-11.5* Hct-33.9* MCV-101* MCH-34.4* MCHC-33.9 RDW-13.9 Plt Ct-106* [2126-8-30] 03:29AM BLOOD PT-12.0 PTT-26.6 INR(PT)-1.0 [2126-8-31] 06:11AM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-137 K-4.6 Cl-101 HCO3-26 AnGap-15 [2126-8-31] 06:11AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.8 [2126-8-31] 06:11AM BLOOD ALT-97* AST-307* AlkPhos-120 TotBili-1.5 [2126-8-29] 05:00AM BLOOD cTropnT-<0.01 [2126-8-29] 10:55AM BLOOD cTropnT-<0.01 [2126-8-29] 05:41PM BLOOD CK-MB-2 cTropnT-<0.01 [2126-8-29] 05:00AM BLOOD ASA-NEG Ethanol-214* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ECG [2126-8-29] Sinus rhythm. Borderline low voltage in the limb leads. Compared to the previous tracing of [2126-7-28] the rate is slower. CXR [2126-8-29] IMPRESSION: No acute intrathoracic process though the costophrenic angles were partially excluded. Brief Hospital Course: Patient is a 57yo homeless man with history of EtOH abuse, myocardial infarction, cardiomyopathy, atrial fibrillation (not on coumadin), hypertension, hepatitis B and C, who presented in the ED complaining of left-sided chest pain, and became tremulous. . ACTIVE ISSUES: # Chest pain: history suggestive of ACS (substernal chest pain, left arm pain), but ECG showed no acute ischemic changes and TnT was <0.01 x3. Pneumonia was unlikiely given the lack of fevers and CXR with no infiltrates. Most likely etiology is costocondritis; resolved in the ED. . # Alcohol withdrawal: In the ED patient became agitated, diaphoretic, and increasingly tachycardic. CXR was unremarkable. He was given 3mg ativan, 15mg of diazepam for CIWA>10, and was transferred to the MICU for management of alcohol withdrawal. He received B12 and Folic Acid. In the MICU he was afebrile, hypertensive to 161/100, tachycardic to 114, and was somewhat tremulous and diaphoretic. He was placed on Diazepam 5 mg PO Q1H:PRN for CIWA > 14. He was otherwise comfortable and stable, no longer reported any chest pain, and was speaking in full sentences, and was alert and oriented to person, place, and date. He was restarted on his home metoprolol and diltiazem dose, and was started on B12, folic acid, and thiamine. The next morning the patient was requiring less diazepam (5mg q4H:PRN for CIWA>14) and was no longer tachycardic, hypertensive, tremulous or diaphoretic. He was therefore transferred to the floor. On the floor he was initially comfortable and stable, and his diazepam requirement decreased to 5mg q8H: PRN for CIWA>10. Social work was consulted given frequent admissions for alcohol abuse. However, on the morning of [2126-8-31] he was dissatisfied with his lunch and became agitated. Despite receiving 2 doses of 5mg diazepam q2H, he continued to be agitated and abusive to nursing staff, and stated in no uncertain terms that he wanted to leave. The risks of leaving while undergoing treatment for alcohol withdrawal were explained to the patient, including seizures and death; however, he insisted on leaving and left the hospital against medical advice. . # Tachycardia (sinus): unresponsive to IV fluids in ED. Likely due to EtOH withdrawal. Patient was placed on telemetry; home metoprolol, diltiazem were continued; he received maintenance IV fluids at 100cc/hr and Diazepam for EtOH withdrawal (as per above). . INACTIVE ISSUES # Hypokalemia: admission K 2.7, possibly due to long-standing alcoholism accompanied by vomiting and diarrhea, as well as this patient's use of HCTZ and furosemide. K was trended daily and repleted as necessary. . # Anemia, thrombocytopenia: Hct was stable in low 30's. Iron studies ([3-27]) had shown Iron 203, TIBC 239, Transferrin 184, ferritin 278, B12 407, folate 15.6. Plt 102, which is approximately at the patient's baseline. Both anemia and thrombocytopenia are likely due to alcohol-induced bone marrow suppression, though on this admission B12 was wnl (308). CBC was monitored; thiamine, folate were given daily. . #. Back pain: chronic for about 13yrs; no surgical intervention per neurosurg (see last d/c sum). Pain was controlled with lidocaine patches. . #. Hepatitis B/C: alcoholic pattern. Has h/o grade 3 fibrosis. Outpatient management was recommended. . #. Atrial fibrillation: not on coumadin due to risks with homelessness. Patient reports receiving prior cardioversion. ECG is sinus here. - Continue metoprolol and diltiazem TRANSITIONAL ISSUES None - patient left AMA. Medications on Admission: One Multivitamin by mouth daily Toprol XL: one 25mg tablet by mouth daily Omeprazole: one 20mg tablet by mouth daily HCTZ: one 50 mg tablet by mouth daily Folic Acid: one 1mg tablet by mouth daily Vitamin B1: one 100mg tablet by mouth daily Diltiazem XR: one 120mg tablet by mouth daily Furosemide: one 20mg tablet tablet by mouth daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Alcohol withdrawal Secondary: atrial fibrillation, hypertension, liver cirrhosis, hepatitis C. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 14879], You were admitted to the [Hospital1 18] for chest pain on [8-29]. Your tests showed you did not suffer from a heart attack, but you experienced symptoms of alcohol withdrawal and were admitted to the hospital. You were given Diazepam to help with withdrawal symptoms, and you became more calm; however, on [8-31] you chose to leave the hospital against medical advice (AMA). The risks of leaving were explained to you; these incluse worsened alcohol withdrawal, seizure, and death. Followup Instructions: Please follow-up with your regular primary care physician.	[ "724.5", "303.91", "070.54", "V43.65", "070.32", "V12.72", "571.2", "427.89", "287.49", "291.81", "401.9", "412", "427.31", "V60.0", "285.8" ]	icd9cm	[ [ [] ] ]	[ "94.62" ]	icd9pcs	[ [ [] ] ]	7664, 7670	3104, 3360	315, 322	7818, 7818	2168, 3081	8527, 8589	1425, 1593		7021, 7641		7691, 7797		6659, 6998			7971, 8504									1608, 2149																							245, 277		3375, 6633				350, 883									7833, 7947						905, 1146	1162, 1409
11,205	193,883	12265+56360+56349	Discharge summary	report+addendum+addendum	Admission Date: [2147-5-30] Discharge Date: [2121-2-10] Date of Birth: [2071-7-12] Sex: M Service: Please see addendum to discharge summary for hospital course starting on [2147-6-2]. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old male with a history of diabetes, peripheral vascular disease, with chronic lower extremity ulcers, coronary artery disease status post coronary artery bypass graft and aortic valve replacement in [2147-3-13], who was transferred from [Hospital 1474] Hospital for fever, hypotension, hypoxia, and elevated CKs for question of emergent cardiac catheterization. The patient presented approximately 24 hours earlier to [Hospital 1474] Hospital, where he complained of two days of generalized fatigue and malaise. He was noted to have a fever to 102.8, with a blood pressure of 90/30 on admission. His chest x-ray was concerning for bilateral infiltrate. He was initially treated with ceftriaxone and azithromycin. This was then changed to vancomycin and gentamicin. He was initially on a dopamine drip for hypotension, which was weaned after approximately ten hours. He was then noted to have elevated CKs and troponin. Echocardiogram revealed an ejection fraction of approximately 40%, which was unchanged from prior. He was started on a heparin drip for concern for acute coronary syndrome. By report, he was approximately 2 liters positive from normal saline resuscitation while in the Emergency Department at [Hospital1 1474]. The patient was also noted to be anemic to 29 from a prior hematocrit of 38 approximately ten days earlier. He was therefore transfused one unit of packed red blood cells, with a resultant decrease in his oxygen saturations secondary to possible pulmonary edema. The patient was minimally responsive to lasix at that time, and ultimately required intubation for hypoxic respiratory failure. Following intubation, the patient became progressively more hypotensive and tachycardic, and was started on a dopamine drip again. Electrocardiogram at that time revealed deepening of anterolateral ST depressions. CKs rose to 667. The dopamine drip was weaned off, and a Neo-Synephrine drip was started. Cardiology was consulted, and a Swan-Ganz catheter was placed, which revealed right atrial pressure of 20/4, right ventricular pressure of 44/10, pulmonary artery pressure of 48/24, and pulmonary capillary wedge pressure of 22. Three sets of blood cultures were sent. The patient had a urinalysis which revealed moderate leukocytes and bacteria. A urine culture was not sent. Just prior to transfer, the patient was started on a heparin drip. On arrival to [Hospital1 69], his blood pressure was in the 80s systolic. The Neo-Synephrine drip was weaned off, and the patient was started on Levophed for pressor support. PAST MEDICAL HISTORY: 1. History of lower extremity ulcers 2. Diabetes 3. History of peripheral vascular disease status post right femoral-to-posterior tibial bypass in [2147-3-13]; status post right fourth toe amputation at that time 4. Elevated cholesterol 5. History of hearing loss 6. Status post transurethral resection of prostate x 3 7. Status post right total hip replacement 8. Coronary artery disease status post coronary artery bypass graft in [2147-3-13], status post aortic valve replacement at the same time with bovine valve; patient with a history of a non-Q wave myocardial infarction in the setting of his vascular surgery, which was pre-coronary artery bypass graft 9. History of hematuria with urologic workup pending; the patient has had an ultrasound in the past revealing an echogenic bladder mass, concerning for thrombus vs. questionable malignancy 10. Question history of paroxysmal atrial fibrillation MEDICATIONS ON TRANSFER: 1. Vancomycin 750 mg intravenously twice a day 2. Gentamicin 120 mg intravenously x one dose given on the morning of his transfer to [Hospital1 188] 3. Aspirin 4. Pepcid 20 mg intravenously twice a day 5. Neo-Synephrine drip 6. Heparin drip started one hour prior to transfer HOME MEDICATIONS: 1. Lopressor 25 mg by mouth twice a day 2. Colace 100 mg by mouth twice a day 3. Enteric-coated aspirin 325 mg by mouth once daily 4. Protonix 40 mg by mouth once daily 5. Lasix 20 mg by mouth once daily 6. Darvocet as needed for foot pain 7. Simethicone 80 mg by mouth four times a day 8. Zinc 9. Prevacid 10. Multivitamin 11. Tylenol as needed SOCIAL HISTORY: The patient has a smoking history of one pack per day for 50 years. He is a retired corrections officer, and currently lives at home with his wife and has a supportive family. PHYSICAL EXAMINATION: On admission, vital signs: Temperature 101.6 rectally, pulse 63, blood pressure 86/49, respiratory rate 12. General appearance: The patient was intubated and sedated on arrival. He withdrew to pain, but was unresponsive to voice and touch. Head, eyes, ears, nose and throat: Pupils were 2 to 3 mm and fixed. The sclerae were anicteric. The neck was notable for a right internal jugular with a Swan in place. Cardiovascular: Regular rate, with intermittent ectopy, a II/VI systolic murmur at the left upper sternal border. Chest revealed a midline sternotomy scar. The lungs had bilateral mild coarse rhonchi on the ventilator, with no appreciable wheezes. Abdomen was soft, nontender, nondistended, with active bowel sounds. Extremities revealed no edema. The patient had bilateral ulcerations with mild serosanguinous drainage over his medial malleoli. His left foot was notable for a black dusky-appearing second toe. His upper extremities were warm and pink, although his lower extremities were cool bilaterally. LABORATORY DATA: On admission, white blood count 9.5, hematocrit 30.4, platelets 260. Sodium 135, potassium 4.9, chloride 102, bicarbonate 24, BUN 46, creatinine 2.2, glucose 191. Calcium 8.5, magnesium 1.8, phosphate 4.7. CK was 440, with a troponin greater than 50, MB fraction of 40. Blood and urine cultures were sent at [Hospital1 188], which proved to be negative. HOSPITAL COURSE BY SYSTEM: 1. Cardiovascular: Patient with a history of coronary artery disease status post coronary artery bypass graft and aortic valve replacement approximately two months ago. He presented with elevation in CKs and troponins, with evidence of anterolateral electrocardiogram changes. Admission electrocardiogram was notable for persistent 1 to [Street Address(2) 2051] depressions in V3 through V6, as well as T wave inversions in I and AVL. The patient's ischemic picture was thought to be more consistent with demand-related ischemia in the setting of his sepsis and anemia. The patient had a normal cardiac index. Despite evidence of bilateral fluffy infiltrates suggestive of congestive heart failure, the patient had a normal pulmonary capillary wedge pressure, suggesting that the pulmonary process was more likely acute lung injury vs. adult respiratory distress syndrome in the setting of sepsis. The patient was started on aspirin, and heparin was continued for approximately 36 hours. No beta blocker or ACE inhibitor was given, given the patient's low blood pressure and pressor dependence. His CKs were cycled, and noted to trend downward over the course of his hospitalization. The patient had no episodes of chest pain or complaints of shortness of breath, even following extubation. Once his blood pressure improves, the patient will be considered a candidate for institution of beta blockade, as he was on 25 by mouth twice a day at home. Regarding the patient's pump function, he was noted to have an ejection fraction of approximately 40% by cardiac catheterization in [Month (only) 958]. His ejection fraction was not substantially changed according to echocardiogram report from [Hospital 1474] Hospital. As noted above, the patient had a normal pulmonary capillary wedge pressure and a normal cardiac index, suggesting that he was not in cardiogenic shock, and that his ischemic changes were most likely secondary to demand. The patient did have a repeat echocardiogram in the form of a transesophageal echocardiogram during this hospital stay, principally to evaluate for evidence of endocarditis. Transesophageal echocardiogram revealed left ventricular systolic function likely to be decreased. It was also notable for some simple atheroma in the aorta. There was no evidence of any valvular lesions consistent with congestive heart failure. The patient's blood pressure remained low when he was first admitted to the hospital. He was started on a Levophed drip and a vasopressin drip was added approximately 24 hours later for additional pressor support. Following treatment with antibiotics and other symptomatic care, the patient became less pressor dependent, and was gradually weaned off of pressors. 2. Infectious Disease: The patient presented with septic shock, found to be secondary to high-grade enterococcal bacteremia. Six out of six blood cultures that were initially drawn at [Hospital 1474] Hospital were positive for enterococcus fecalis, which was pansensitive, including sensitivities to ampicillin, vancomycin and levofloxacin, all of which the patient received at one time or another. Upon admission to [Hospital1 69], he was continued on vancomycin, which had been started at the outside hospital, and also was started on levofloxacin for concern for a pulmonary process, as the chest x-ray was concerning for a right-sided infiltrate, although this was difficult to evaluate in the setting of bilateral fluffy infiltrates. The patient had frequent fever spikes over the first 48 hours of his hospitalization. Blood and urine cultures drawn at this institution were negative. The patient did have heavy growth of yeast in his urine, and his Foley was changed as a result. Follow-up review of the urinalysis which was done at [Hospital 1474] Hospital showed evidence of a urinary tract infection, although a urine culture was never done. The etiology of the patient's enterococcal sepsis was thought most likely to be urinary. An abdominal CT was performed to look for evidence of an abdominal process to explain it. Other possible sources included the right hip prosthesis with possible seeding, as well as possible prostatitis given his history of transurethral resections of prostate. There was no evidence by abdominal CT of a prosthetic abscess, although it was a non-contrast CT. The patient gradually defervesced on antibiotics. After the culture results from [Hospital1 1474] were noted to reveal a pansensitive enterococcus, the patient's antibiotic regimen was simplified to ampicillin. The patient was evaluated by the Infectious Disease consult service, who suggested at least a four week of antibiotics, given his prosthetic valve and prosthetic hip. The Infectious Disease service also recommended the patient have follow-up urologic evaluation for hematuria and bladder mass, especially as it might result in his presentation in urosepsis. 3. Renal: The patient presented with mild elevation in his creatinine in the setting of sepsis. His creatinine later trended down to baseline. The patient also had a mild anion gap acidosis with a normal lactate which resolved within a day or two. 4. Hematology: The patient was noted to have an approximately ten point drop in his hematocrit at the outside hospital from ten days prior. He was transfused one unit of packed red blood cells at the outside hospital. On arrival to [Hospital1 69], his hematocrit was 30.6, and remained stable for the first three days of the hospitalization. On [2147-6-1], it was noted to drop five points overnight. The patient was also noted to have some hematuria in the setting of his heparin drip on arrival, which later cleared. He was also noted to have some guaiac-positive stools. The patient did report a history of hematuria as well as a history of rectal bleeding secondary to hemorrhoids. The patient was transfused two units of packed red blood cells to get his hematocrit over 30 on [2147-6-1]. His hematocrit was checked twice a day for several days. Should his hematocrit remain stable, he warrants an outpatient colonoscopy. 5. Genitourinary: Patient with a history of prostate cancer with transurethral resection of prostate x 3. He also has a history of hematuria and evidence of an echogenic mass on prior ultrasound, suggestive of thrombus vs. malignancy. The patient has had follow up with his outpatient urologist, although it is unclear if he has had a repeat cystoscopy. Given presentation with probable urosepsis, it is important that the patient have prompt urologic follow up as an outpatient. 6. Pulmonary: The patient presented with bilateral fluffy infiltrates, most likely consistent with acute lung injury in the setting of sepsis. These improved with treatment of his underlying sepsis. The patient was extubated on [2147-5-31] and did well on room air. He was noted to have some bilateral crackles on examination on [2147-6-1], and will likely require some diuresis prior to discharge. 7. Gastrointestinal: Patient noted to have guaiac-positive stools in the setting of his low hematocrit. He was transfused as above. He was continued on Protonix, and remained hemodynamically stable with twice a day checks of his hematocrit. The patient should receive an outpatient workup for gastrointestinal bleeding source, although the patient does report a history of rectal bleeding from hemorrhoids. 8. Endocrine: Patient with a history of diabetes. He was maintained on a regular insulin sliding scale during this hospitalization. The patient is apparently diet controlled as an outpatient. 9. Lines: The patient had a right internal jugular cordis with a Swan catheter in place at the time of admission to the [Hospital1 69]. His Swan was utilized for several days for hemodynamic monitoring, which revealed a relatively normal pulmonary capillary wedge pressure, normal cardiac index. The Swan catheter was discontinued on [2147-6-1]. At that time, he was noted to have a normal wedge pressure with mildly elevated pulmonary artery diastolic pressures. NOTE: Please see addendum to this discharge summary for the remainder of the hospital course beginning on [2147-6-2], as well as for discharge diagnoses, medications, and follow up. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern4) 4689] MEDQUIST36 D: [2147-6-1] 23:41 T: [2147-6-2] 01:24 JOB#: [Job Number 26297] Name: [Known lastname 6930], [Known firstname ] Unit No: [Numeric Identifier 6931] Admission Date: [2147-5-30] Discharge Date: [2147-6-5] Date of Birth: [2071-7-12] Sex: M Service: HOSPITAL COURSE: (Continued) Please see discharge summary of [2147-6-1]. Mr. [Known lastname ] remained stable on the previous treatment. On [2147-6-4], he was transferred to the Medicine Team. While on the Medicine Service, he had a chest x-ray which showed a PICC line in the mid superior vena cava. effusions. There was no evidence of pneumonia or congestive heart failure. There was no pneumothorax. He also had an ultrasound of the bladder. This showed that the previous mass noted on ultrasound in [2147-2-10] had resolved. The prostate was not enlarged. Mr. [Known lastname ] was started on Captopril to treat his heart failure. He tolerated this well. He was discharged to rehabilitation at the [Location (un) 42] Transitional Care DISCHARGE DIAGNOSIS: 1. Enterococcus sepsis 2. Myocardial infarction 3. Congestive heart failure 4. Hematuria 5. Chronic renal insufficiency 6. Diabetes 7. Bilateral ankle ulcers DISCHARGE MEDICATIONS: 1. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn 2. Simethicone 60 mg p.o. t.i.d. prn 3. Enteric coated Aspirin 325 mg p.o. q.d. 4. Pantoprazole 40 mg p.o. q. 24 h. 5. Anusol ointments, one application p.r. q.d. prn 6. Ampicillin 2 gm intravenously by PICC line q. 6 h. This should continue until [2147-6-27]. 7. Captopril 6.25 mg p.o. t.i.d. He is also receiving wound care and dressings to his bilateral ankle ulcers q.d. DISCHARGE FOLLOW UP: Mr. [Known lastname ] will follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2031]. He will require a colonoscopy as an outpatient to work up his rectal bleeding. He will also require cystoscopy to investigate his hematuria. He also has a lipid study pending. DR.[First Name (STitle) ],[First Name3 (LF) 520] 12-927 Dictated By:[Last Name (NamePattern1) 1170] MEDQUIST36 D: [2147-6-5] 15:42 T: [2147-6-5] 15:53 JOB#: [Job Number 6977] Name: [Known lastname 6930], [Known firstname ] Unit No: [Numeric Identifier 6931] Admission Date: [2147-5-30] Discharge Date: [2147-6-6] Date of Birth: [2071-7-12] Sex: M ADDENDUM: On the morning of [6-6], Mr. [Known lastname ] was noted to have low blood pressure at 80/52; therefore, Captopril was discontinued. His blood pressure improved and he was asymptomatic. As a result, the patient was discharged to rehabilitation. [First Name11 (Name Pattern1) 520] [Last Name (NamePattern4) 521], M.D. [MD Number(1) 522] Dictated By:[Last Name (NamePattern1) 1170] MEDQUIST36 D: [2147-6-6] 11:26 T: [2147-6-6] 11:42 JOB#: [Job Number 6932]	[ "V45.81", "112.2", "518.81", "428.0", "707.14", "410.01", "V42.2", "038.49", "443.9" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]									16003, 16449		15814, 15980			15033, 15793							6154, 15015									4137, 4493				16461, 17834			4713, 6127																	251, 2860														3832, 4119	2882, 3807	4511, 4689
44,451	149,944	12539	Discharge summary	report	Admission Date: [2125-1-8] Discharge Date: [2125-1-15] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 710] Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: Hemodialysis. History of Present Illness: Ms. [Known lastname 25143] was admitted admitted overnight with pancreatitis. She has no history of EtOH, and imaging did not show stones or CBD dilatation. She routinely has HD M-W-F, but does make some urine. The floor team requested a transfer given her overall poor status with Ransom score of 3 (age, LDH, and AST), tenuous volume status (looking vol depleted given Hct 42 with baseline upper 20'S- low 30'S), elevated BP (SBP 170-200's needing IV medications) and concern for poor MS. . Her baseline mental status is reported as Ox2-3 per [10-4] d/s summary (usually missing exact date but otherwise oriented to elements of time). Presently she appears uncomfortable with groaning and is oriented to person and place. She reports that her abdominal pain started yesterday. I tried calling her son at 10:15 this morning to clarify the history and left a message on his voicemail. . Per NF admission note: 86 yo F with PMH of ESRD - HD dependent [Month/Year (2) 12075], AF on coumadin, type II diabetes, [Month/Year (2) ]/CVA, CAD, Anemia, MGUS, hypercholesterolemia, and hypertension admission last year with cdiff pan-colitis, sepsis presenting with acute onset abdominal pain, nausea, vomiting x 1 day. . Per PCP call in, she was started on Augmentin on [1-5] for uncertain reasons (no note in OMR yet). On admission, c/o constipation, abdominal pain, nausea, and vomiting per her son. [Name (NI) ] states that emesis appeared dark brown "like blood" and that she is a warfarin patient. Denies fever, dysuria. Unable to get more history from patient due to mental status. . In the ED, initial VS were: T96.7 HR66 BP137/70s -> SBP 170, 200s RR18 100% on RA Labs significant for Lip: 1754, Tbili: 1.8, ALT: 167, AST: 454, Cr 3.2. UA with 6-10 WBCs. CXR showed no acute cardiopulmonary process, Initially worried about ischemic colitis but CT abd/pelvis showed no evidence ischemic colitis but evidence of pancreatitis with hypoenhancement, edema, adjacent stranding especially of pancreatic head. Gallbladder dilation with sludge unchanged, no e/o stone, no CBD dilation. RUQ US showed dilated gallbladder [Doctor Last Name ] to prior, with sludge, but no pericholecystic fluid or CBD dilation. Patient declined NGT. Guiac negative. Foley in, making urine. . Patient given 4mg IV morphine x 3, and 4mg zofran x 2 with improvement and pain and nausea. Also given 2L IVF. . Vitals in ED prior to transfer were T97.9, HR95, BP209/69 (SBP 224 was her highest at 9pm, 11pm - ranging btw 170-200s) - not given any BP lower meds in ED with concern about fluid shifts, RR22, 99 on 2L. . On the floor, patient with mild headache, not complaining of chest pain, abdominal pain at rest. . REASON FOR TRANSFER to the ICU: Ransom score of 3, hypertensive, altered mental status, overall borderline status Past Medical History: Recent admissions in [10-4] for GIB thought to be from C diff colitis while on anticoagulation (confirmed with son that was restarted) Atrial fibrillation: on coumadin Diabetes mellitus type 2 on insulin Chronic renal failure secondary to diabetes mellitus type 2, on hemodialysis [Date Range 12075] at [Location (un) ], has right arm fistula Cdiff with pancolitis in hospital admission [10-4] [Month/Year (2) ]/CVA Coronary artery disease. Anemia. Hypercholesteremia. Hypertension. MGUS. Osteoarthritis, especially in knees Hemarthrosis R knee Popliteal DVT RLE [1-29] Social History: Per last discharge summary, she is a nonsmoker and doesn't drink ETOH (confirmed with son) She has been at rehab facilities after her last admissions (unclear where she came from) and prior to that she lived alone in [Location (un) 686] in a [Location (un) 1773] apartment. She has ten children. She has been living with son for over a month since being discharged from rehab. Family History: As above, she has ten children. She has a strong family history of diabetes and hypertension. No known history of coronary disease. Physical Exam: Vitals prior to transfer: 97.4 (afebrile overnight), BP 185/63 (ranging 170-200's), HR 77 (ranging 70-80's), 20, 96% 2LNC VS on arrival to the ICU: afberile, 184/66, 71, RR 25-28 98% on ?2LNC General: Elderly AA woman, thin, AOx2 (slef, hosp, not date; reportedly same as last night), speaking in full senetnces though is graoing and is obviously uncomfortable HEENT: Sclera anicteric, MMdry, edentulous Neck: supple, JVP not elevated, no LAD, right EJ Lungs: Bilateral bibasilar crackles anteriorly (cannot sit upright for posterior exam due to abd pain) CV: RR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: high pitched bowel sounds; +TTP in RUQ and LUQ, not in lower quadrants. No rebound or guarding. Ext: R AVF with bruit, WWP, 1+ pulses, no clubbing/cyanosis or no [Location (un) ] Neuro: AA, Ox2, appears uncomfortable, moving all limbs, difficult time cooperating for full exam due to pain Pertinent Results: On transfer to the ICU, notable for WBC 6.7 with 89% PMNs, lipase 1700+, lactate 2.2 (2.0 yest evening), AST 1000+, ALT 700+ (rising), TBili 3.6 (1.8 last night), neg CE, Ca 8.4 w/ nml alb (though down from 9.9 yest) . MICRO: [2124-12-28] UCx: ESCHERICHIA COLI. >100,000 ORGANISMS/ML AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R . Images: CTA abd/pelvis [1-8]: No evidence ischemic colitis. CT evidence of pancreatitis with hypoenhancement, edema, adjacent stranding especially of pancreatic head. No pseudocyst, abscess, SMV thrombosis, etc. Gallbladder dilation with sludge unchanged, no e/o stone, no CBD dilation. . RUQ US [1-7]: Similarly dilated gallbladder to prior, with sludge, but no pericholecystic fluid or CBD dilation. Correlate with fasting, which can explain such gallbladder dilation, but if there is high concern for acute cholecystitis, HIDA may be helpful. . CXR [1-7]: Wet read: CXR rotated, slight blunting of distal costophrenic angles, no infiltrate seen . ECHO [10-4]: TTE The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets are mildly thickened (?). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . EKG: [1-7]: NSR at 68bpm with normal axis, normal intervals, no ST changes . [1-11] CXR: Cardiac size is top normal. The aorta is tortuous. Left PICC line remains in place. There is no pneumothorax. Mild pulmonary edema is stable. Small bilateral pleural effusions, greater on the left side, are unchanged. Left lower lobe retrocardiac opacity is stable, could be due to atelectasis, though pneumonia cannot be excluded. . Leaving the ICU, labs notable for: Hct 32.5 Plt 63 INR 5.0 All LFT's improved from [1-8] to [1-11] . [1-9]: URINE CULTURE (Final [2125-1-10]): YEAST. 10,000-100,000 ORGANISMS/ML. . Brief Hospital Course: Please follow up with your primary care provider. [Name10 (NameIs) ] will need to have a blood test (CBC) on discharge to ensure your blood counts are normal. (due to: ?dysplasia on peripheral smear, thrombocytopenia) You will need to schedule an appointment with a general surgery physician on discharge for outpatient evaluation of your gallbladder, which was abnormally dilated on CT scan. #. PANCREATITIS: acute with no h/o pancreatitis per son, reportedly no EtOH, nml TG; slight effusion and volume depletion likely related; Ca normal now though a little lower than last night; in considerable pain. Appears volume depleted per labs with hemoconcentration, though is hypertensive (got 2L in ED, 125cc/hr overnight). Unclear cause-- possibly from augmentin which was started 2 days prior to sx though not highly associated with pancreatitis (though is a/w cholestatic jaundice), possibly due to gallstone that has now passed. - Pain controlled with fentanyl and morphine; patient NPO and then diet advanced as tolerated; aggressive fluid repletion at first, and then tapered off given patient receives HD so were cautious regarding fluid-overloading her; electrolytes repleted as needed. NG tube not placed as symptomatically improved and were concerned could aggravate delirium. Patient improved significantly with medical management. . #. HYPERTENSION: Patient with elevated BP into 200-220s SBP in context of pain with pancreatitis and also with fluid administration though not obviously volume overloaded. At home was on imdur, metoprolol, and norvasc. Continued home meds and addressed pain control; BP better controlled but will probably need further optimization of BP control while on floor. Had HD while hospitalized in ICU, per regular HD scheduled. Continued HD while on the floor. . # ESRD on HD: Patient M,W,F HD usually at [Hospital1 2177], followed by Dr. [Last Name (STitle) ]. Has R AVF. Had HD per schedule. . # AFIB: Patient had RVR on [1-10], metoprolol unresponsive, so started on diltiazem drip; then out of RVR, dilt gtt d/c'd. Continued home oral medications and home coumadin (although held coumadin as appropriate, in setting of INR that went from subtherapeutic to supratherapeutic). No active issues on the floor. . # Question of infiltrate on CXR, but no respiratory symptoms, so did not treat with course of antibiotics. Had one fever spike on [1-9] (due to: pancreatitis, post-PICC placement, urinary infection); then afebrile. Patient remained stable without any e/o PNA on the floor. . # DMII: Low blood sugars while NPO were treated with D50, then used home NPH and humalog insulin sliding scale. No active issues on the floor. . # Delirium: Patient confused, oriented x1-2 in the ICU. Reassurance and reorientation were helpful. Continued to remain intermittently delerious on the floor, this improved overtime with reassurance. Tramadol was also discontinued which was thought to contribute to the delerium. . # Frequent urinary tract infections: Patient with know frequent UTIs recently started on Macrodantin 100mg QHS for ppx. Reportedly was started on augmentin three days prior to ICU transfer for UCx + on [12-28], though no note yet in OMR. We chose to avoid augmentin given risk of cholestatic jaundice with current elevated LFT's; [12-28] showed sensitivities to ceftriaxone --> wrote for ceftriaxone 1 g IV QD x 10 days (starting [1-8]). No e/o active UTI, patient's abx were discontinued and patient remained stable throughout her stay on the floor. . #. History of Anemia. Patient's Hct is up from baseline, likely [2-28] hemoconcentration. Patient without evidence of active bleeding from GI tract, however did note some trace hematemesis, declined NGT in ED. With IVF administration and HD, saw Hct drifting down closer to baseline. No evidence of frank acute bleed. . # h/o [Month/Day (2) ]/CVA: No acute concerns or neuro deficits. . # Hypercholesterolemia: - Held home atorvastatin with elevated LFT's (for now). Restarted upon discharge. Medications on Admission: AMLODIPINE - 5 mg daily ATORVASTATIN - 10 mg daily FLUTICASONE - 50 mcg Spray [Hospital1 ] HYDROCORTISONE - 1 % Cream - apply topically to rash [Hospital1 ] x 14 days ([12-28]) INSULIN LISPRO - per sliding scale QID ISOSORBIDE MONONITRATE - 60 mg SR daily LIDOCAINE PATCH - 5 % to lower back METOPROLOL TARTRATE - 50 mg TID NITROFURANTOIN MACROCRYSTAL - 50 mg [Hospital1 ] NITROGLYCERIN SL prn chest pain OXYCODONE - 5 mg Q6hr prn pain SEVELAMER CARBONATE - 800 mg TID TRAMADOL - 75 mg QAM, 25mg QPM WARFARIN - 4 mg daily ACETAMINOPHEN - 1gm [Hospital1 ] DOCUSATE SODIUM - 100 mg [Hospital1 ] NPH INSULIN 15 u q day as directed once a day Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). 3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) UNITS Subcutaneous once a day. 9. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Oxycodone 5 mg Tablet Sig: 2.5 Tablets PO every six (6) hours as needed for pain. 13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:30 Tablet, Rapid Dissolve(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: 1) Acute pancreatitis 2) End stage renal disease 3) Delerium 4) Atrial fibrillation with rapid ventricular response Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: It was a pleasure to take care of you here at [Hospital1 18]. You were admitted for abdominal pain that turned out to be pancreatitis or serious inflammation of your pancreas. Fortunately, you were stabilized in the intensive care unit and your pancreatitis improved significantly. You came to the floor and were able to eat food without any significant problems. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. We have made the following changes to your medications: STOP taking tramadol 50mg [1-28] tablet twice daily for pain START Take zofran 4mg by mouth every 8 hours for nausea Followup Instructions: You have an appointment with Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. Phone:[Telephone/Fax (1) 721] Date/Time:[2125-1-18] 9:00 You have an appointment with Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2125-3-29] 12:00 You have an appointment with Provider: [Name10 (NameIs) 38848] [Name11 (NameIs) ], MD Phone: [Telephone/Fax (1) 2998] in the [Hospital Ward Name 23] bldg, [Location (un) 10043] surgical specialties. Date/Time: [2124-2-10] 09:45am. Completed by:[2125-2-1]	[ "599.0", "403.91", "V45.11", "577.0", "041.4", "293.0", "250.40", "427.31", "273.1", "287.5", "585.6", "338.29", "V12.54", "276.1", "272.4", "724.5", "V58.61", "285.21", "V12.51", "715.96", "275.3" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	13958, 14015	7909, 11950	293, 308	14175, 14175	5281, 7886	14980, 15617	4201, 4337		12663, 13935		14036, 14154		11976, 12640			14320, 14806									4352, 5262																	14835, 14957						221, 255						336, 3163									14189, 14296						3185, 3782	3798, 4185
81,456	115,732	50880	Discharge summary	report	Admission Date: [2121-12-1] Discharge Date: [2121-12-8] Date of Birth: [2066-12-15] Sex: F Service: MEDICINE Allergies: Penicillins / Ciprofloxacin / Benzodiazepines Attending:[Male First Name (un) 5282] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: 1. Diagnostic paracentesis [2121-12-1] 2. Hemodialysis M/W/F during this admission 3. Cardiac catheterization [2121-12-5] History of Present Illness: This is a 54 year old female with a history of ESLD [12-23] HCV complicated by HRS and SBP in past, HTN, DM who presents with one day of worsening mental status. Per husband patient was in usual state of health one day prior to admit. Over course of day her mental status decreased until she was answering one word answers. She has not been oriented to person, place or time and has been having increasing agitation over the past 24 hours. Per husband who spoke to renal fellow, no N/V/C/D, no F/C. Last HD was on Friday. Of note patient recently admitted and D/Ced for AMS, at that time no etiology could be found but patient improved with lactulose. Durring last admit patient started on cefpodoxime for SBP proph. In the ED initial vitals were: 98.0 78 117/101 20 100 on RA. Labs were significant for a UA which appeared infected. A CT head was done, the prelim read was no acute process. The patient was given 2mg of ativan for agitation after which she became minimally responsive. A diagnostic para was performed which was negative for SBP, Cx pending. On the floor, patient was somnolent and was not able to answer questions. 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: Hep C cirrhosis c/b ascites and encephalopathy, known grade I varices last EGD in [3-/2120], active on [Year (4 digits) ] list ESRD on HD started [5-/2121] schedule MWF Cerebral Infarction - multifocal, thought to be embolic [5-/2121] Patent foramen ovale - open, not repairable per cards Diabetes on Insulin Hypertension Mitral Regurgitation (2+) S/p [Year (4 digits) 105777] [Year (4 digits) 32050] hernia repair [5-11] by Dr. [Last Name (STitle) ] H/o sub-segmental PE in [5-/2121] not on anticoagulation Social History: Worked as staff accountant at Sound life financial. Lives in [Hospital1 392] with husband who is primary caretaker. [Name (NI) ] children. Nonsmoker. No etoh. No ivdu Family History: No history of liver disease. Father with CVA in 50s. Mother with DM and CHF Sister with DM. Physical Exam: General: somnolent HEENT: Sclera anicteric, MMM, oropharynx clear, Pupils 4-5mm, reactive to light 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: midline abdominal inscision. Soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Ascities present. GU: foley, Reducible mass palpated. Ext: warm, well perfused, no clubbing, cyanosis, + pitting edema in LE b/l Neuro: Patient withdraws to pain, occasional movement of all four limbs. Pertinent Results: Labs on Admission: [2121-12-1] 11:08PM TYPE-ART TEMP-35.7 PO2-108* PCO2-34* PH-7.53* TOTAL CO2-29 BASE XS-6 [2121-12-1] 07:00PM ASCITES WBC-155* RBC-216* POLYS-0 LYMPHS-4* MONOS-12* MACROPHAG-84* [2121-12-1] 03:20PM GLUCOSE-151* UREA N-27* CREAT-7.4# SODIUM-136 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [2121-12-1] 03:20PM estGFR-Using this [2121-12-1] 03:20PM URINE HOURS-RANDOM [2121-12-1] 03:20PM URINE GR HOLD-HOLD [2121-12-1] 03:20PM PT-18.5 PTT-40.2* INR(PT)-1.7* [2121-12-1] 03:20PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.016 [2121-12-1] 03:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-TR [2121-12-1] 03:20PM URINE RBC-[1-23]* WBC-[10-10]* BACTERIA-FEW YEAST-NONE EPI-[10-10] TRANS EPI-0-2 RENAL EPI-0-2 [2121-12-1] 03:20PM URINE WBCCLUMP-MANY [2121-12-1] 02:45PM GLUCOSE-162* LACTATE-1.9 NA+-137 K+-4.8 CL--95* TCO2-29 [2121-12-1] 02:45PM WBC-4.4 RBC-3.39# HGB-10.6# HCT-34.7# MCV-102 MCH-31.2 MCHC-30.5* RDW-17.5* [2121-12-1] 02:45PM NEUTS-64.5 LYMPHS-21.4 MONOS-11.2* EOS-1.4 BASOS-1.5 [2121-12-1] 02:30PM AMMONIA-158* [2121-12-1] 12:18PM CREAT-6.9# SODIUM-132 POTASSIUM-5.0 CHLORIDE-96 [2121-12-1] 12:18PM estGFR-Using this [2121-12-1] 12:18PM TOT BILI-4.2* [2121-12-1] 12:18PM ALBUMIN-2.5* [2121-12-1] 12:18PM PT-18.6* INR(PT)-1.7* Labs on Discharge: [2121-12-8] 07:00AM BLOOD WBC-5.7 RBC-2.56* Hgb-8.1* Hct-26.9* MCV-105* MCH-31.8 MCHC-30.2* RDW-18.0* Plt Ct-45* [2121-12-8] 07:00AM BLOOD PT-21.8* PTT-49.3* INR(PT)-2.0* [2121-12-8] 07:00AM BLOOD Glucose-161* UreaN-23* Creat-6.6# Na-135 K-4.5 Cl-100 HCO3-27 AnGap-13 [2121-12-8] 07:00AM BLOOD ALT-17 AST-45 AlkPhos-155* TotBili-3.9* [2121-12-8] 07:00AM BLOOD Calcium-9.4 Phos-4.4 Mg-1.9 Micro: Studies: [2121-12-1] ECG - Sinus rhythm. Borderline Q-T interval prolongation. Since the previous tracing of [2121-11-22] probably no signifiant change. [2121-12-1] CXR (port AP) - Low lung volumes, but no focal consolidations. [2121-12-1] NCHCT - Suboptimal exam due to patient motion. No acute intracranial pathology seen. [2121-12-1] CXR (port AP) - No pneumothorax is identified. Allowing for low lung volumes, no definite lung infiltrate is seen. [2121-12-2] TTE - The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The right ventricular cavity is borderline dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular systolic function. Mild resting outflow tract [Year (4 digits) ]. Minimal aortic stenosis. Moderate pulmonary hypertension. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2121-7-2], the severity of mitral regurgitation has increased while the severity of tricuspid regurgitation has decreased. Right ventricular size is smaller. Estimated pulmonary artery pressures are higher. The heart rate is faster. [2121-12-2] ECG - Normal sinus rhythm. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [2121-12-1] there is no diagnostic interim change. [2121-12-2] RUQ U/S 1. Patent portal vein and hepatic veins. 2. The portal vein has normal hepatopetal flow; however, the splenic vein demonstrates a hepatofugal flow. This appearance suggest underlying spontaneous porto-systemic shunt, most likely splenorenal. 3. Unchanged cholelithiasis with no signs of cholecystitis. 4. Findings compatible with cirrhosis. Increasing ascites. [2121-12-4] CXR (port AP) - low lung volumes which is unchanged. Nasogastric tube ends in the stomach. A right central venous catheter ends in the right atrium, unchanged from the previous study. There is no pneumothorax. Cardiac, mediastinal, and hilar contours are unchanged. [2121-12-5] Cardiac catheterization (right heart) COMMENTS: 1. Resting hemodynamics revealed normal right sided filling pressures with RVEDP 13mmHg and mildly elevated pulmonary capillary wedge pressure with PCWP 14mmHg. The pulmonary arterial pressure was normal with PASP 33mmHg. The cardiac index was preserved at 3.4 L/min/m2. The pulmonary vascular resistance was normal at 147 dynes-sec/cm5. FINAL DIAGNOSIS: 1. Normal filling pressures. 2. Pulmonary pressures consistent with those seen on echocardiogram. [2121-12-5] ECG Sinus rhythm. Non-specific inferolateral ST-T wave changes. Q-T interval prolongation and slowing of the rate as compared with prior tracing of [2121-12-4]. The ST-T wave changes have improved. Otherwise, no diagnostic interim change. [2121-12-5] Chest x-ray IMPRESSION: AP chest compared to [12-4]: There is no pneumothorax, pleural effusion or mediastinal widening. Bronchial cuffing both hila is new which could be the earliest indication of cardiac decompensation though heart size is stable. There is no edema manifested elsewhere in the lungs and pleural effusion if any is minimal. A dual-channel right-sided central venous line ends close to the anticipated location of the tricuspid valve. [2121-12-5] US vein study FINDINGS: Focus color and Doppler son[Name (NI) 493] evaluation of bilateral subclavian and internal jugular veins demonstrated normal flow and compressibility. Wall-to-wall flow is demonstrated within the internal jugular veins. There was no hematoma in the surrounding soft tissue. IMPRESSION: Normal flow and compressibility of bilateral internal jugular veins without evidence of internal jugular vein thrombus. Brief Hospital Course: MICU COURSE: [12-1] - Episode of hypertension to 190/82 overnight treated with an extra home dose Nadolol - Obtained ABG due to concern regarding tachypnea although saturating well, 7.53/34/108/29 BaseXS . [12-2] - Renal: HD last night, 1.5 liters removed. - [Month/Year (2) 1326]: - as noted by hepatology team, rifaximin, lactulose, cultures,f/u head ct; [Month/Year (2) 1326] surgery will follow. F/U peritoneal cultures, blood cultures, stool cultures. Monitor mental status exam - Abd US with Doppler: Cirrhotic liver, ascites, gallstone, reverse flow in her splenic vein (some type of shunt), portal vein is patent. - ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The right ventricular cavity is borderline dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular systolic function. Mild resting outflow tract [Month/Year (2) ]. Minimal aortic stenosis. Moderate pulmonary hypertension. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2121-7-2], the severity of mitral regurgitation has increased while the severity of tricuspid regurgitation has decreased. Right ventricular size is smaller. Estimated pulmonary artery pressures are higher. The heart rate is faster. - Tox Screen: Negative - Mental Status/Bowel Movement: Increased lactulose to Q4Hrs moving bowels, Flexiseal placed. Decreased back to Q6Hrs given copius bowel movements. Patient slightly more arrousable to pain. -Tachycardic during HD. EKG with Sinus Tachycardia. Resolved after HD. [12-3] - Mental status clearing. - Had [Month/Year (2) 2286] in early afternoon, with 1.2 L taken off. Was tachycardic at times during [Month/Year (2) 2286], but maintained pressure. - Stated was thirsty in the evening so started sponge sticks and ice chips. - Several runs of VT, often around 20 beats. On 20 mg QD nadolol. Did not increase overnight, but would consider this in the a.m. - Sustained SVT at 115 later with maintained pressures, SBP ~ 100s. Distinct from runs of VT. - EKG 115 bmp, Normal intervals and axis. Sinus tachycardia. - Very dry on physical exam with flat JVP, dry mouth and thirsty. Gave 500 mL LR. - Reduced lactulose from 45 mg q6 to q8 given loose stool. ===== FLOOR COURSE: The following issues were addressed during this admission after the patient was transferred to the floor: # Altered mental status. The patient continued to improve while on the floor and became progressively more alert. She was initially only partially oriented (confusion over date, place), but was fully oriented at the time of discharge. Her confusion was attributed to hepatic encephalopathy. There was no clear precipitating factor - diagnostic tap was negative for SBP, no evidence of GIB, per husband patient had been medication-compliant and was having 3 bowel movements daily. Worsening cirrhosis is a possibility. She was continued on her home medications and lactulose was titrated to [1-22] BM daily. # Pulmonary hypertension. Patient had no further arrhythmia after arrival to the floor. However, echocardiogram raised concern for possible pulmonary hypertension that could represent a contraindication to [Month/Day (3) ]. An attempt was made to place a Swan [Last Name (un) 26645] catheter, but it could not be advanced. The patient was evaluated by cardiology and referred for right heart catheterization. She tolerated the procedure well. Mean pulmonary artery pressure was 23 mmHg, compatible with [Last Name (un) ]. # Wheeze, shortness of breath. Once transferred to the floor, the patient experienced no further symptoms. Repeat CXR showed no evidence of worsening infiltrate. # UE venous study. As Swan [Last Name (un) 26645] catheter was not possible to place, there was concern for possible venous occlusion in the upper extremity. Patient underwent an ultrasound study which showed patent vessels. # UTI. Patient was treated with ceftriaxone for a possible UTI, but culture showed no growth, so this medication was discontinued. # ESLD, ESRD. Patient is on the liver-kidney [Last Name (un) ] list. The patient was continued on hemodialysis per renal consult team throughout this admission. She was clinically volume-overloaded, with abdominal exam pertinent for full but not tense abdomen. She considered this degree of ascites consistent with her baseline and had no pain or shortness of breath so therapeutic tap was deferred. Her MELD score remained in the low 30s throughout this admission. # Diabetes mellitus type II. Patient was maintained on an insulin sliding scale. # FEN: No IVF, replete electrolytes, regular diet # Prophylaxis: Pneumoboots # Access: PIVs # Communication: Patient, husband [Name (NI) 9261] # [Name2 (NI) 7092]: Full Medications on Admission: Lactulose 30ml PO QID titrate to [1-22] BMs daily Lansoprazole 30mg PO daily Rifaximin 400mg PO TID Cefpodoxime 200mg PO QHD Insulin SS Aranesp 300mcg/ml with HD B-complex vitamins 1capsule PO daily Caltrate 600mg (1500mg) PO daily Ferrous sulfate 325mg (65mg Iron) PO TID Nephplex Rx 1-60-300-12.5 mg-mg-mcg-mg Tablet PO daily Miconazole nitrate 2% cream topical daily Nadolol 20mg PO daily Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. Lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: 15-30 MLs PO three times a day: Increase dose until you are having at least 3 bowel movements a day. 3. Rifaximin 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 4. Cefpodoxime 100 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO QHD (each hemodialysis). 5. Aranesp (Polysorbate) 300 mcg/mL Solution [Last Name (STitle) ]: One (1) injection Injection QHD (on hemodialysis days). 6. B Complex Vitamins Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day. 7. Caltrate 600 600 mg (1,500 mg) Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 9. Nephplex Rx 1-60-300-12.5 mg-mg-mcg-mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 10. Miconazole Nitrate 2 % Cream [Last Name (STitle) ]: One (1) application Topical once a day: Apply to affected area. 11. Insulin Please continue your insulin sliding scale according to your home regimen. 12. Nadolol 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: - Hepatic encephalopathy - Cirrhosis of the liver secondary to hepatitis C virus Secondary: - Diabetes mellitus type II - End stage renal disease, on hemodialysis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to [Hospital1 69] with confusion. You were unable to take medication by mouth, so you were admitted to the medical intensive care unit and a feeding tube was placed. Two days later, you appeared improved so you were transferred to the liver floor service. You were taken for a cardiac catheterization procedure to make sure that the vessels supplying blood to your lungs are healthy enough for you to undergo a [Hospital1 ] surgery - it appears that they are. You tolerated this procedure very well. The following day, your feeding tube was removed and you were able to walk with physical therapy. Your confusion improved, and you were discharged home. We have made no changes to your medication regimen. Please remember to take your lactulose regularly and increase the dose until you are having at least 3 bowel movements daily. This will help to prevent confusion in the future. Please schedule follow up with the liver clinic as directed below. Followup Instructions: Please call the liver clinic at [Telephone/Fax (1) 673] to schedule an appointment for 1-2 weeks from the time of discharge to discuss this admission. Completed by:[2121-12-11]	[ "571.5", "V49.83", "416.8", "585.6", "572.3", "070.44", "427.0", "V12.54", "403.91", "456.21", "250.00", "427.1", "745.5", "572.4", "285.21", "789.59", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "54.91", "38.93", "96.6", "89.64", "39.95", "89.59" ]	icd9pcs	[ [ [] ] ]	17120, 17169	9881, 15313	333, 465	17386, 17386	3636, 3641	18567, 18754	2883, 2977		15760, 17097		17190, 17365		15339, 15737		8574, 9858	17566, 18544									2992, 3617																		1660, 2107					272, 295				5124, 8557		493, 1641								3655, 5105	17401, 17542						2129, 2674	2690, 2867
5,525	197,426	52671	Discharge summary	report	Admission Date: [2115-10-29] Discharge Date: [2115-11-7] Date of Birth: [2050-4-3] Sex: M Service: MEDICINE Allergies: Neupogen Attending:[First Name3 (LF) 905] Chief Complaint: chills and fever Major Surgical or Invasive Procedure: Hemodialysis Operative Joint washout: medial parapatellar arthrotomy with complete anterior synovectomy. History of Present Illness: HPI: This is a 65 year old male with hx afib (not on coumadin for fall risk), with ESRD (s/p cadaveric transplant now failed) on HD, with recent septic left knee p/w chills and fever. The patient was recently discharged to rehab on [2115-10-12] after tx for septic joint; he received wash out by orthopedics and was discharged on Vancomycin for a 4 weeks course. He is currently still in rehab. This morning he had chills. He was then transfered to HD, where 4 kg were removed. During HD, he had chills and fever to 101. From HD, he was transfered to the ED. The patient himself feels well. He attributes chills to cold temperature at HD and states that his BP typically run 90/60 and can dip to 80's after HD. He denies any fevers, cough, SOB, CP, N/V/D. He does state that his knee has continued to be tender. . In the ED: The patient presented to the ED feeling well. In the ED, he was febrile to 101. Initially, SBP in 110's but then dropped his blood pressure to 60/40. He was given a 500cc bolus with increase in SBP 85-90. His lactate was 1.8. He was pan cultured. His left knee was found to be warm and swollen; a arthrocentesis was performed demonstrating many WBC and neutrophils. Orthopedics consulted in the ED and will be following this patient. Past Medical History: PMH: 1) Atrial Fibrillation - s/p cardioversion in [10-14]. Was maintained on coumadin for 6 months. Currently not anticoagulated due to fall risk. 2) Pericardial effusion - s/p drainage, unclear etiology 3) ESRD from ATN in setting of acute gastroenteritis, s/p failed cadaveric kidney transplant in [2109]. Dialyzed at [Location (un) ] Tues, Thurs, Sat. 4) Abdominal wall hernia - s/p repair after transplant 5) Multiple knee surgeries 20 years ago 6) Poor access, Right Tunnelled line 7) Baseline SBP's in 90s 9) Hypercapnia due to obesity hypoventilation syndrome 10) non-melanoma skin cancer 11) septic knee Social History: Denies any history of Tobacco use, no EtOh use for [Last Name (un) ] than 20 years, no drug use. Lives with his wife, now on disability. Used to work as a spray painter. Has 3 children and multiple grandchildren. Family History: History of CAD (mother died at age 70), cancer Physical Exam: On admission: Vitals: T: 97.3 P: 138 BP: 106/65 R: 18 SaO2:98%RA General: Awake, alert, NAD, well appearing w/o rigors or sweats HEENT: NC/AT, PERRL, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated, right subclavian tunneled line w/o TTP, swelling or discharge 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: left swollen knee w/ warmth, effusion and TTP; medial inscision is healing well; no distal edema b/l Lymphatics: No cervical, supraclavicular LAD Skin: no rashes or lesions noted other than noted above on left knee Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. . At discharge: Some erythema within demarcated area surrounding well-healed scar on left knee, no exudate. Knee brace in place. Afebrile. Extensive purpura on extremities. Some mild Left lower ext edema at ankle. Pertinent Results: [2115-10-29] 05:00PM BLOOD WBC-8.2 RBC-3.48* Hgb-10.4* Hct-33.9* MCV-97 MCH-29.9 MCHC-30.7* RDW-19.7* Plt Ct-209 [2115-10-30] 08:37AM BLOOD WBC-5.0 RBC-2.85* Hgb-8.6* Hct-27.8* MCV-98 MCH-30.3 MCHC-31.0 RDW-18.4* Plt Ct-158 [2115-11-6] 06:23AM BLOOD WBC-5.2 RBC-2.80* Hgb-8.8* Hct-26.7* MCV-95 MCH-31.3 MCHC-32.9 RDW-18.1* Plt Ct-183 [2115-11-7] 05:48AM BLOOD WBC-6.0 RBC-2.89* Hgb-8.8* Hct-27.9* MCV-97 MCH-30.5 MCHC-31.6 RDW-17.9* Plt Ct-201 [2115-10-29] 05:00PM BLOOD Neuts-81.3* Lymphs-12.3* Monos-4.1 Eos-2.2 Baso-0.2 [2115-11-4] 06:11AM BLOOD PT-14.3* PTT-31.1 INR(PT)-1.2* [2115-10-31] 08:00AM BLOOD Ret Aut-5.9* [2115-11-5] 05:30AM BLOOD Glucose-40* UreaN-31* Creat-5.5* Na-139 K-3.8 Cl-107 HCO3-25 AnGap-11 [2115-11-6] 06:23AM BLOOD Glucose-84 UreaN-18 Na-140 K-4.0 Cl-105 HCO3-29 AnGap-10 [2115-11-7] 05:48AM BLOOD Glucose-85 UreaN-26* Creat-4.7* Na-137 K-4.2 Cl-102 HCO3-26 AnGap-13 [2115-10-29] 04:30PM BLOOD ALT-11 AST-15 AlkPhos-149* TotBili-0.4 [2115-10-31] 08:00AM BLOOD ALT-7 AST-12 LD(LDH)-163 AlkPhos-90 TotBili-0.4 [2115-11-7] 05:48AM BLOOD Calcium-7.8* Phos-2.2* Mg-1.8 [2115-11-5] 05:30AM BLOOD Cortsol-3.6 [2115-11-5] 06:11AM BLOOD Cortsol-6.7 [2115-11-5] 06:45AM BLOOD Cortsol-8.3 [2115-11-2] 05:26AM BLOOD calTIBC-120* Ferritn-828* TRF-92* [2115-10-29] 04:43PM BLOOD Glucose-47* Lactate-2.0 Na-144 K-4.1 Cl-96* calHCO3-32* [2115-10-29] 05:50PM JOINT FLUID WBC-[Numeric Identifier 29194]* RBC-[Numeric Identifier 10489]* Polys-94* Lymphs-1 Monos-5 =================== Joint fluid grew MSSA sensitive to Vancomycin =================== CXR [10-29] PORTABLE UPRIGHT CHEST, ONE VIEW: Hemodialysis catheter tip terminates in the cavoatrial junction, unchanged. The heart is moderately enlarged in size, with atherosclerotic calcifications of the aorta, unchanged. Otherwise, cardiomediastinal and hilar contours are unremarkable. The lungs are clear, without consolidation or pulmonary edema. There is no pleural effusion or pneumothorax. Osseous structures are unremarkable. IMPRESSION: Stable moderate cardiomegaly, without acute cardiopulmonary process. Brief Hospital Course: 65 year old male with hx afib (not on coumadin for fall risk), with ESRD (s/p cadaveric transplant now failed) on HD, with recent septic left knee p/w hypotension and fever c/w SIRS. At time of discharge, patient is s/p operative cleaning of joint and will get FIVE more weeks of vancomycin dosed at dialysis. . # SIRS: Patient with fever and hypotension, but fluid responsive. Cause was septic joint. Blood cultures had no growth. No sign of systemic infection at the time of discharge. . # Septic Joint: Tap in ED demonstrated ongoing infection with significant WBC's and neutrophils. Ortho performed operative Joint washout: medial parapatellar arthrotomy with complete anterior synovectomy. Vanco dosed at dialysis with trough to be drawn at every session should be continued for a total of six weeks starting on [10-30], terminating on approximately [11-13]. Pt should have follow-up with Orthopedics by [11-15]--he will call to make appt. Staples in place at time of discharge, will be removed by ortho at follow-up. . # Afib: Pt had episodes of AFib with RVR before taking his medications (diltiazem and metoprolol). These episodes were responsive to IV metoprolol 5mg push. Pt discharged on previous outpatient doses of diltiazem and toprol xl. He has f/u scheduled with his cardiologist. . # Hypogylcemia: The patient was noted to have hypoglycemia, which has been ongoing since last admission. Acutely managed with juice and amps of D50. Endocrine consulted and they reccommended the following: Increase prednisone to 10mg qam and 5mg qpm for three days. His prednisone dose should be decreased to 5mg QD on the morning on [11-10]. His blood sugar should be checked every 6 hours for a few days. If he becomes hypoglycemic in the mornings despite having cornstarch at bedtime, he should get 2.5mg of prednisone at night in addition to the 5mg he takes in the morning. He should continue the 5/2.5 schedule until seeing an endocrinologist if the hypoglycemia recurs. . # Anemia: The patient was anemic at presentation and his HCT decreased several points from his baseline (fluctuating, but anemic throughout). He was transfused 2 units of PRBCs with an less than optimal, but adequate response. He was able to mantain his counts prior to DC. He is guiaic positive. Follow up with his PCP is necessary for further work up. Colonoscopy is indicated as an outpt. . # ESRD: The patient appeared with fluid overload on exam. He continued to have HD every other day. His vanc was dosed during these sesssions as above. #PPD + CONTACT: Wife found to be PPD positive recently with clear chest xray. The patient also has a clear chest x-ray. A PPD has been placed on his right forearm. Because the patient is immunosuppressed, a control ([Female First Name (un) ] antigen) was also placed on his right forearm. These two sites have been circled and labeled T (for Tuberculin) and C (for control). The control site is distal to the tuberculin site. If he has a sufficient reaction in both sites, this means he has been exposed to TB. If he has no reaction in both sites, the test is meaningless. If he has a reaction at the control site, but not at the tuberculin site, then the test is definitive and he has not been exposed to tuberculosis. # ACCESS: In order to optimize acces for IVF and medications to control BP anf HR a PICC line was placed. The patient's pIV acces was lost and replacement proved very difficult. Medications on Admission: Medications on Transfer from Rehab: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous QHD PROTOCOL for 4 weeks. Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Vancomycin in Dextrose 1 gram/250 mL Solution Sig: asdir Intravenous Tu Th Sat: to be given at dialysis for a total of 6 weeks starting on [10-30]. 7. Dextrose 50% in Water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for FSBS<50. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 13. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 16. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Systemic inflamatory response syndrome atrial fibrilation hypoglycemia anemia endstage renal disease Discharge Condition: Good Discharge Instructions: Dear Mr. [Known lastname ], You were admited for low blood presure in the setting of knee joint infection. You should continue to take antibiotics (vancomycin) at dialysis for 5 more weeks. We continued all of your old medications and had to temporarily increase your dose of prednisone. You need to follow up with an endocrine doctor to be further evaluated for low blood sugar if this problem does not resolve. The plan is for three days of increased prednisone (15mg per day). After this is completed, an attempt will be made to return to your 5mg per day routine. If you again suffer from low sugar, you should take 5mg in the morning plus an extra 2.5mg of prednisone at night. The cornstarch you are taking should Please call ([Telephone/Fax (1) 108686] to schedule an appointment You need to follow up with your regular doctor to be further evaluated for your anemia. Please call your regular doctor or return to the ED if you experience fevers, confusion or any other symptoms that concern you. Followup Instructions: Provider: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern4) 2761], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2115-12-2] 1:00 Please follow up with endocrinology in two months; if low blood sugar continues to be a problem, please make an appointment sooner. Their phone is ([Telephone/Fax (1) 108686]. You must call [Telephone/Fax (1) 1228] today or tomorrow to make an appointment with [First Name11 (Name Pattern1) 2191] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] (Orthopedics) to be seen within one week. Please call your PCP to make an appointment within the next two weeks [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2115-11-7]	[ "427.31", "285.9", "711.06", "995.91", "251.2", "585.6", "038.9", "996.81" ]	icd9cm	[ [ [] ] ]	[ "39.95", "81.91", "38.93", "80.76" ]	icd9pcs	[ [ [] ] ]	11974, 12044	5868, 9318	285, 393	12189, 12196	3678, 5845	13261, 14027	2587, 2637		10354, 11951		12065, 12168		9344, 10331			12220, 13238									2652, 2652													3460, 3659										229, 247						421, 1686								2666, 3365	3380, 3446						1708, 2337	2353, 2571
23,533	127,683	51867+51868+51869	Discharge summary	report+report+report	Admission Date: [2181-11-10] Discharge Date: [2181-12-5] Date of Birth: [2104-9-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 297] Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: central line placement History of Present Illness: 77 y.o. male with HTN, diabetes, COPD on home O2 s/p admission to [Hospital1 18] [Date range (3) 107406] for MRSA PNA and COPD requiring intubation and trach placement on [2181-10-22] now presents from rehab facility with progressive hypoxia and somnolence. He was noted to have sats of 90% on 70% FiO2. Cr noted to be 3.6. K of 5.3. Hct:31.8. TemP:97.0 HR:60, BP:124/58, RR:20. Unfortunately, nurse caring for patient was unavailable at the time of admission to provide additional details. Past Medical History: . HTN 2. DM2 3. CHF, EF 65% by Echo [2181-10-3] 4. COPD on home O2 PFTs [9-5]: "FVC:moderately to severely reduced. The FEV1 and FEV1/FVC ratio are severely reduced. Flow-Volume Loop: Marked expiratory coving and reduced volume excursion. Impression: Marked obstructive ventilatory defect. The reduced FVC likely reflects gas trapping although a concurrent restrictive process cannot be ruled out." 5. OSA on home bipap 6. MRSA PNA in [10-6], intubated and s/p Trach/PEG [2181-10-22]. 7. Afib on amiodarone load with taper to 200 daily on [2181-11-7]. 8. CKD with BLC 1.4. ATN on last admission in the setting of hypotension. 9. Diverticulosis by CT ABD Social History: Pt is married and has two sons who are very involved in his care. 68 pack year hx, quit 25 years ago. No drugs. Asbestos exposure >30 years ago. [Known firstname ], [First Name3 (LF) ], his son is his proxy. The patient's son states, "my dad would be happy just to sit an watch a ball game, even with trach and PEG" Family History: [Name (NI) 1094] father died of bleeding complications from PUD. His mother died at 93 from unknown causes. No fhx of cad or lung disease. Physical Exam: Temp: 98.0 BP: 95/33, HR:58 RR:12 O2: 88% on AC 550 x 14/10/0.5 Gen: Intubated, sedated. Opens eye to pain, but not to deep sternal rub or voice. Appears comfortable. HEENT: PEARLA. No spontaneous nystagmus. OP: no lesions. Tracheostomy is c/d/i. CV: RR. No murmurs Pulm: Rales at bases b/l. Decreased breath sounds throughout. ABD: Soft, distended. No obvious pain with palpation. Some paradoxical ABD wall motion. No HSM. Ext: 2+ edema b/l. Neuro: MAE. Withdraws to pain. Babinski downgoing Pertinent Results: WBC:16.6 HCT-27.7 Plt:234 7.33/81/70 [2181-11-10] 03:10AM GLUCOSE-142* UREA N-119* CREAT-4.3# SODIUM-140 POTASSIUM-5.3 CHLORIDE-96 TOTAL CO2-38* ANION GAP-11 [2181-11-10] 03:10AM ALT(SGPT)-10 AST(SGOT)-14 LD(LDH)-247 CK(CPK)-17* ALK PHOS-110 AMYLASE-58 TOT BILI-0.1 [2181-11-10] 03:10AM LIPASE-43 [2181-11-10] 03:10AM ALBUMIN-2.6* CALCIUM-10.0 PHOSPHATE-6.2# MAGNESIUM-3.1 [2181-11-10] 03:10AM PLT COUNT-234 [2181-11-10] 03:10AM PT-13.6* PTT-21.5* INR(PT)-1.2 Brief Hospital Course: 77 y.o. male with COPD on home O2 now s/p trach/PEG [10-22] during admission for MRSA PNA presented from rehab with progessive hypoxemia x 1 week and acute renal failure. The hypoxia was of unclear time course. He was noted to have sat of 90% on FiO2 of 70%. Here his initial ABG demonstrating ARDS by P/F ratio of 100 and CXR with b/l lower lobe infiltrates. He was managed with ARDS-NET Vent strategy 6cc/kg. His Ht is 5'8" so 6cc/kg of IBW would be ~400 ccs, his HOB was elevated, his PIPs and Plateau pressures were closely monitored. An Echo with bubble study was performed to assess for shunt showed no shunt. With concern for PE lower extremity ultrasounds were performed and were negative. However as he continued to be hypoxic he was started on Heparin drip for possible PE given new RV dilation and Pulm HTN on Echo [2181-11-12]. Efforts were made to monitor Pplat closely and keep <35. Heparin also continued for AFib and Left IJ clot. CTA was not performed due to renal failure. On [11-26] had increased secretions around trach site but not so much from suctioning; continued pulmonary toilet. On [12-1] he was paralyzed to help with oxygenation. He continued to require aggressive settings on ventilator. He had little improvement in his respiratory status. He also required antibiotics for ventilator associated pneumonia. His blood pressure required pressor support. On [12-6] he passed away from cardiovascular collapse after requiring four pressors with no blood pressure response. Secondary issues Hypercapnic Resp Failure - likely has high pCO2 at baseline given severe COPD. pCO2 was maintained in the 50's with a strategy of permissive hypercapnea. He was treated with steroids given his underlying COPD. He was also treated with nebulizers [Hospital 107407] hospital [Last Name (un) 10128]. Sepsis - He completed 7 day course of inhaled tobramycin for Acinetobacter VAP. He grew GPC in his sputum [11-24] with acute worsening including fever and hypotension. The final speciation was MRSA. On [11-26] sources of infection likely MRSA VAP or peri-trachostomy abscess/tracheobronchitis. He was maintained on Vancomycin. He was briefly in tigarcillin and gent for history of acinitobacter in his sputum however this was discontinued when he grew MRSA. On [12-1] he grew G- rods in Blood culture. His abx were changed to meropenem, vanc by levels and gent by levels. Despite continued antibiotics he was requiring ongoing pressor support with Levophed and Vasopressin. On [12-5] his pressor requirement increased dramatically, he was maxed out on four pressors at the time of his death. Acid-Base: On [11-26] he had a metabolic acidosis with anion gap; lactate was only 1.6 but BUN 130's. Thus it was felt his metabolic acidosis was from uremia. He was treated with bicarb and dialysis as needed. ARF - This was felt to be likely secondary to ATN. He was initiated on dialysis via a right sub-clavian catheter. He later had dialysis via a right femoral catheter however there were difficulties with flow. He then got a new right subclavian dialysis catheter and was started on CVVH given his continued hypotension. He was treated with phosphate binders and all meds were renally dosed. Anemia - He had several drops in his HCT, unclear if dilutional or acute blood loss, he was guiaic positive on multiple occasions. He was continued on PPI and treated with IV blood transfusions as needed. He was also treated with Epogen per renal recs. Delta MS - He was noted to be less interactive, likely due to sepsis. Head CT only c/w atrophy and small vessel ischemia, old. He was also on sedating meds now but delta MS is likely from toxic-metabolic as it did not resolve when these meds were held. DM - He was managed with an insulin drip. Attempts to wean this off by starting SC long acting insulin were not successful, likely due to poor SC absorption. FEN - He was maintained on tube feeds throughout his hospitalization. Medications on Admission: Medications at [Hospital1 ] 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO TID (3 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 13. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 14. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 14 days: Continue until [2181-11-6] (last dose that day), then start 200 mg qd. 16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Start on [2181-11-7] after 14-day course of 400 mg qd completed on [2181-11-6]. 17. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY ontinue 18. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 19. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Lorazepam 2 mg/mL Syringe Sig: 0.5 Injection Q6H (every 6 hours) as needed. 21. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 8 days. 22. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two (2) grams Intravenous Q12H (every 12 hours) for 8 days. 23. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Two (22) units Subcutaneous twice a day: 22 units in morning and in evening. 24. Insulin Regular Human 100 unit/mL Solution Sig: as directed below units Injection per sliding scale: Please check fingersticks QACHS and cover with regular insulin per scale below: Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Sepsis Respiratory Failure Renal failure Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A Admission Date: [2181-11-10] Discharge Date: [2181-12-5] Date of Birth: [2104-9-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 297] Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: central line placement History of Present Illness: 77 y.o. male with HTN, diabetes, COPD on home O2 s/p admission to [Hospital1 18] [Date range (3) 107406] for MRSA PNA and COPD requiring intubation and trach placement on [2181-10-22] now presents from rehab facility with progressive hypoxia and somnolence. He was noted to have sats of 90% on 70% FiO2. Cr noted to be 3.6. K of 5.3. Hct:31.8. TemP:97.0 HR:60, BP:124/58, RR:20. Unfortunately, nurse caring for patient was unavailable at the time of admission to provide additional details. Past Medical History: . HTN 2. DM2 3. CHF, EF 65% by Echo [2181-10-3] 4. COPD on home O2 PFTs [9-5]: "FVC:moderately to severely reduced. The FEV1 and FEV1/FVC ratio are severely reduced. Flow-Volume Loop: Marked expiratory coving and reduced volume excursion. Impression: Marked obstructive ventilatory defect. The reduced FVC likely reflects gas trapping although a concurrent restrictive process cannot be ruled out." 5. OSA on home bipap 6. MRSA PNA in [10-6], intubated and s/p Trach/PEG [2181-10-22]. 7. Afib on amiodarone load with taper to 200 daily on [2181-11-7]. 8. CKD with BLC 1.4. ATN on last admission in the setting of hypotension. 9. Diverticulosis by CT ABD Social History: Pt is married and has two sons who are very involved in his care. 68 pack year hx, quit 25 years ago. No drugs. Asbestos exposure >30 years ago. [Known firstname ], [First Name3 (LF) ], his son is his proxy. The patient's son states, "my dad would be happy just to sit an watch a ball game, even with trach and PEG" Family History: [Name (NI) 1094] father died of bleeding complications from PUD. His mother died at 93 from unknown causes. No fhx of cad or lung disease. Physical Exam: Temp: 98.0 BP: 95/33, HR:58 RR:12 O2: 88% on AC 550 x 14/10/0.5 Gen: Intubated, sedated. Opens eye to pain, but not to deep sternal rub or voice. Appears comfortable. HEENT: PEARLA. No spontaneous nystagmus. OP: no lesions. Tracheostomy is c/d/i. CV: RR. No murmurs Pulm: Rales at bases b/l. Decreased breath sounds throughout. ABD: Soft, distended. No obvious pain with palpation. Some paradoxical ABD wall motion. No HSM. Ext: 2+ edema b/l. Neuro: MAE. Withdraws to pain. Babinski downgoing Pertinent Results: WBC:16.6 HCT-27.7 Plt:234 7.33/81/70 [2181-11-10] 03:10AM GLUCOSE-142* UREA N-119* CREAT-4.3# SODIUM-140 POTASSIUM-5.3 CHLORIDE-96 TOTAL CO2-38* ANION GAP-11 [2181-11-10] 03:10AM ALT(SGPT)-10 AST(SGOT)-14 LD(LDH)-247 CK(CPK)-17* ALK PHOS-110 AMYLASE-58 TOT BILI-0.1 [2181-11-10] 03:10AM LIPASE-43 [2181-11-10] 03:10AM ALBUMIN-2.6* CALCIUM-10.0 PHOSPHATE-6.2# MAGNESIUM-3.1 [2181-11-10] 03:10AM PLT COUNT-234 [2181-11-10] 03:10AM PT-13.6* PTT-21.5* INR(PT)-1.2 Brief Hospital Course: 77 y.o. male with COPD on home O2 now s/p trach/PEG [10-22] during admission for MRSA PNA presented from rehab with progessive hypoxemia x 1 week and acute renal failure. The hypoxia was of unclear time course. He was noted to have sat of 90% on FiO2 of 70%. Here his initial ABG demonstrating ARDS by P/F ratio of 100 and CXR with b/l lower lobe infiltrates. He was managed with ARDS-NET Vent strategy 6cc/kg. His Ht is 5'8" so 6cc/kg of IBW would be ~400 ccs, his HOB was elevated, his PIPs and Plateau pressures were closely monitored. An Echo with bubble study was performed to assess for shunt showed no shunt. With concern for PE lower extremity ultrasounds were performed and were negative. However as he continued to be hypoxic he was started on Heparin drip for possible PE given new RV dilation and Pulm HTN on Echo [2181-11-12]. Efforts were made to monitor Pplat closely and keep <35. Heparin also continued for AFib and Left IJ clot. CTA was not performed due to renal failure. On [11-26] had increased secretions around trach site but not so much from suctioning; continued pulmonary toilet. On [12-1] he was paralyzed to help with oxygenation. He continued to require aggressive settings on ventilator. He had little improvement in his respiratory status. He also required antibiotics for ventilator associated pneumonia. His blood pressure required pressor support. On [12-6] he passed away from cardiovascular collapse after requiring four pressors with no blood pressure response. Secondary issues Hypercapnic Resp Failure - likely has high pCO2 at baseline given severe COPD. pCO2 was maintained in the 50's with a strategy of permissive hypercapnea. He was treated with steroids given his underlying COPD. He was also treated with nebulizers [Hospital 107407] hospital [Last Name (un) 10128]. Sepsis - He completed 7 day course of inhaled tobramycin for Acinetobacter VAP. He grew GPC in his sputum [11-24] with acute worsening including fever and hypotension. The final speciation was MRSA. On [11-26] sources of infection likely MRSA VAP or peri-trachostomy abscess/tracheobronchitis. He was maintained on Vancomycin. He was briefly in tigarcillin and gent for history of acinitobacter in his sputum however this was discontinued when he grew MRSA. On [12-1] he grew G- rods in Blood culture. His abx were changed to meropenem, vanc by levels and gent by levels. Despite continued antibiotics he was requiring ongoing pressor support with Levophed and Vasopressin. On [12-5] his pressor requirement increased dramatically, he was maxed out on four pressors at the time of his death. Acid-Base: On [11-26] he had a metabolic acidosis with anion gap; lactate was only 1.6 but BUN 130's. Thus it was felt his metabolic acidosis was from uremia. He was treated with bicarb and dialysis as needed. ARF - This was felt to be likely secondary to ATN. He was initiated on dialysis via a right sub-clavian catheter. He later had dialysis via a right femoral catheter however there were difficulties with flow. He then got a new right subclavian dialysis catheter and was started on CVVH given his continued hypotension. He was treated with phosphate binders and all meds were renally dosed. Anemia - He had several drops in his HCT, unclear if dilutional or acute blood loss, he was guiaic positive on multiple occasions. He was continued on PPI and treated with IV blood transfusions as needed. He was also treated with Epogen per renal recs. Delta MS - He was noted to be less interactive, likely due to sepsis. Head CT only c/w atrophy and small vessel ischemia, old. He was also on sedating meds now but delta MS is likely from toxic-metabolic as it did not resolve when these meds were held. DM - He was managed with an insulin drip. Attempts to wean this off by starting SC long acting insulin were not successful, likely due to poor SC absorption. FEN - He was maintained on tube feeds throughout his hospitalization. Medications on Admission: Medications at [Hospital1 ] 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO TID (3 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 13. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 14. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 14 days: Continue until [2181-11-6] (last dose that day), then start 200 mg qd. 16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Start on [2181-11-7] after 14-day course of 400 mg qd completed on [2181-11-6]. 17. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY ontinue 18. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 19. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Lorazepam 2 mg/mL Syringe Sig: 0.5 Injection Q6H (every 6 hours) as needed. 21. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 8 days. 22. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two (2) grams Intravenous Q12H (every 12 hours) for 8 days. 23. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Two (22) units Subcutaneous twice a day: 22 units in morning and in evening. 24. Insulin Regular Human 100 unit/mL Solution Sig: as directed below units Injection per sliding scale: Please check fingersticks QACHS and cover with regular insulin per scale below: Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Sepsis Respiratory Failure Renal failure Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A Admission Date: [2181-11-10] Discharge Date: [2181-12-5] Date of Birth: [2104-9-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 297] Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: central line placement History of Present Illness: 77 y.o. male with HTN, diabetes, COPD on home O2 s/p admission to [Hospital1 18] [Date range (3) 107406] for MRSA PNA and COPD requiring intubation and trach placement on [2181-10-22] now presents from rehab facility with progressive hypoxia and somnolence. He was noted to have sats of 90% on 70% FiO2. Cr noted to be 3.6. K of 5.3. Hct:31.8. TemP:97.0 HR:60, BP:124/58, RR:20. Unfortunately, nurse caring for patient was unavailable at the time of admission to provide additional details. Past Medical History: . HTN 2. DM2 3. CHF, EF 65% by Echo [2181-10-3] 4. COPD on home O2 PFTs [9-5]: "FVC:moderately to severely reduced. The FEV1 and FEV1/FVC ratio are severely reduced. Flow-Volume Loop: Marked expiratory coving and reduced volume excursion. Impression: Marked obstructive ventilatory defect. The reduced FVC likely reflects gas trapping although a concurrent restrictive process cannot be ruled out." 5. OSA on home bipap 6. MRSA PNA in [10-6], intubated and s/p Trach/PEG [2181-10-22]. 7. Afib on amiodarone load with taper to 200 daily on [2181-11-7]. 8. CKD with BLC 1.4. ATN on last admission in the setting of hypotension. 9. Diverticulosis by CT ABD Social History: Pt is married and has two sons who are very involved in his care. 68 pack year hx, quit 25 years ago. No drugs. Asbestos exposure >30 years ago. [Known firstname ], [First Name3 (LF) ], his son is his proxy. The patient's son states, "my dad would be happy just to sit an watch a ball game, even with trach and PEG" Family History: [Name (NI) 1094] father died of bleeding complications from PUD. His mother died at 93 from unknown causes. No fhx of cad or lung disease. Physical Exam: Temp: 98.0 BP: 95/33, HR:58 RR:12 O2: 88% on AC 550 x 14/10/0.5 Gen: Intubated, sedated. Opens eye to pain, but not to deep sternal rub or voice. Appears comfortable. HEENT: PEARLA. No spontaneous nystagmus. OP: no lesions. Tracheostomy is c/d/i. CV: RR. No murmurs Pulm: Rales at bases b/l. Decreased breath sounds throughout. ABD: Soft, distended. No obvious pain with palpation. Some paradoxical ABD wall motion. No HSM. Ext: 2+ edema b/l. Neuro: MAE. Withdraws to pain. Babinski downgoing Pertinent Results: WBC:16.6 HCT-27.7 Plt:234 7.33/81/70 [2181-11-10] 03:10AM GLUCOSE-142* UREA N-119* CREAT-4.3# SODIUM-140 POTASSIUM-5.3 CHLORIDE-96 TOTAL CO2-38* ANION GAP-11 [2181-11-10] 03:10AM ALT(SGPT)-10 AST(SGOT)-14 LD(LDH)-247 CK(CPK)-17* ALK PHOS-110 AMYLASE-58 TOT BILI-0.1 [2181-11-10] 03:10AM LIPASE-43 [2181-11-10] 03:10AM ALBUMIN-2.6* CALCIUM-10.0 PHOSPHATE-6.2# MAGNESIUM-3.1 [2181-11-10] 03:10AM PLT COUNT-234 [2181-11-10] 03:10AM PT-13.6* PTT-21.5* INR(PT)-1.2 Brief Hospital Course: 77 y.o. male with COPD on home O2 now s/p trach/PEG [10-22] during admission for MRSA PNA presented from rehab with progessive hypoxemia x 1 week and acute renal failure. The hypoxia was of unclear time course. He was noted to have sat of 90% on FiO2 of 70%. Here his initial ABG demonstrating ARDS by P/F ratio of 100 and CXR with b/l lower lobe infiltrates. He was managed with ARDS-NET Vent strategy 6cc/kg. His Ht is 5'8" so 6cc/kg of IBW would be ~400 ccs, his HOB was elevated, his PIPs and Plateau pressures were closely monitored. An Echo with bubble study was performed to assess for shunt showed no shunt. With concern for PE lower extremity ultrasounds were performed and were negative. However as he continued to be hypoxic he was started on Heparin drip for possible PE given new RV dilation and Pulm HTN on Echo [2181-11-12]. Efforts were made to monitor Pplat closely and keep <35. Heparin also continued for AFib and Left IJ clot. CTA was not performed due to renal failure. On [11-26] had increased secretions around trach site but not so much from suctioning; continued pulmonary toilet. On [12-1] he was paralyzed to help with oxygenation. He continued to require aggressive settings on ventilator. He had little improvement in his respiratory status. He also required antibiotics for ventilator associated pneumonia. His blood pressure required pressor support. On [12-6] he passed away from cardiovascular collapse after requiring four pressors with no blood pressure response. Secondary issues Hypercapnic Resp Failure - likely has high pCO2 at baseline given severe COPD. pCO2 was maintained in the 50's with a strategy of permissive hypercapnea. He was treated with steroids given his underlying COPD. He was also treated with nebulizers [Hospital 107407] hospital [Last Name (un) 10128]. Sepsis - He completed 7 day course of inhaled tobramycin for Acinetobacter VAP. He grew GPC in his sputum [11-24] with acute worsening including fever and hypotension. The final speciation was MRSA. On [11-26] sources of infection likely MRSA VAP or peri-trachostomy abscess/tracheobronchitis. He was maintained on Vancomycin. He was briefly in tigarcillin and gent for history of acinitobacter in his sputum however this was discontinued when he grew MRSA. On [12-1] he grew G- rods in Blood culture. His abx were changed to meropenem, vanc by levels and gent by levels. Despite continued antibiotics he was requiring ongoing pressor support with Levophed and Vasopressin. On [12-5] his pressor requirement increased dramatically, he was maxed out on four pressors at the time of his death. Acid-Base: On [11-26] he had a metabolic acidosis with anion gap; lactate was only 1.6 but BUN 130's. Thus it was felt his metabolic acidosis was from uremia. He was treated with bicarb and dialysis as needed. ARF - This was felt to be likely secondary to ATN. He was initiated on dialysis via a right sub-clavian catheter. He later had dialysis via a right femoral catheter however there were difficulties with flow. He then got a new right subclavian dialysis catheter and was started on CVVH given his continued hypotension. He was treated with phosphate binders and all meds were renally dosed. Anemia - He had several drops in his HCT, unclear if dilutional or acute blood loss, he was guiaic positive on multiple occasions. He was continued on PPI and treated with IV blood transfusions as needed. He was also treated with Epogen per renal recs. Delta MS - He was noted to be less interactive, likely due to sepsis. Head CT only c/w atrophy and small vessel ischemia, old. He was also on sedating meds now but delta MS is likely from toxic-metabolic as it did not resolve when these meds were held. DM - He was managed with an insulin drip. Attempts to wean this off by starting SC long acting insulin were not successful, likely due to poor SC absorption. FEN - He was maintained on tube feeds throughout his hospitalization. Medications on Admission: Medications at [Hospital1 ] 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO TID (3 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 13. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 14. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 14 days: Continue until [2181-11-6] (last dose that day), then start 200 mg qd. 16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Start on [2181-11-7] after 14-day course of 400 mg qd completed on [2181-11-6]. 17. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY ontinue 18. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 19. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Lorazepam 2 mg/mL Syringe Sig: 0.5 Injection Q6H (every 6 hours) as needed. 21. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 8 days. 22. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two (2) grams Intravenous Q12H (every 12 hours) for 8 days. 23. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Two (22) units Subcutaneous twice a day: 22 units in morning and in evening. 24. Insulin Regular Human 100 unit/mL Solution Sig: as directed below units Injection per sliding scale: Please check fingersticks QACHS and cover with regular insulin per scale below: Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Sepsis Respiratory Failure Renal failure Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A	[ "403.91", "278.01", "V58.65", "428.0", "V58.67", "995.92", "584.5", "038.11", "038.49", "996.74", "482.83", "V09.0", "785.52", "250.92", "518.84", "453.8", "V44.0", "427.5", "482.41", "496", "038.3", "327.23", "276.7" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.95", "38.93", "00.17", "99.04", "39.95", "38.91", "99.07", "96.6" ]	icd9pcs	[ [ [] ] ]	29438, 29447	22895, 26932	20054, 20078	29531, 29536	22369, 22872	29588, 29594	21678, 21825		29409, 29415		29468, 29510		26958, 29386			29560, 29565									21840, 22350																							20005, 20016						20106, 20617															20639, 21317	21333, 21662
74,891	192,552	29179	Discharge summary	report	Admission Date: [2120-5-13] Discharge Date: [2120-5-23] Date of Birth: [2053-5-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Delirium Major Surgical or Invasive Procedure: Bronchoscopy Surgical Aspiration of Left Occipital Brain Metastasis Mechanical Intubation and Ventilation History of Present Illness: HPI: 66M COPD baseline on 3L O2 at home. Participating clinical trial examining reduction of lung volumes in patients w/ emphysema. He got - CT Chest [4-23]: this was a screening high res CT scan (part of clinical trial and showed a 4x4 left hilar mass. - His wife also noted recent changes in mental status changes with word-finding difficulties, able to recognize objects but lost the ability to read, write. - CT Brain at OSH showed left parietal lesion - Bronch at [Hospital1 18] on [5-13]: Cytology suspicious for small cell lung cancer - Brain MRI [5-14]: ring-enhancing mass lesion on the left occipital lobe; lesion associated with vasogenic edema; no significant midline shift demonstrated. Mild mass effect is noted on the left occipital ventricular [Doctor Last Name 534] - CT Abd/Pelvis [5-15]: Numerous hepatic metastases involving all lobes of the liver. Lytic lesion within the left femoral head and left acetabulum - RadOnc: recommended Decardon - Neurosurg: Likely Stereotactic biopsy of mass later in week - Onc: chemo to likely start on [5-16] in AM Past Medical History: Past Medical History: s/p MI with stent COPD s/p left upper extremity sympathectomy s/p hernia repair anemia Social History: 100 pack yrs of smoking. Lives with wife on [Location (un) ], has four children. Family History: Non-contributory Physical Exam: Gen: comfrotable, communicating very well, AOx3 HEENT: PERLA, no LAD palpable CVS: RRR, no murmurs Resp: decreased breath sounds, course breath sounds on left Abd: voluntary guarding, distended, non-tender Ext: 1+ edema up to knees, no rashes; righ shoulder and hand twiched consistently throughout visit Pertinent Results: AMDISSION LABS: Chem7: [2120-5-13] 04:55PM GLUCOSE-136* UREA N-28* CREAT-1.4* SODIUM-143 POTASSIUM-5.8* CHLORIDE-103 TOTAL CO2-35* ANION GAP-11 [2120-5-13] 04:55PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-2.7* . CBC w/ coags: [2120-5-13] 04:55PM WBC-13.6* RBC-3.48* HGB-9.8* HCT-31.5* MCV-91 MCH-28.2 MCHC-31.2 RDW-14.2 [2120-5-13] 04:55PM PLT COUNT-475* [2120-5-13] 04:55PM PT-12.5 PTT-23.3 INR(PT)-1.1 . Imaging: . CT Chest [4-23]: this was a screening high res CT scan (part of clinical trial and showed a 4x4 left hilar mass. . - CT Brain at OSH showed left parietal lesion . - Brain MRI [5-14]: ring-enhancing mass lesion on the left occipital lobe; lesion associated with vasogenic edema; no significant midline shift demonstrated. Mild mass effect is noted on the left occipital ventricular [Doctor Last Name 534] . - CT Abd/Pelvis [5-15]: Numerous hepatic metastases involving all lobes of the liver. Lytic lesion within the left femoral head and left acetabulum Echo: ([5-13]) The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with inferolateral akinesis, inferior and inferoseptal hypokinesis. The remaining segments contract normally (LVEF = 40-45%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. Trace aortic regurgitation is seen. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction, c/w CAD. No major valvular abnormalities seen. Bilateral pleural effusions. Technically-difficult study. . EEG: IMPRESSION: This is a moderately abnormal EEG due to the presence of a slow background with multifocal slow transients; this pattern is most consistent with a mild to moderate encephalopathy or other process involving both hemispheres equally. No epileptiform features were seen. . Pathology: Tissue specimen: (Lung) Left main bronchus, endobronchial biopsy: Poorly differentiated carcinoma, consistent with small cell carcinoma; see note. Note: By immunohistochemistry, the tumor cells are positive for cytokeratin cocktail, TTF-1, synaptophysin and chromogranin. Focal, faint staining by cytokeratin 7 is identified. The tumor cells are negative for cytokeratin 20 and leukocyte common antigen, with satisfactory controls. This immunophenotype supports the above diagnosis. [2120-5-21] NON-CONTRAST CHEST CT: 1. Large left sided pleural effusion. 2. Small right sided pleural effusion. 3. Large left hilar mass with resultant bronchial obstruction. Confluent liver metastases. 4. Large right paratracheal lymph node with mass effect on the SVC. Brief Hospital Course: Mr. [Known lastname 1968] is a 66 yo man with newly, incidentally diagnosed SCLC with metastases to the liver, bones, and brain, who was admitted on [2120-5-13] for AMS attributed to worsening encephalopathy. He was started on Keppra for seziure prophylaxis, as well as dexamethasone; XRT was deferred this admission due to his tenuous overall status. On [2120-5-17] he began a three-day course of carboplatin/etopiside chemotherapy. On [2120-5-19], he developed worsening mental status and was intubated for hypoxemia. He was treated with levofloxacin and metronidazole to cover CAP or possible postobstructive PNA. He also required pressor support with phenylephrine, as well IVF. Repeat chest CT was performed on [2120-5-21], which showed a new, left-sided loculated effusion, as well as possible increase in the size of the tumors in his chest. There was also concern for compression of the SVC by a large right paratracheal lymph node, likley contributing to his hypotension and pressor-dependence. On [2120-5-22], the patient's sedation was lightened and the decision to withdrawal the ET tube was made after a conversation with the patient and his family (wife and four children). It was felt he was fully competent to make the decision to become CMO, and the family felt this would be consistent with his prior wishes given the progression of the tumor and its effects. The ET tube was removed in the early afternoon and he was placed on a morphine drip. He had several hours of consciousness where he was able to talk to his family at the bedside before he passed away in the early morning on [2120-5-23]. Medications on Admission: Wellbutrin 200 mg [Hospital1 ] Simvastatin Diovan 40 Metoprolol 12.5 mg [Hospital1 ] Plavix 75mg QD Requip 2mg /day Spiriva Albuterol Aspirin 81 mg Discharge Medications: NA-- patient expired Discharge Disposition: Expired Discharge Diagnosis: Small cell lung cancer, metastatic COPD Hypercarbic respiratory failure Discharge Condition: Expired Discharge Instructions: Patient has expired Followup Instructions: None [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "162.2", "E947.8", "412", "492.8", "198.5", "584.9", "198.3", "414.01", "196.0", "V45.82", "518.81", "485", "197.7", "348.30" ]	icd9cm	[ [ [] ] ]	[ "99.25", "96.71", "38.93", "33.24", "96.04" ]	icd9pcs	[ [ [] ] ]	7076, 7085	5170, 6824	331, 439	7201, 7211	2177, 5147	7279, 7423	1818, 1836		7031, 7053		7106, 7180		6850, 7008			7235, 7256									1851, 2158																							283, 293						467, 1567															1611, 1700	1716, 1802
81,247	102,230	43153	Discharge summary	report	Admission Date: [2184-1-20] Discharge Date: [2184-2-3] Date of Birth: [2113-8-15] Sex: M Service: MEDICINE Allergies: Bactrim DS / Lipitor / Atenolol / Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[First Name3 (LF) 1436] Chief Complaint: Neurogenic claudication Major Surgical or Invasive Procedure: L4/L5 decompressive laminectomies with instrumented fusion History of Present Illness: In brief, patient is a 70 yo M w PMH of CAD(CABG ((LIMA-obtuse marginal branch, SVG-LAD and known occluded SVG-RCA)in [2170], PCI in [2181]), PVD, unprovoked PE, negative LENIs in [2183-4-4], who was admitted to the ortho spine service for laminectomy. He had successful L4-L5 laminectomy on [2184-1-20]. On [2183-1-22] he developed chest/shoulder pain, tachycardia, EKG changes and troponin elevation consistent with [Date Range 7792]. His EKG showed STD in I, II, aVL, AVF, V2-V5 as well as STE in AVR. His troponin was elevated at 0.12, Ck MB 11. He was also tachycardic to the 120s. His EKG changes improved with better rate control. He also had fevers on [2184-1-21] and [2184-1-22]. Given concern for possible recurrent PE, STAT echo was done at bedside this morning and did not show right ventricular dysfunction or strain. Chest x-ray showed multifocal pneumonia, so he was started on antibiotics for HCAP coverage. He underwent cardiac catheterization on [2183-1-22] which showed occlusion of the severely diseased LMCA that supplied a diffusely diseased OM1 that measured previously 0.5 mm and a small (0.75 mm) diagonal system. . At 03:30 am on [2183-1-23] he flipped into atrial fibrillation with rapid ventricular response (heart rate 130s to 140s), with rate related ST-depressions. Patient reported some palpitations, but no new chest pain. He also desaturated to the high 80s and oxygen requirement increased. He was transitioned from 4L NC to face tent with 35% Oxygen. He was administered 5mg IV metoprolol with improvement of heart rate to the 110s, but also a drop in SBP to the 80s. SBP trended back up to the low 100s in about 15 minutes. He was given 500cc NS over 60 minutes and transferred to the CCU for further management of Afib with RVR. He previously had one episode of atrial fibrillation following his CABG. . On arrival in the CCU he denies any chest pain, palpitations subjective dyspnea except for an inability to take deep breaths, no cough. He was AAOx3 and mentating well. Rate control was attempted with diltiazem 5 mg IV. His HR went down to 100-110s, and BP was down to 80s/60s, with MAPs in low 60s. Past Medical History: PMH: CAD w/ MI, mild chronic stable angina, hypercholesterol, abdominal hernia, PAD PSH: CABG [54], [2181-5-2] R [Name (NI) 1793] PTA/stent Social History: Lives with wife. [Name (NI) ] teaches finance in [University/College 5130] [Location (un) ]. Family History: noncontributory Physical Exam: Admission Physical Exam: AVSS Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions BUE: [5-8] [Doctor First Name ]/Tri/Bic/WE/WF/FF/IO BUE: tone normal, negative [Doctor Last Name 937], 2+ symmetric DTR bic/bra/tri All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: SILT L1-S1 dermatomal distributions BLE: [5-8] IP/Qu/HS/TA/GS/[Last Name (un) 938]/FHL/Per BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses spinal wound is c/d/i Discharge Physical Exam: Vitals: Tmax: 97.9 T current: 97.9 HR: 80-87 RR: 16 BP: 105-115/65-66 O2 sat 100% on RA. I/O: 24hr: [Telephone/Fax (1) 18904] 8Hr: 100/575 WEight: 76.8 (77.4) . Physical Exam: GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. sl dry MM NECK: Supple with JVP of 9 cm. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTABL. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 1+ pitting edema at the ankles, No femoral bruits. PULSES: Right: DP 1+ PT 2+ Left: DP 1+ PT 2+ Pertinent Results: TTE [2184-1-22] The left atrium is mildly dilated. There is mild regional left ventricular systolic dysfunction with mid- and distal septal hypokinesis. The remaining segments contract normally (LVEF = 45%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild aortic regurgitation. Moderate mitral regurgitation. Mild pulmonary hypertension. . Cardiac cath showed [2184-1-22] Cardiac Catheterisation [2184-1-22] . Hemodynamic Measurements (mmHg) Baseline Site Sys [Last Name (un) 6043] Mean HR AO 105 60 72 102 Findings ESTIMATED blood loss: <100 cc Hemodynamics (see above): Left ventriculography: mitral regurgitation; LVEF %; Coronary angiography: right dominant LMCA: Ostially occluded LAD: Occluded mid vessel. Heavily calcified. Fills via SVG graft and has mild disease. LCX: Occluded mid vessel. Distal Cx and OM2 vessel fills via the LIMA and has minimal disease. The rPL and rPDA system fill via collaterals from the AV groove Cx. RCA: Occluded proximally and distally fills via collaterals from the LCA via the LIMA graft and SVG to LAD graft SVG-RCA: Known occluded SVG to LAD: Widely patent. 20-30% proximal ISR LIMA-OM2: Widely patent. Assessment & Recommendations 1.Secondary prevention CAD 2.Infarction appears to be occlusion of the severely diseased LMCA that supplied a diffusely diseased OM1 that measured previously 0.5 mm and a small (0.75 mm) diagonal system. 3.Medical management for [Last Name (un) 7792]. 4.No need to continue heparin and would not manage with clopidogrel given recent spine surgery. 5.ASA po QD. . ETT: [2184-1-7] INTERPRETATION: 69 yo man s/p CABG in [2154] and stent to LAD in [2170] was referred to evaluate an atypical chest discomfort. The patient was administered 0.142 mg/kg/min of Persantine over 4 minutes. No chest, back, neck or arm discomforts were reported. No significant ST segment changes were noted. The rhythm was sinus with rare isolated APDs and VPDs noted. The hemodynamic response to the Persantine infusion was appropriate. Post-infusion, the patient was administered 125 mg Aminophylline IV. . IMPRESSION: No anginal symptoms or ischemic ST segment changes. Nuclear report sent separately. . CARDIAC CATH: [2181] 1. Successful PTCA and stenting of the SVG-LAD anastomosis stenosis and distal 50% stenosis with a 2.25x20mm Taxus Atom stent that was postdilated to 2.5mm in the mid and proximal portion. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow. 2. Successful deployment of angioseal vascular closure device. FINAL DIAGNOSIS: 1. Patent SVG-LAD stents. 2. Successful PCI to SVG-LAD. 3. Successful deployment of angioseal closure device. . CXR [2184-1-22] FINDINGS: As compared to the previous radiograph, there is evidence of a newly appeared parenchymal opacity at both the right lung base and in the left lung, notably in the perihilar areas in the retrocardiac space. The distribution suggests pneumonia rather than pulmonary edema, notably given the absence of pleural effusions and the absence of other findings indicative of fluid overload. Borderline size of the cardiac silhouette. Status post CABG. No hilar or mediastinal changes. . CTA chest [2184-1-23] FINDINGS: Sternal wires and post CABG changes are present. Mild calcification of the coronary arteries is stable. The heart is normal in shape and size. The right ventricle is not enlarged. The interentricular septum is normal is shape and contour. There is no pericardial effusion. The aorta unremarkable without aneurysm or dissection. The pulmonary arteries are patent to the subsegmental level without evidence of pulmonary embolism. There is no axillary, hilar or mediastinal lymphadenopathy. Moderate bilateral pleural effusions are present, including an intrafissural component of effusion on the left. Small homogeneous symmetric consolidations are present in the dependent regions, which is most consistent with atelectasis. Evaluation of the lung parenchyma is somewhat limited due to extensive respiratory motion. Despite these limitations, there are nonspecific scattered ground-glass opacities which likely represent atelectasis and a small component of mild pulmonary edema. There is no definite pneumonia. There is an increase in size of the lymphatic tissues in the right hilum in the inferior aspect. There are degenerative changes of the spine without concerning lytic or sclerotic bone lesions. The osseous structures are otherwise unremarkable. IMPRESSION: 1. No pulmonary embolism. 2. Moderate bilateral pleural effusions. 3. Bilateral atelectasis. 4. Mild pulmonary edema. Brief Hospital Course: 70 yo M with PMH significant for CAD s/p CABG and PCI, PVD and h/o [Hospital ] transferred to CCU on POD#3 [2184-1-22] s/p L4-L5 laminectomy, with [Month/Day/Year 7792]. . #L4/L5 laminectomy: Patient was admitted to the [Hospital1 18] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. Pnemoboots were used for postoperative DVT prophylaxis. ASA 81 mg was resumed as well on POD 3 as dictated preoperatively by his cardiologist. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2. Physical therapy was consulted for mobilization OOB to ambulate. Pt experienced an [Hospital1 7792] on [2184-1-22] in postop setting and was transferred to the CCU - see [Date Range 7792] below. . #[Date Range 7792]/ACS - pt s/p [Date Range 7792] [2184-1-22] in postop setting. Cardiac cath at that time showed infarction appeared to be occlusion of the severely diseased LMCA that supplied a diffusely diseased OM1 that measured previously 0.5 mm and a small (0.75 mm) diagonal system. Medical management for [Month/Day/Year 7792] was pursued. CP resolved until [1-28] when pt had midnight episode of chest tightness - he described this as similar to previous episodes at home relieved with nitro although those episodes on exertion and this time lying in bed. no radiation of pain. K had just been repleted (was at 3.8) ECG showed NSR at 100 (had been in 80s earlier in the night - on tele sped up slowly, in sinus) new 1mm depression in lead I, avF with 2mm dep in lead II. V1 with 1mm St elevation, V3-V5 with 3mm depression, V6 with 2mm dep. Within 10 minutes pain improved, stated tightness was gone prior to recieving any medications. HR had gone down to 80s spontaneously. Repeat ECG showed resolution of changes mentioned above but pt now with inverted T waves V1 V2 V3, NSR at rate 80. V4 and V5 with 2mm depressions V6 with only 1mm dep now. BP maintained at low 100s/60s throughout, O2 sat 96 on 2L nc. Pt had a similar episode the following night prompted by urinating in a urinal by lying down. Again pronounced ECG depressions in same leads (anterolateral and inferior) which resolved within 10 minutes, this time pt was administered IV metoprolol with po for longer-lasting effect. These anginal episodes recurred the following 2 nights as well with rapid resolution of ECG changes. Pt endorsed significant component of anxiety during and prior to both events. Although in sinus tach each time, his HR had been creeping up from 70s up to 100 at which point he experienced the chest pain. Most likely [2-5] demand ischemia in territory of diseased RCA supplied by collateral circulation. Long acting nitro was uptitrated with good effect. Isosorbide dinitrate was started, which was exchanged for nitro patch prior to discharge. Patient also started on Renolazine. Cardiac catheterization images revisited and it was felt that pt did not have any visible occlusions to intervene on, in which case CABG was also not an option. - recurrent episodes of nocturnal stable angina managed by uptitration of antianginals: nitro patch and Ranolazine. # Atrial Fibrillation with RVR: Patient has one prior documented history of AFib shortly after CABG, none since. On [2184-1-23] pt went into Afib with HR in 110s, SBP 90s-100s, 3 hours later back into sinus tack, then an hour later with RVR 140-150s, dilt gtt started. Dropped pressures on metoprolol, pressures slightly better on diltiazem. This pattern of flipping in and out of Afib with RVR continued for the next few days. Apart from [Name (NI) 7792], pt also had fevers, leukocytosis, and CXR findings concerning for ?pneumonia on transfer to the CCU. It was felt that infection and tachycardia with demand was likely triggering aFib. Most likely pt had dilation of [Doctor Last Name 1754] in setting of MR [First Name (Titles) 6643] [Last Name (Titles) 93010]d Afib. Initially rate was controlled with dilt drip and pt was anticoagulated with heparin gtt (no bolus - this was approved by orthopedics in post-op setting) and was initiated in setting of [Last Name (Titles) 7792]. PT was monitored on telemetry, and did not require electrical cardioversion as he was never unstable. [2184-1-26] pt started on metoprolol and loaded with digoxin and given daily doses until [2184-2-1]. After adequate diuresis and resolution of decompensated heart failure, patient spontaneously converted to sinus rhythm and digoxin was discontinued. Given high CHADS score, patient was continued on anticoagulation for PAF with heparin gtt transitioned to warfarin. On day of discharge, INR was 2.0 - initiation of metoprolol to 75mg [Hospital1 ] for rate control - initiation of warfarin for anticoagulation # CAD: Patient has known CAD, s/p CABG and occluded SVG-RCA. Given tachycardia, troponin was checked and found to be elevated, ruled in for [Hospital1 7792]. s/p Echo which showed no new wall motion abnormalities, EF 45% at baseline, s/p cardiac catheterisation which showed OM1 lesion. No stents placed, plan was to continue medical management. Continued on aspirin 325, initially heparin gtt, plavix was held as pt was in post-op setting. Metoprolol initially not tolerated by the pt but was eventually able to wean from dilt gtt and metoprolol was started. Continued rosuvastatin and glucose control. - optimize medical management for CAD: ASA 325mg, initiation of bblocker, statin - if renal function stabilzes, please consider initiation of ACEI #fevers/leukocytosis: On transfer to CCU pt had fevers, leukocytosis>16, CXR findings suggestive of multifocal pneumonia. C/f HCAP and started treatment with vancomycin/cefepime/levofloxacin. Blood and sputum cx showed no growth. Antibiotics continued for 7d HCAP treatment course. There was also c/f PE; pt with history of unprovoked PE in [Month (only) 547] [2183], no hypercoagulability workup done at the time. Fever/leukocytosis and tachycardia along with recent immobility s/p spinal surgery, high risk for PE. CXR changes however thought to be more consistent with pneumonia. Pt was started on empiric heparin gtt for [Year (4 digits) 7792] which also addressed possibility of PE. # Hct drop: Hct drop to nadir 23.4 from 32.1 on [2184-1-22], pt is s/p laminectomy. Ortho was following and examined the spine without concerns. Pt did not have overt bleeding/swelling or pain. Initially hct monitored QID in setting of beginning heparin gtt. Stools were guiaic negative. Pt received 1u pRBCs. Patient reported his last colonoscopy 10 years ago, due for a followup colonoscopy in [Month (only) 956], of note his mother died of colon CA at age 63. - recommend outpatient colonoscopy in [Month (only) 956] # CHF: Patient has no known history of CHF. Echo done at bedside showing preserved EF but mitral regurg worsened. Pt was significantly fluid overloaded on transfer to the CCU and was diuresed aggressively on lasix gtt transitioned to boluses. # Hypotension: Concern for cardiogenic shock vs. PE with hemodynamic instability vs. septic shock from multifocal pneumonia (as below). Pt had no evidence of right ventricular strain on echo, so massive PE with hemodynamic instability felt unlikely. HCAP coverage was continued to cover possible septic state from multifocal pna. Most likely hypotension was [2-5] cardiogenic shock as pt with recent [Month/Day (2) 7792] now with increased mitral valve regurgitation. Pt also developed Afib which exacerbated hypotension. BP improved with control of Afib and aggressive diuresis. #hyperkalemia - central venous line was placed to deliver larger quantities of potassium. Hyperkalemia resolved with aggressive diuresis. #abdominal distension - pt was noted to lack bowel sounds and was with distended abdomen after laminectomy. KUB showed ileus but no evidence of obstruction and exam was otherwise benign. At this time levoquin was DCd (see fever/leukocytosis above, C/f HCAP) and flagyl was initiated, with good response. Pt eventually tolerated liquids and diet was advanced without issue. #Emesis - pt developed several episodes of watery, nonbloody nonbilious emesis. concurrently his heart rate would drop into the 60s. This was felt to represent a vasovagal episode and these episodes self-terminated. #singultus - pt was given thorazine for hiccups and became extremely somnolent with difficulty finding words. This medication was discontinued, hiccups resolved on their own. #anxiety - pt had considerable component of anxiety and this was felt to precipitate his episodes of chest pain somewhat. Pt was treated with ativan prn with good effect. TRANSITIONS OF CARE: - continue medical management of CAD/ angina with uptitration of nitrates as needed. Currently on nitro patch and ranolazine. Also on ASA, bblocker and statin - continue anticoagulation with coumadin for paroxysmal afib - consider initiation of ACEI given significant CHF once renal function has stabilized - f/u with [Last Name (un) ] as needed for laminectomy Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1 puff tid prn HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth [Hospital1 ] prn NITROGLYCERIN - 0.4 mg Tablet, Sublingual - Place one tablet under tongue for chest pain, repeat every 5 minutes times 2 prn Lipitor TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply topically to legs once every 1-2 weeks as needed Lovenox OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet, Delayed Release (E.C.) - 0.5 (One half) Tablet(s) by mouth daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal QHS (once a day (at bedtime)). Disp:30 Patch 24 hr(s) Refills:2 5. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO BID (2 times a day). Disp:60 Tablet Extended Release 12 hr(s) Refills:2 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: alternate with 7mg (3.5 tablets) . Disp:180 Tablet(s) Refills:2 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety/insomnia. Disp:15 Tablet(s) Refills:0 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO Q 12H (Every 12 Hours). Disp:180 Tablet Extended Release 24 hr(s) Refills:2 10. 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. 11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Disp:25 tablets Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Lumbar spinal stenosis at L4-L5 with grade I spondylolisthesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: Provider: [First Name4 (NamePattern1) 1141] [Last Name (NamePattern1) 4983], [MD Number(3) 1240]:[Telephone/Fax (1) 3736] Date/Time:[2184-2-3] 10:00	[ "560.1", "V12.55", "997.49", "530.81", "V45.81", "756.12", "E878.8", "785.51", "427.31", "276.8", "584.9", "780.2", "786.8", "410.71", "300.00", "486", "724.03", "414.01", "412", "276.69", "272.4", "790.01", "276.7", "V45.82", "787.03", "440.20", "424.0" ]	icd9cm	[ [ [] ] ]	[ "77.70", "88.56", "38.93", "81.07", "88.57", "81.62" ]	icd9pcs	[ [ [] ] ]	20741, 20799	9247, 18290	363, 424	20906, 20906	4159, 7162	21056, 21228	2962, 2979		19263, 20718		20820, 20885		18705, 19240		7179, 9224										3751, 4140																							300, 325						452, 2647									20921, 21033	18311, 18679					2669, 2822	2838, 2946					3571, 3736
16,601	133,200	11237	Discharge summary	report	Admission Date: [2153-2-26] Discharge Date: [2153-3-4] Date of Birth: [2103-5-27] Sex: F Service: PLASTIC Allergies: Cephalexin Attending:[First Name3 (LF) 16920] Chief Complaint: intraductal carcinoma left breast Major Surgical or Invasive Procedure: left modified mastectomy with immediate reconstruction with [Last Name (un) 5884] flap. History of Present Illness: 49 yo woman w/ h/o left intraductal carcinoma, presents for left radical modified mastectomy with immediate reconstruction with [Last Name (un) 5884] flap. CA dx [11-6], followed by radiation oncology prior to presentation for mastectomy Past Medical History: 1 seizure @ age 17 hypothyroidism wide local excision precancerous lesion back Social History: G3, P1, miscarriage times two. Menarche age of 13, menopause. She has a regular period. First, delivery age of 39. Denies oral contraceptives. She has been on low-dose estrogen for four years for hot flash. She denies smoking or ETOH use. She works three days a week in office in [Location (un) 2498]. Family History: Mother had a breast carcinoma at age of 75 and she was treated with a breast lumpectomy and tamoxifen. She is alive and well. Lymphoma in brother at age 55. He is alive and well. Physical Exam: Patient is a well-appearing, in NAD. HEENT exam is unremarkable. No adenopathy in the cervical, supra/infra clavicular or axillary region. Lungs are clear to auscultation bilaterally. Cardiac exam unremarkable. No tenderness of the spine, ribcage or CVA. Breasts are moderate in size. The right breast is unremarkable. Left breast is slightly larger. There is a localized induration and fullness in the left upper outer quadrant, most likely post biopsy changes. slight irregular thickening of the breast tissue at 11 to 10 o'clock position at the edge of the areola, probably glandular breast tissue. No axillary adenopathy. Abdomen is benign. No pedal edema or calf tenderness. Pertinent Results: [2153-2-26] 09:12PM GLUCOSE-230* UREA N-12 CREAT-0.8 SODIUM-143 POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-24 ANION GAP-15 [2153-2-26] 09:12PM LD(LDH)-155 CK(CPK)-344* [2153-2-26] 09:12PM cTropnT-<0.01 [2153-2-26] 09:12PM CK-MB-11* MB INDX-3.2 [2153-2-26] 09:12PM WBC-24.9# RBC-2.99# HGB-9.3# HCT-28.5# MCV-96 MCH-31.0 MCHC-32.5 RDW-12.1 [2153-2-26] 09:12PM CALCIUM-8.2* PHOSPHATE-6.1* MAGNESIUM-1.6 [2153-2-26] 09:12PM PLT COUNT-464# [2153-2-26] 09:12PM PT-14.5 PTT-26.4 INR(PT)-1.3 Brief Hospital Course: Pt underwent left modified radical mastectomy w/ immediate reconstruction with [Last Name (un) 5884] flap. See operative note for details re: operative course. Immediately following the case, she developed SVT to 130s which was controlled w/ esmolol & verapamil. She also experienced some thrashing upper & lower extremity movements & possible eye rolling. On POD#0, she was taken back to the OR for re-evaluation of her flap after it lost doppler signals (see operative note). She was transferred intubated to the SICU. She was weaned off sedation & extubated POD#2. On POD #3, she developed ecchymotic skin changes around her breast & the flap was mottled - she was taken back to the OR for evaluation of possible hematoma (see operative note). The flap remained viable & in place. On POD#4, she was out of bed & ambulating with assistance. On POD35, she was transferred to the floor. On POD36 after progressing well, she was discharged home w/ VNA care for drain care for her remaining JP drains. She was evaluated by neurology (See notes). No new medications were started. Medications on Admission: levoxyl 100 qd Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). Disp:60 Tablet, Chewable(s) Refills:2 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 932] Area VNA Discharge Diagnosis: intraductal carcinoma left breast Discharge Condition: good Discharge Instructions: Keep dressings clean & dry. Keep the insertion sites of the drains clean & dry. Followup Instructions: With Dr. [First Name (STitle) 3228] next week. Please call his office as soon as possible at ([Telephone/Fax (1) 23640] to schedule an appointment. DR. [Doctor Last Name 36105]CC5 BREAST SURGERY BREAST SURGERY (PRIVATE) CC-5 (NHB) Where: BREAST SURGERY (PRIVATE) CC-5 (NHB) Date/Time:[2153-4-3] 1:40	[ "427.89", "444.89", "998.12", "244.9", "780.39", "174.8", "458.29", "996.52" ]	icd9cm	[ [ [] ] ]	[ "99.04", "86.04", "99.10", "85.7", "85.45", "39.98", "99.00", "85.89" ]	icd9pcs	[ [ [] ] ]	4118, 4181	2571, 3654	304, 398	4259, 4265	2014, 2548	4393, 4713	1115, 1296		3719, 4095		4202, 4238		3680, 3696			4289, 4370									1311, 1995																							231, 266						426, 673															695, 775	791, 1099
48,281	188,089	49499	Discharge summary	report	Admission Date: [2114-11-12] Discharge Date: [2114-12-8] Date of Birth: [2035-2-2] Sex: M Service: [Year (4 digits) 662] Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1253] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: Sigmoidectomy and end colostomy (Hartmann pouch) [2114-11-15] Cardiac Catherization [2114-11-23] PICC line placement IR guided [2114-11-29] NGT placement x2 History of Present Illness: 70 y/o M with diffuse large B cell lymphoma admitted for BRBPR. Patient was recently discharged from OMED service on [11-9] after receiving R-ICE chemotherapy. Tolerated well, received neulasta [2114-11-9] and was doing well at home. Over the weekend he experienced some lower leg aches and took 2 regular strength aspirin on saturday. He had a bowel movment on Saturday. On Sunday he felt fine but had no bowel movement. This morning at 5am pt awoke and felt the urge to defecate, which was unusual as he never feels this in the mornings, and he passed a large volume of what he thought was diarrhea but saw dark red blood in the toilet. Called his primary oncologist who advised him to go to the ED. In the ED he had another large volume bloody diarrhea around noon. Pt states he has never had red blood per rectum before. Of note, pt had a colonoscopy on [10-30] that showed diverticulosis of the sigmoid colon and ascending colon, a polyp at 80cm in the colon (single piece polypectomy with cold snare), and friability and congestion in the sigmoid colon. Pt does also have a history of hepatitis C, untreated (per pt preference) and history of Hep B core antibody + in [2111]. . In the [Name (NI) ], pt felt well, had no complaints. Denied dizziness/lightheadedness, denied n/v/abdominal pain. Pt was normotensive but given 500 cc 1/2 NS and 2u pRBC were put on hold but not transfused. Pt was admitted for GI bleed. Labs showed stable H/H at 11.3/ 33.2 (11.9/34.6 on DC friday). PLT 145 (170 on DC), and WBC of 17.3. . HPI from admission to Internal [Name (NI) ] (pt was transferred to [2-9] service this admission, IM was the last one) Mr. [Known lastname ] is a 79M with h/o DLBCL s/p RICE chemotherapy, adriamycin-induced cardiomyopathy,Hepatitis C, prostate cancer, and diabetes who presented on [11-12] with BRBPR and is now s/p sigmoidectomy and end colostomy for necrotic sigmoid colon lesions. Pt had a colonoscopy on [10-30] for thickening of his sigmoid colon seen on CT scan. Sigmoid not well visualized, but biopsies showed ulceration consistent with radiation proctitis. He also had a polypectomy at that time. Then admitted [11-5] to [11-9] after recurrence of his DLBCL was seen on R buttock biopsy. He received chemotherapy and got R-ICE therapy. His Lasix was continued but [Month/Day (2) ] held due to concern for thrombocytopenia from chemotherapy. He was then readmitted [11-12] for painless hematochezia episodes. His Hct and hemodynamics were stable, and he had elevated WBC's after being given Neulasta recently. Had sigmoidoscopy [11-13] which was unrevealing due to poor prep. Repeat colonoscopy was done [11-15] and was concerning for necrosis of mid-sigmoid and proximal sigmoid. He went to the OR on [11-15] where he had ex-lap, sigmoid colectomy, and end colostomy. He was doing well post-operatively. Rheumatology was consulted on [11-20] for R knee pain and swelling and fever to 102 and tapped his knee which showed monosodium urate crystals consistent with his h/o gout; Gstain and culture were negative. . On [11-21] he got acutely SOB, was diaphoretic, and was put on non-rebreather and transferred to MICU. He was felt to be in flash pulmonary edema, confirmed by CXR, and was already diuresing by the time he got to MICU. EKG was concerning for septal elevations, with TWI in II-III, and cardiac enzymes were seen to be elevated with an elevated BNP as well. ICU consulted Cardiology. Echo showed EF 35-40%, TR gradient 33, near akinesis of the septum, 1+MR, [12-10]+TR, RV normal. . The evening of [11-23], had episode of fever, tachypnea, tachycardia, increased work or breathing. Trop 0.24->0.34. Has cardiomyopathy was at baseline. Cardiology was consulted and felt this was related to demand ischemia, but felt further work-up indicated. . Pt was taken to cath on [11-23] where he was found to have new 3vd including 60-70% LMCA dz, LVEDP 7, given 300 cc's. No interventions were done, recommended medical therapy given comorbidities. CXR now shows substantial improvement in the previously moderately-severe pulmonary edema. He was started on statin. Past Medical History: Pt has low grade grade [1-11] follicular center lymphoma, diagnosed [2099] with transformation into large cell lymphoma in subcut nodules in [2102]. Rx'd 6 cycles CHOP with CR. Developed subsequent cardiomyopathy. 4-6 weeks ago pt p/w new pain in his right buttock with radiation down his right leg. It was felt to be degenerative arthritis, pt given tramadol. Pain has continued and more recently he developed left lower quadrant pain and tenderness that was felt possibly to be due to diverticulitis. Given cipro with some improvement in his abdominal pain. CT abd showed thickening of the distal descending colon as well as a small splenic mass and a large 6 cm mass in his buttock as well as new spiculated nodules at the base of his lungs. He had a needle biopsy of his buttock mass done by IR at [Hospital1 ] which showed recurrence of his large cell lymphoma from [2102]. Pt denies wt loss, fever/chills, n/v. He underwent a colonoscopy earlier in [Month (only) ] that showed some very mild thickening of his colon that did not look malignant, biopsies consistent with radiation induced colitis. Pt was admitted [11-5] for R-ICE therapy which he tolerated well (infusion reaction to rituxan resolved with slower rate of infusion and solumedrol) and was discharged [2114-11-9] and recieved neulasta that day in clinic. . . PAST MEDICAL HISTORY: Hepatitis C with normal liver function tests, antibodies to hepatitis B core with a negative hep B surface antigen, negative HIV test Mild cardiomyopathy felt possibly to be do to his previous chemotherapy with Adriamycin for which he is on diuretics Large GIB, s/p sigmoidectomy and end colostomy (Hartmann pouch in [11/2114]) course complicated by NSTEMI, flash edema, high grade SBO but not surgical candidate, treated medically/CMO Diabetes type 2 uncontrolled Liver mass hypertension lumbar spinal stenosis abdominal aortic aneurysm hyperlipidemia h/o colonic adenoma prostate CA s/p radiation lymphoma Social History: Marital Status: Married with 3 children. REtired, lives in [Hospital1 1474] with wife. Former longstanding smoker quit in [2084]. Wife smokes. Alcohol use rarely. No IVDA. Family History: Noncontributory Physical Exam: ON ADMISSION: Vitals - T: 97.2 BP 134/64 HR 64 RR 20 99%RA GENERAL: NAD, sitting comfortably in bed SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BUTTOCKS: right buttock with barely palpable tender mass roughly 4 inches in diameter near the lateral aspect almost over the trochanter, no longer painful as it was during past admission M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, A&Ox3 5/5 strength EXTREMITIES: trace pitting edema bilaterally . AT DISCHARGE: 97.5, 137/84, 89, 20, 99RA General: Alert, oriented, thin/frail, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, midline staples were removed, diffusely tender to palpation, more distended than before, no rebound tenderness or guarding, ostomy on right abdomen with gas and minimal stool, surgical wound draining less than before Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: [2114-11-12] 10:45AM BLOOD WBC-17.3# RBC-3.87 Hgb-11.3* Hct-33.2* MCV-86 MCH-29.3 MCHC-34.2 RDW-14.6 Plt Ct-145* [2114-11-12] 10:45AM BLOOD Neuts-93* Bands-0 Lymphs-5* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2114-11-12] 10:45AM BLOOD PT-10.3 PTT-23.9* INR(PT)-0.9 [2114-11-12] 10:45AM BLOOD Glucose-132* UreaN-36* Creat-0.9 Na-138 K-4.0 Cl-101 HCO3-25 AnGap-16 [2114-11-13] 07:10AM BLOOD ALT-38 AST-41* AlkPhos-71 TotBili-0.7 [2114-11-14] 08:54PM BLOOD CK-MB-2 cTropnT-<0.01 [2114-11-15] 08:10PM BLOOD CK-MB-3 cTropnT-<0.01 [2114-11-13] 07:10AM BLOOD Calcium-9.4 Phos-2.8 Mg-1.8 [2114-11-13] 07:10AM BLOOD Cryoglb-NO CRYOGLO [2114-11-12] 10:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE IgM HBc-NEGATIVE [2114-11-15] 07:40AM BLOOD HIV Ab-NEGATIVE [2114-11-12] 10:45AM BLOOD HEPATITIS Be ANTIGEN-Negative . LABS DURING ICU ADMISSION: [2114-11-23] 04:04AM BLOOD WBC-13.2* RBC-3.26* Hgb-9.5* Hct-27.7* MCV-85 MCH-29.2 MCHC-34.4 RDW-15.1 Plt Ct-266 [2114-11-22] 01:31PM BLOOD WBC-22.9* RBC-3.54* Hgb-10.2* Hct-30.6* MCV-86 MCH-28.9 MCHC-33.5 RDW-15.1 Plt Ct-305 [2114-11-23] 11:02AM BLOOD PT-21.5* PTT-75.4* INR(PT)-2.0* [2114-11-22] 08:00PM BLOOD Glucose-168* UreaN-21* Creat-0.8 Na-130* K-3.3 Cl-93* HCO3-30 AnGap-10 [2114-11-22] 05:33AM BLOOD CK-MB-4 cTropnT-0.34* proBNP-[Numeric Identifier 103568]* [2114-11-22] 01:31PM BLOOD CK-MB-4 cTropnT-0.30* proBNP-[Numeric Identifier 103569]* [2114-11-22] 08:00PM BLOOD CK-MB-3 cTropnT-0.34* [2114-11-23] 04:04AM BLOOD CK-MB-2 cTropnT-0.38* [2114-11-22] 02:36AM BLOOD Type-ART Temp-37.7 O2 Flow-15 pO2-66* pCO2-39 pH-7.46* calTCO2-29 Base XS-3 Intubat-NOT INTUBA Comment-NON-REBREA [2114-11-22] 12:45PM BLOOD Glucose-220* Lactate-3.8* Na-128* K-3.8 Cl-95* [2114-11-22] 12:45PM BLOOD freeCa-1.06* . IMAGING: [2114-10-30] colonoscopy: Diverticulosis of the sigmoid colon and ascending colon Polyp at 80cm in the colon (polypectomy) Friability and congestion in the sigmoid colon (biopsy) Otherwise normal colonoscopy to cecum . [2114-11-13] sigmoidoscopy: Poor prep with stools and old blood in the rectum and sigmoid colon . [2114-11-15] sigmoidoscopy: Ulceration in the mid-sigmoid colon and proximal sigmoid colon compatible with necrotic tissue (biopsy) Otherwise normal colonoscopy to sigmoid colon . [2114-11-22] SURFACE ECHO: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. Normal IVC diameter (<=2.1cm) with >50% decrease with sniff (estimated RA pressure (0-5 mmHg). LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild-moderate regional LV systolic dysfunction. Beat-to-beat variability on LVEF due to irregular rhythm/premature beats. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[12-10]+] TR. Mild PA systolic hypertension. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Suboptimal image quality - patient unable to cooperate. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis/near-akinesis of the septum. There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Focused study/Limited views. Mild symmetric left ventricular hypertrophy with normal left ventricular cavity size. Mild to moderate left ventricular systolic dysfunction with regional wall motion abnormalities as described above. Normal right ventricular cavity size with preserved right ventricular systolic function. Mild mitral regurgitation. Mild to moderate tricuspid regurgitation. Mild pulmonary artery systolic hypertension Cardiac Cath [2114-11-23]: COMMENTS: 1. Selective coronary angiography of this right-dominant system demonstrated severe three-vessel CAD. The LMCA had diffuse 60-70% calcified stenosis. This was best visualized in the [Doctor Last Name ] caudal and AP cranial projections, as other projections were limited by contrast streaming. The LAD had 60% heavily calcified stenoses in the mid to distal vessel segments. The D1 branch had a 70% origin stenosis. The true distal LCX had diffuse 80-90% stenosis prior to the takeoff of the OM1 branch. The dominant RCA had a 60% stenosis in the mid-vessel segment, and 80-90% stenosis in the PLSA prior to two small PL branches. 2. Limited resting hemodynamics revealed normal left and right-sided filling pressures. RVEDP and LVEDP were 5mmHg and 8mmHg, respectively. There was no pulmonary hypertension with a measured mean PAP 17mmHg. Cardiac output and index were preserved at 5.2L/min and 2.7L/min/m2, respectively. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Left main and three vessel CAD 2. Reduced left ventricular function. 3. Recommend medical therapy. CT Abdomen and Pelvis [2114-11-28]: IMPRESSION: 1. High-grade small bowel obstruction with transition point in the right lower quadrant. 2. Residual pneumoperitoneum. 3. Improving basilar pulmonary nodules, likely due to infectious etiology. 4. 3.5-cm infrarenal abdominal aortic aneurysm. 5. Cholelithiasis without evidence of cholecystitis. CT abdomen/pelvis [12-2] IMPRESSION: 1. Persisting high grade small bowel obstruction with a transition point in the right lower quadrant has increased in severity since [2114-11-28]. 2. Multiple bubbly air pockets in the pelvis could be either within the bowel loops or could be extraluminal, likely from previous surgery. However there is no walled off fluid collection. 3. Residual pneumoperitoneum in the right perihepatic region improved and mild free fluid in abdomen and pelvis has resolved. 4. Multiple pulmonary nodules in the lower lung have grown smaller since [2114-10-15]. 5. 3-3.5 cm infrarenal abdominal aortic aneurysm, stable since [2114-10-9]. 6. Cholelithiasis without evidence of cholecystitis. Brief Hospital Course: 79M with very complicated course and >3wk admission, but briefly: h/o DLBCL s/p RICE chemotherapy, adriamycin-induced cardiomyopathy, Hepatitis C, prostate cancer, and diabetes. . In the past few months, he had recurrence of lymphoma and was admitted for R-ICE chemo in 11/[2113]. He had a CT abdomen which showed colonic thickening, and had colonoscopy [10-30] with biopsies showing ulceration consistent with radiation proctitis, but given poor prep, was difficult to visualize; also had polypectomy. He then presented [11-12] with BRBPR (radiation proctitis vs lymphoma?) and had sigmoidoscopy [11-13] and colonoscopy [11-15] concerning for necrosis of mid-sigmoid and proximal sigmoid. He went to the OR on [11-15] where he had ex-lap, sigmoid colectomy, and end colostomy ([Doctor Last Name 3379]). He was doing fairly well post-operatively, except for KUB showing multiple dilated loops of small bowel consistent with ileus. On post-op day 4, in the setting of fevers, pt underwent CT abdomen showing a 5.7 x 2.7cm partially organized fluid collection in the pelvis - likely representing a seroma given the time-frame post-op (as the patient had no intraabdominal intestinal anastomosis, there was no possibility that this could represent an anastomotic leak). He was then noted to have large R knee effusion and this was tapped by Rheumatology, showing acute gout flare. Fevers and R knee pain resolved after aspiration. . On [11-21] he began having chest pressure, acutely SOB and hypoxic, so started on NRB and CXR showed flash edema and transferred to MICU for diuresis. There, on [11-23] he NSTEMI'd with positive uptrending cardiac enzymes and EKG changes, thought to be due to demand ischemia, so taken to cardiac cath which showed bad 3vd and 60-70% left main disease, but he was not felt to be an operable / intervenable candidate, so it was medically managed with [Last Name (LF) ], [First Name3 (LF) ], and ACS medications. Heparin drip was stopped. . He was then transferred out of ICU to general [First Name3 (LF) ], where he was OK initially but after a few days, he began to feel very weak and was dwindling, not getting OOB, and seen to be very weak and orthostatic. His cardiac regimen including antiHTN meds were adjusted. However, he then started vomiting and had abdominal pain, had a WBC count, and was tachycardic and found to have on CTAP [11-28] to have SBO with high grade transition point in the RLQ. He was also noted to have some purulence coming from the inferior-most part of his surgical wound -- this grew Ecoli but was not thought to be the sole reason for his fevers/leukocytosis as the supposed wound infection was quite small. He was started on empiric broad spectrum ABx, surgery consulted, NGT placed, TPN started eventually. Most of his oral medication regimen at that time was held. . He defervesced, but over the next ~5-6 days his SBO was not getting better, NGT was putting out >1L of bilious vomit per day, WBC count back up, and he was persistently tachycardic. Repeat CT abdomen [12-2] showed persistent high grade SBO in same location, getting worse with larger loops of bowel. Surgery came and saw him, and said he was not operable because extremely poor prognosis and surgery would likely kill him. . So his SBO was medically managed with broad spectrum ABx, NGT to suction, Octreotide for secretions, and family was very aware and involved in the grim prognosis. On the night of [12-4] he again flashed, got more hypoxic and required NRB mask, and was diuresed. At this point, in discussion with family, especially [Doctor First Name ] his wife, it became more and more apparent that the pt was dwindling further, and spiraling towards CMO. Broad spectrum ABx were stopped on [12-5], Morphine was given more liberally. . Patient was discharged to a skilled nursing facilty with comfort measures only. Prior to discharge his pain was well controlled with concentrated oral morphine [9-27] mL Q2H:PRN pain and air hunger. additionally he recieved 8 mg Ondansetron ODT Q8H:PRN for nausea and Ativan 0.5-1 mg PO Q2H:PRN anxiety, nausea or air hunger. His SBO was not active at the time of discharge, but earlier in his course his secretions and symptoms were well controlled with SC ondansetron TID. . TRANSITIONAL ISSUES: -The patient is CMO and is not to be readmitted to the hospital. -Would recomend sub cutaneous octreotide if bowel obstruction symptoms worsen -Patient stable on Oral morphine, ativan and zofran PRN for symptom management as above. Medications on Admission: Latanoprost 0.005 % Ophthalmic Drops Furosemide 20 mg daily Tramadol 50 mg q6h Lisinopril 40 mg daily Carvedilol 25 mg [Hospital1 ] Brimonidine 0.2 % Ophthalmic Drops [Hospital1 ] Amlodipine 5 mg daily Niacin (SLO-NIACIN) 500 mg [Hospital1 ] ERGOCALCIFEROL (VITAMIN D ORAL) once a day FISH OIL CONCENTRATE 1,000 MG TID CENTRUM SILVER TAB (MULTIVITAMINS W-MINERALS/LUT) daily ativan 0.5mg QID:PRN nausea Discharge Medications: 1. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:7 Tablet, Rapid Dissolve(s) Refills:5 2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: [9-27] mL PO Q2H (every 2 hours) as needed for pain. Disp:500 mL Refills:5 3. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for anxiety/air hunger. Disp:20 Tablet(s) Refills:5 Discharge Disposition: Extended Care Facility: Guardian [Name (NI) ] Discharge Diagnosis: GIB s/p colectomy and colostomy Demand related NSTEMI Severe 3 vessel coronary artery disease Flash pulmonay edema Fevers Leukocytosis Sinus tachycardia Small bowel obstruction Discharge Condition: Comfort measures only Discharge Instructions: Mr. [Known lastname ], It was a pleasure to care for you while you were admitted to [Hospital1 18]. You were admitted after having evidence of a GI bleed. You underwent a surgery to remove part of your colon and had a colostomy afterwards. Your postoperateive course was complicated by a stress-related heart attack, fluid in your lungs causing low oxygen levels, fevers, a high white blood cell count, a fast heart rate. You had a cardiac catheterization that showed diffuse severe coronary artery disease but you were felt to be too high risk for interventions at this time, so your heart attack was treated medically. After the catheterization, you also had evidence of a small bowel obstruction, for which you were given broad spectrum antibiotics and were watched. This did not end up resolving, and our surgery colleagues felt you to be extremely high risk for surgery, and that it could kill you. Therefore, we treated you medically for the bowel obstruction as well, but unfortunately this did not improve either. In conjunction with your family, we have decided to focus on your comfort at this point. The following changes were made to your medication regimen: STOP the following medications: Latanoprost 0.005 % Ophthalmic Drops instill 1 drop to each eye AT BEDTIME (IC: FOR XALATAN) Furosemide 20 mg Oral Tablet take 1 tablet a day or as directed Tramadol 50 mg Oral Tablet take 1 tablet up to every 6 hours as needed for pain Lisinopril 40 mg Oral Tablet take one tablet daily. Carvedilol 25 mg Oral Tablet TAKE 1 TABLET TWICE A DAY Brimonidine 0.2 % Ophthalmic Drops instill 1 drop into both eyes twice daily Amlodipine 5 mg Oral Tablet take one tablet a day Niacin (SLO-NIACIN) 500 mg Oral Tablet Extended Release 1 tablet twice daily (OTC) ERGOCALCIFEROL (VITAMIN D ORAL) once a day FISH OIL CONCENTRATE 1,000 MG CAP (OMEGA-3 FATTY ACIDS) Aim for 3000mg omega-3 (EPA + DHA) per day (for example, as 1000mg three times daily) CENTRUM SILVER TAB (MULTIVITAMINS W-MINERALS/LUT) once a day ativan 0.5mg QID:PRN nausea START the following medications: -Concentrated morphine liquid [9-27] mL every 2 hours as needed for pain and air hunger -Ativan 0.5-1 mg every 2 hours as needed for anxiety and air hunger -Zofran ODT 8 mg every 8 hours as needed for nausea Followup Instructions: please follow up with your primary care doctor as needed	[ "250.42", "997.1", "202.80", "583.81", "458.0", "V10.86", "441.4", "070.54", "428.0", "274.01", "414.01", "560.89", "E933.1", "410.71", "V49.86", "428.23", "998.59", "E934.8", "997.49", "041.49", "425.4", "E878.8", "562.13", "401.9", "427.89", "998.13", "V58.67", "V66.7" ]	icd9cm	[ [ [] ] ]	[ "45.75", "38.97", "37.23", "46.10", "99.15", "45.25", "81.91", "88.56", "48.23" ]	icd9pcs	[ [ [] ] ]	20873, 20925	15351, 19681	349, 519	21146, 21170	8494, 8494	23504, 23564	6973, 6990		20403, 20850		20946, 21125		19963, 20380		14144, 15328	21194, 23481									7005, 7005													7863, 8475			19702, 19937							282, 311						547, 4739					8510, 14127			7019, 7849							6145, 6759	6775, 6957
61,441	192,049	36377	Discharge summary	report	Admission Date: [2157-8-12] Discharge Date: [2157-8-16] Date of Birth: [2091-12-19] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2569] Chief Complaint: incomprehensible speech Major Surgical or Invasive Procedure: IV TPA at outside Hospital History of Present Illness: Mr. [Known lastname 82426] is a 65 y/o LHM with PMH of HTN, HL, AFib not on coumadin since cardioversion, who presented from [Hospital ]Hospital following IV tPA for acute onset "garbled speech". According to his wife, he had felt unwell the day prior to presentation but could not be more specific. He was last seen well between 4-4:30 PM at a friends weekly [Name2 (NI) 82427] when he was noted to have garbled speech as well as shaking in his extremities. There was no LOC, or any asymmetry to the extremity shaking. The friend asked him if he was drunk and took away his keys when the patient tried to leave, calling 911. The wife noted him in the [Name (NI) ] to be slightly "excited" unlike himself and not making any sense- she describes language as misarticulations, confusion with words and loud volume. At the OSH, a telestroke consult was done by Dr. [First Name (STitle) 3234]; examination at that time revealed an aphasia as well as leg drift (not documented which side). A NCHCT showed a subacute infarction in the right posterior insular cortex as well as a possible M3 thrombus. The patient received IV tPA at 19:25 PM and then was transferred here for evaluation for possible neurointervention. En route he reportedly became very agitated and had a large amount of fecal incontinence. Past Medical History: -HTN -HL -AFib not on coumadin, s/p cardioversion 1 year prior -?peripheral neuropathy with tremulousness, gait disorder for which he sees Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital3 ], who did not feel he had PD Social History: married, lives at home with wife in [Name (NI) ], works as director of bank and mortgages. Smoker, unknown amount for 50 years, unknown alcohol intake though possible more than patient admits (per wife). 2 children- 1 daughter and 1 son. Family History: Father had severe PD, died in late 70s, mother had CHF and may have had a stroke, died at 80. 3 sisters- alive and healthy. Physical Exam: VS-HR-68, B.P-14/98, RR-16, O2 sats-98%RA GPE: moderately built and nourished elderly male agitated, but NAD. HEENT: atraumatic, normocephalic CVS: RRR, no m/r/g or carotid bruits. Pulm: CTAB Abdomen: soft, NT/ND Extremities: no edema, well perfused Neurological examination: Mental status: awake, alert and agitated. Unable to answer any questions but follows midline and some appendicular commands but inconsistently. He had a severe fluent aphasia with nonsensical speech and neologisms. He was unable to name any pictures on the stroke card and kept saying the word "diesel", he was able to read some sentences with several semantic paraphasic errors. He was able to describe the cookie jar picture to some degree with paraphasic errors. He was able to write his name correctly. Cranial nerves: PERRLA 3-2mm bilaterally, VFFTC, EOMI, facial sensations intact and face appears grossly symmetric, hearing intact to conversational stimuli. Tongue protrudes midline, palate elevates symmetrically and there is no dysarthria. Chin strength and shoulder shrug normal. Motor: Bulk and tone are normal. Strength appears full in all four extremities, though individual muscle testing was challenging due to aphasia. Reflexes: 2+ throughout with mute plantar responses bilaterally. Pertinent Results: [2157-8-12] 10:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [2157-8-12] 10:15PM URINE RBC-1 WBC-16* BACTERIA-FEW YEAST-NONE EPI-0 [2157-8-12] 08:39PM UREA N-17 [2157-8-12] 08:39PM PT-13.7* PTT-31.2 INR(PT)-1.3* [2157-8-12] 08:39PM WBC-13.7* RBC-5.09 HGB-16.9 HCT-50.7 MCV-100* MCH-33.1* MCHC-33.3 RDW-14.1 [2157-8-12] 08:30PM estGFR-Using this [2157-8-12] 08:30PM CREAT-0.8 CT/CTA/CTP: NON-CONTRAST HEAD CT: There is an ill-defined area of hypodensity extending from the right posterior insula superiorly into the right parietal lobe. There is a smaller ill-defined area of hypodensity in the left posterior insula, and another small area of subcortical hypodensity in the left parietal lobe (image 2:25). There is mild subcortical hyperdensity in the right post-central gyrus (image 2:33), suggesting blood products. There is no significant mass effect. There is no shift of midline structures. There is mild cerebral atrophy with mild prominence of the sylvian fissures and biparietal sulci. The ventricles are normal in size for age. There is a small mucus retention cyst in the left maxillary sinus. There is an opacified left posterior ethmoid air cell. CT PERFUSION: The CT perfusion study is markedly limited due to the tilt of the patient's head, with resultant apparent asymmetries in the mean transit time and blood volume maps which cannot be interpreted in a meaningful fashion. CTA NECK: There is a three-vessel aortic arch. The cervical common carotid, internal carotid, and vertebral arteries are widely patent without evidence of hemodynamically significant stenoses. There is a small focus of calcified plaque at the origin of the left internal carotid artery. The distal cervical internal carotid arteries measure 3.8 mm in diameter on the right and 3.8 mm in diameter on the left. Emphysema is noted in the imaged upper lungs with paraseptal bullae. There is nodularity within the thyroid gland, with the largest discrete nodule on the right measuring 9 mm. CTA HEAD [8-12]: There is mild calcified plaque in the cavernous and supraclinoid internal carotid arteries bilaterally. There is a sharp cutoff in an inferior division branch of the right middle cerebral artery (images 500b:20 and 4:322). No evidence of occlusion or stenosis is seen in the posterior circulation. There is no evidence for an intracranial aneurysm. EEG: This is a normal waking and drowsy EEG. There is frequent blinking of eyes during the study, but no epileptiform discharges are seen in association with the blinking. No focal abnormalities or epileptiform discharges are present at any point. If clinically indicated, repeat EEG with sleep recording may provide additional information. MRI: Evolving acute infarctions in the posterior insula and inferior parietal lobes bilaterally, as well as medial temporal lobes. Stable extent of hemorrhagic transformation in the right postcentral gyrus. CT head [8-14]: Unchanged right post-central gyrus intra-axial hemorrhage since [2157-8-12]. No new hemorrhage. Echo:Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Dilated thoracic aorta. No definite structural cardiac source of embolism identified. Brief Hospital Course: 65 yo LHM h/o HTN,HL,AFib not on coumadin feeling unwell since yesterday presents with acute onset garbled speech and head CT from OSH showing subacute RMCA territory posterior insular cortex hypodensity, consistent with ischemic stroke. He received full dose of IV tPA at the OSH and was transferred here for further management. CTA H&N did not reveal significant vessel occlusion and the patient did not have any motor deficit, hence he was not considered a candidate for endovascular intervention NEURO: Mr [Known lastname 82426] was admitted to the ICU for post tPA monitoring. He remained stable overnight and CT the following day which showed a small but stable hemorrhage in the right post central gyrus. The follow morning the patient's language had improved so that he was able to express himself though still with frequent neologisms and phonetic replacements. He also had a notably elevated mood and would frequently interrupt the examiners. He was transferred to the floor and continued to show improvement in his language. At this time his wife noted that his personality was very different, more energetic and happy. He had an echocardiogram which showed no cardioembolic source. He was monitored on telemetry and remained in normal sinus rhythm. MRI showed posterior insula and inferior parietal lobes bilaterally, as well as medial temporal lobes. Given the initial reports or shaking the patient underwent EEG which showed no signs of seizure. When the patient was able to contribute to the history he reported that he had a baseline tremor that was likely the source of this report. Given the location of the stroke and the history of atrial fibrillation it is most likely that the stroke was due to embolus. The patient was therefore started on coumadin. He was seen by OT and speech and language and was discharged home with no services. 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 55 ) - () No 5. Intensive statin therapy administered? (for LDL > 100) () Yes - (x) No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? unknown () Yes - () No (Reason () non-smoker - () unable to participate) 7. Stroke education given? (x) Yes - () No 8. Assessment for rehabilitation? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? (x) Yes (Type: () Antiplatelet - (x) Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PCP. 1. FoLIC Acid 800 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Metoprolol Tartrate 50 mg PO BID 4. Flecainide Acetate 75 mg PO Q12H 5. Caduet NF (amlodipine-atorvastatin) 5-40 mg Oral daily Discharge Medications: 1. Lisinopril 10 mg PO DAILY RX lisinopril 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Enoxaparin Sodium 80 mg SC Q12H RX enoxaparin 80 mg/0.8 mL inject subcutaneously every twelve (12) hours Disp #10 Syringe Refills:0 3. Warfarin 5 mg PO DAILY16 RX Coumadin 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. FoLIC Acid 800 mg PO DAILY 5. Flecainide Acetate 75 mg PO Q 24H 6. Atorvastatin 40 mg PO DAILY RX atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Outpatient Speech/Swallowing Therapy dx: stroke Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Bilateral insular cortex and inferior parietal lob infarct Discharge Condition: alert and oriented. elevated mood, somewhat impulsive an uninhibited. Mild anomia, no dysarthria, no naming difficulty. Has occassional paraphasic errors that he now corrects himself. Strength, coordination and gait fully intact. Discharge Instructions: Dear Mr. [Known lastname 82426], You were admitted for a stroke. This was thought to be secondary to your atrial fibrillation. Your echocardiogram showed no cardioembolic source. THere was a mildly dilated thoracic aorta. You were started back on coumadin for stroke protection. Your stroke risk factors were checked. You should continue to not smoke. Your LDL cholesterol was 55. You were continued on statin. You were checked for blood glucose control with a HgB A1c. The level was 5.3 which is normal. You need to continue your blood pressure control. You should continue to eat a low fat healthy diet, and follow up with your primary care physician and stroke Neurology. It was a pleasure taking care of you. Followup Instructions: Please Follow up with Dr. [Last Name (STitle) ] for INR checks Please See Dr. [First Name (STitle) ] on [10-17] at 2:30. [Hospital Ward Name 23] Building [Location (un) ]. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575]	[ "272.4", "784.69", "401.9", "305.1", "427.31", "434.11", "V45.88", "781.0", "784.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10715, 10764	7068, 9783	330, 359	10867, 11099	3706, 4210	11880, 12187	2266, 2391		10119, 10692		10785, 10846		9809, 10096			11123, 11857									2406, 2683																							267, 292						387, 1710	3207, 3687			4220, 7045					2698, 3191						1732, 1990	2006, 2250
16,257	104,350	46397	Discharge summary	report	Admission Date: [2189-10-19] Discharge Date: [2189-10-23] Date of Birth: [2126-9-25] Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6157] Chief Complaint: 63 yo female with 2cm R upper pole renal mass found on CT. Major Surgical or Invasive Procedure: Partial right nephrectomy History of Present Illness: 63F w/ Hx B breast CA s/p surgery/chemo/XRT and chronic anemia, with 2cm R upper pole renal mass found on CT A/P obtained for persistent anemia and elevated AFP. Percutaneous Bx not possible due to proximity to lung. Past Medical History: 1) L breast CA treated with lumpectomy, chemotherapy, and XRT. 2) subsequent R breast CA [2188] treated with RT. 3) anemia 4) pleurisy 5) HTN Social History: Nonsmoker. 1 cup caffeinated products per day. 2 cups of wine per day. Family History: No family history of kidney cancer. Physical Exam: HEENT: No supraclavicular lymphadenopathy. No carotid bruits. Heart: RRR. Chest: CTAB ABD: Soft, nontender. No palpable mass or suprapubic discomfort Extrem: No C/C/E. Pertinent Results: [2189-10-22] 07:20AM BLOOD WBC-8.6 RBC-2.76* Hgb-9.5* Hct-28.2* MCV-102* MCH-34.3* MCHC-33.5 RDW-21.1* Plt Ct-175 [2189-10-21] 05:05AM BLOOD WBC-8.3 RBC-2.84# Hgb-9.7# Hct-28.1* MCV-99# MCH-34.2 MCHC-34.6 RDW-21.8* Plt Ct-157 [2189-10-20] 08:10PM BLOOD Hct-30.2# [2189-10-20] 12:20PM BLOOD WBC-7.5 RBC-1.88 Hgb-6.7* Hct-21.3* MCV-113* MCH-35.8* MCHC-31.7 RDW-16.5* Plt Ct-178 [2189-10-20] 06:40AM BLOOD WBC-7.6 RBC-2.03* Hgb-7.4* Hct-22.5* MCV-111* MCH-36.5* MCHC-33.0 RDW-16.2* Plt Ct-215 [2189-10-19] 05:47PM BLOOD Hct-25.1* [2189-10-19] 12:54PM BLOOD WBC-9.2 RBC-2.12* Hgb-8.0* Hct-23.5* MCV-111* MCH-37.9* MCHC-34.3 RDW-16.4* Plt Ct-223 [2189-10-22] 07:20AM BLOOD Plt Ct-175 [2189-10-21] 05:05AM BLOOD Plt Ct-157 [2189-10-20] 12:20PM BLOOD Plt Ct-178 [2189-10-20] 12:20PM BLOOD PT-11.0 PTT-28.9 INR(PT)-0.9 [2189-10-20] 06:40AM BLOOD Plt Ct-215 [2189-10-19] 12:54PM BLOOD Plt Ct-223 [2189-10-19] 12:54PM BLOOD PT-13.6* PTT-32.2 INR(PT)-1.2* [2189-10-22] 07:20AM BLOOD Glucose-129* UreaN-18 Creat-1.4* Na-130* K-3.6 Cl-102 HCO3-22 AnGap-10 [2189-10-21] 05:05AM BLOOD Glucose-119* UreaN-19 Creat-1.5* Na-130* K-4.5 Cl-101 HCO3-19* AnGap-15 [2189-10-20] 08:10PM BLOOD Glucose-124* UreaN-19 Creat-1.6* Na-131* K-4.8 Cl-100 HCO3-20* AnGap-16 [2189-10-20] 12:20PM BLOOD Glucose-147* UreaN-20 Creat-1.7* Na-131* K-5.9* Cl-103 HCO3-20* AnGap-14 [2189-10-20] 06:40AM BLOOD Glucose-156* UreaN-20 Creat-1.6* Na-129* K-5.4* Cl-101 HCO3-21* AnGap-12 [2189-10-19] 12:54PM BLOOD Glucose-137* UreaN-17 Creat-1.2* Na-131* K-3.8 Cl-99 HCO3-16* AnGap-20 [2189-10-22] 07:20AM BLOOD Calcium-8.2* Mg-1.6 [2189-10-21] 05:05AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.5* [2189-10-20] 08:10PM BLOOD Calcium-7.8* Phos-3.7 Mg-1.7 [2189-10-20] 12:20PM BLOOD Calcium-7.1* Mg-1.7 [2189-10-20] 06:40AM BLOOD Calcium-7.4* Mg-1.8 [2189-10-19] 05:47PM BLOOD Mg-2.1 [2189-10-19] 12:54PM BLOOD Calcium-7.8* Mg-0.9* [2189-10-19] 11:03AM BLOOD Type-ART pO2-215* pCO2-36 pH-7.30* calTCO2-18* Base XS--7 Intubat-INTUBATED Vent-CONTROLLED [2189-10-19] 09:53AM BLOOD Type-ART Rates-7/ Tidal V-550 pO2-213* pCO2-43 pH-7.29* calTCO2-22 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [2189-10-19] 11:03AM BLOOD Glucose-117* Lactate-5.3* Na-130* K-3.6 Cl-100 [2189-10-19] 09:53AM BLOOD Glucose-135* Lactate-4.1* Na-134* K-3.8 Cl-100 [2189-10-19] 11:03AM BLOOD Hgb-7.9* calcHCT-24 [2189-10-19] 09:53AM BLOOD Hgb-9.4* calcHCT-28 [2189-10-19] 11:03AM BLOOD freeCa-1.05* [2189-10-19] 09:53AM BLOOD freeCa-1.10* [2189-10-22] 09:25AM OTHER BODY FLUID Creat-1.3 Cardiology Report ECG Study Date of [2189-10-20] 11:57:28 AM Baseline artifact Sinus rhythm Probably normal ECG Since previous tracing of [2189-10-7], T waves less prominent Read by: [Last Name (LF) ],[First Name3 (LF) 177] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 84 192 92 [Telephone/Fax (2) 98576] 21 36 RADIOLOGY Final Report CHEST (PORTABLE AP) [2189-10-19] 2:02 PM CHEST (PORTABLE AP) Reason: R/o PTX. Thank you. [Hospital 93] MEDICAL CONDITION: 63F s/p R partial nephrectomy for incidental R upper pole renal mass. REASON FOR THIS EXAMINATION: R/o PTX. Thank you. CHEST RADIOGRAPH INDICATION: 63-year-old female, status post partial nephrectomy. COMPARISON: Radiograph of the chest dated [2189-10-7]. FINDINGS: Single AP view of the chest demonstrates interval placement of the endotracheal tube with its tip projecting 6 cm above the carina. An oval- shaped opacity in the left upper chest is seen, most likely represents an external overlying device. Clinical correlation is suggested. There is minimal amount of pleural effusion, bilaterally. No evidence of focal areas of parenchymal consolidation. No evidence of pneumothorax. The images of the upper abdomen demonstrate small pneumoperitoneum, consistent with recent surgery. IMPRESSION: 1. Interval placement of an endotracheal tube. 2. Small pneumoperitoneum consistent with recent abdominal surgery. 3. No evidence of pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17726] DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Approved: TUE [2189-10-20] 7:58 AM Brief Hospital Course: POD0 ([2189-10-19]): Patient underwent R upper pole partial nephrectomy with clear surgical margins. 3.5 L of crystalloid were given with 170 cc of urine produced. EBL was 250 cc. She was extubated in the ICU and transferred to the floor. Orders were placed for 24 hours of cefazolin. On postoperative exam, some tremulousness was noted. She was AOx3. Hematocrit was noted to be 23.5 with INR of 1.2 and PT of 13.6. Her JP drain was draining appropriately. POD1: Patient experienced hypotension and anxiety, which prompted transfer to the [Hospital Unit Name 153]. Etiology appeared to be related to a combination of chronic anemia; epidural; and inadequate fluid recussitation. She was transfused with 2 units of packed RBCs and began to feel better in the evening. She began sips in the evening. POD2: Epidural was D/C'ed early in the morning. Her condition was noted to be stable, and so she was transferred back to the floor. She was noted to be hyperkalemic and was treated with kayexalate. She scored 0-1 on the CIWA scale. Patient tolerated clear fluids in the evening [10-22]: Patient complained of some pain and was begun on oral dilaudid. She noted less weakness. On examination, heart was RRR with no M/R/G. Lungs were CTAB. Her Foley catheter was draining slightly turbid fluid. Wound was clean, dry, an d intact. Her JP drained serosanguinous fluid on the order of 160 cc. IV access was heparin locked. She resumed her oral medication regimen. Medications on Admission: diovan, lopressor, femara, folate, B12, procrit 40K qFri Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:60 Capsule(s) Refills:0 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: do not take alcohol with this medication. Do not take more than 4 grams of tylenol with this medication. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Right upper pole kidney mass Discharge Condition: Good Discharge Instructions: You are safe to go home at this time. 1) [Name6 (MD) ] your MD or report to the emergency room if you have a fever >101.5, chest pain, shortness of breath, bleeding, collapse, or anything that concerns you. 2) It is important that you follow up with Dr. [Last Name (STitle) 4229] 3) Do not drink alcohol or drive while taking the pain medication. It is important that you take the stool softener while taking the pain medication. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[0-0-] Date/Time:[2189-11-5] 10:00 Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 6733] Date/Time:[2189-12-3] 9:45 Follow up with Dr. [Last Name (STitle) 4229] in [3-13] weeks. Completed by:[2189-10-23]	[ "276.7", "223.0", "276.52", "585.9", "285.1", "401.9", "V10.3" ]	icd9cm	[ [ [] ] ]	[ "99.04", "55.4" ]	icd9pcs	[ [ [] ] ]	7567, 7573	5552, 7022	375, 403	7646, 7653	1163, 4283	8142, 8558	923, 960		7129, 7544	4320, 4390	7594, 7625		7048, 7106			7677, 8119									975, 1144																							277, 337	4419, 5529					431, 650															672, 819	835, 907
75,193	177,204	1784	Discharge summary	report	Admission Date: [2190-8-16] Discharge Date: [2190-8-20] Date of Birth: [2111-5-18] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2745] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: EGD History of Present Illness: This is a 79 year-old female with h/o hypothyroidism, CVA in [2186], HTN, hyperlipidemia who presents with weakness, palpitations, and feeling presyncopal when upright. She reports weight loss over last few months, dropping two dress sizes since [Month (only) 116], with minimal PO intake over the past few days. She denies diarrhea, BRBPR, fevers, chills, SOB, chest pain. She has no history of colonoscopy. . In the ED, VS T 97.2 BP 108/44 HR 74 RR 16 POx 100% on RA. Orthostatics positive by HR and BP dropping to 84/36 on standing. Guaiac positive stool in ED. NG leavage negative. Patient received 2 units FFP, 2 units PRBCs, 10mg po and 1mg IV vitamin K, IV Protonix, and 1500cc NS. GI contact[Name (NI) ] in the [Name (NI) ] with plan for colonscopy/EGD when INR reversed. 2 large bore IVs placed. . ROS: The patient denies any fevers, chills, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: B12 Deficiency Hypertension Hyperlipidemia S/P CVA [2186] without residual deficits Hypothyroidism Cataract surgery [2188] Social History: lives w/husband in [Name (NI) 10059]. Denies etoh, tobacco, drugs. Retired flight attendant. Family History: CAD in parents, sibling. [Name (NI) 10060] mom, sister. Physical Exam: Vitals: T: 98.5 BP: 108/54 HR:77 RR:18 O2Sat: 100% on RA GEN: Pale, in no acute distress HEENT: NCAT, EOMI, PERRL, sclera anicteric, conj pallor, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses, no rebound or guarding EXT: No C/C/E NEURO: A&Ox3. Interactive and appropriate. SKIN: No jaundice, cyanosis. No ecchymoses. Dry, cracked skin throughout. Pertinent Results: [2190-8-16] 11:50AM PT-25.2* PTT-26.1 INR(PT)-2.5* [2190-8-16] 11:50AM PLT COUNT-342 [2190-8-16] 11:50AM NEUTS-77.5* LYMPHS-17.7* MONOS-3.9 EOS-0.6 BASOS-0.3 [2190-8-16] 11:50AM WBC-11.4* RBC-1.92# HGB-6.0# HCT-17.7# MCV-92 MCH-31.4 MCHC-34.0 RDW-17.1 [2190-8-16] 11:50AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.8 [2190-8-16] 11:50AM CK-MB-NotDone [2190-8-16] 11:50AM cTropnT-<0.01 [2190-8-16] 11:50AM LIPASE-66* [2190-8-16] 11:50AM ALT(SGPT)-22 AST(SGOT)-30 CK(CPK)-50 ALK PHOS-53 TOT BILI-0.3 [2190-8-16] 11:50AM estGFR-Using this [2190-8-16] 11:50AM GLUCOSE-104 UREA N-43* CREAT-1.2* SODIUM-140 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12 [2190-8-16] 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2190-8-16] 01:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2190-8-17] CT abd/pelvis) IMPRESSION: 1. Large infiltrative mass arising from the lesser curvature of the stomach, with possible invasion of the left hepatic lobe and pancreas - findings are consistent with extensive gastric malignancy. There is also omental caking and intra- abdominal fluid consistent with intraperitoneal metastases. 2. Multiple large gallstones within a non-distended gallbladder. 3. Prominence of the CBD with mild intrahepatic biliary ductal dilatation, without definite distal CBD obstruction. Clinical correlation is recommended. 4. Small bilateral pleural effusions. [8-17] Pathology: Stomach mass biopsy: 1. Adenocarcinoma, diffuse cell type. 2. Immunostains of the tumor are positive for cytokeratin cocktail and focally positive for CD68 with satisfactory controls. 3. Special stains (PAS-D and mucicarmine) of the tumor cells are faintly positive for mucin. 4. Chronic mildly active inflammation of the adjacent mucosa. [Doctor Last Name 6311] stain is negative for H. pylori, with satisfactory control. Brief Hospital Course: This is a 79 year-old female with a history of HTN, embolic CVA on coumadin, hypothyroidism who presented with weakness, palpitations, orthostasis and unintentional weight loss found to have +guaiac stools and HCT of 17 in ED. Patient with very low hematocrit, elevated INR of 2.5 on admission and blood in her stool raised initial concern of active GI bleeding, possibly due to undiagnosed malignancy. The patient was transfused 4 units PRBC in ICU and underwent upper endoscopy revealing large gastric adenocarcinoma with CT revealing evidence of likely metastatic spread to left hepatic lobe, pancreas and omental caking. # Metastatic gastric adenocarcinoma) The patient was seen by the GI, oncology, radiation oncology and palliative care services. The patient repetedly stated that she did not any aggressive interventions. She did not want IR embolization if she had a rapid GI bleed. She is not currently a candidate for palliative radiation XRT per radiation oncology. She will f/u with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4149] of palliative care. She did not want hospice at this time. # Anemia of acute blood loss) Stable after PRBC transfusions. # Palpitations: Patient currently without palpitations, issue appears to have resolved. Likely initially secondary to hypotension and orthostasis given poor PO intake. Unlikely to be hyperthyroid given elevated TSH. Troponins negative x2. # Hypotension: Patient currently normotensive (resolved) # CVA: Embolic CVA in [2186], on coumadin. INR 2.5 on admission which is within goal range, however in setting of significant GI bleed from her gastric cancer permanently discontinued her coumadin and aspirin. # Hypertension: patient on atenolol and hctz as outpatient. Restarted on discharge. . # Hyperlipidemia: - continue home statin . # Hypothyroidism: Patient has been on levothyroxine for some time. TSH 7 which is slightly elevated. appears that patient on 100 of levothroxyine at home 6 times a week, will change to daily in the setting of elevated TSH, would also consider uptitration of medication -cont levothyroxine as above Medications on Admission: Coumadin 5 mg qd except 2.5 mg on Sunday atenolol 50mg PO qd HCTZ 25mg po qd atorvastatin 40mg PO qd levothyroxine 100mcg PO 1tab qd 6d/week ASA 81mg PO qd folic acid .4mg PO qd cyanocobalamin 1,000mcg/ml sln, 1cc every other mo. Ca-citrate+ vitamin D+ Mag (OTC) Omega 3 fatty acid (OTC) Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO every other month: OF NOTE, PATIENT WAS receiving cyanocobalamin 1000 mcg/ml sln every other month. 7. omega three Sig: One (1) tab once a day: take per home dose. 8. Calcium Citrate + D with Mag 250-40-5-125 mg-mg-mg-unit Tablet Sig: One (1) Tablet PO once a day: take per prior home dosing. Discharge Disposition: Home Discharge Diagnosis: Metastatic Gastric Adenocarcinoma GI Bleed Anemia, Acute Blood Loss Discharge Condition: Vital Signs Stable Discharge Instructions: Return to Emergency Department if having active bright red blood from the rectum, dizziness, abdominal pain, protracted nausea and vomitting. Followup Instructions: Patient to arrange f/u appointment with PCP [Last Name (NamePattern4) ] 2 week Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 4775]. Patient to f/u with palliative care [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4149]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10061] office to call patient with appointment.	[ "151.8", "244.9", "574.20", "458.0", "272.4", "266.2", "197.8", "197.7", "197.6", "276.52", "285.1", "578.9", "V58.61", "401.9" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.16", "99.07" ]	icd9pcs	[ [ [] ] ]	7628, 7634	4439, 6578	328, 333	7745, 7765	2412, 4416	7955, 8364	1793, 1854		6919, 7605		7655, 7724		6604, 6896			7789, 7932									1869, 2393																							276, 290						361, 1508															1530, 1663	1679, 1777
11,993	195,428	51472	Discharge summary	report	Admission Date: [2185-4-23] Discharge Date: [2185-6-2] Date of Birth: [2116-4-8] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 783] Chief Complaint: Left-sided shaking Major Surgical or Invasive Procedure: Intubation History of Present Illness: 69 yo male with h/o AAA s/p repair, mesenteric ischemia s/p resection, CAD, HTN, PVD, CRI who presented to [Hospital1 18] from rehab with seizures. He was intubated, admitted to ICU, and controlled on VPA, dilantin, phenobarbitol and keppra. He had a prolonged intubation, and had a tracheostomy performed on [2185-5-11]. He has been on nuerology service for propofol induce coma for focal motor status epilepticus presumably due to right hemisphere cortical infarcts. His admission has been highlighted by intubation, tracheostomy, and successful placement of PMV, pneumonia, UTI, GPC bacteremia. . He started becoming hyponatremic around [5-17]. His sodium was normal on admission, and was stable until this time. Since then, it has slowly drifted down to 124. His other electrolytes, including renal function, has been stable during this time. He started with tube feeds on [2185-4-24]. His initial free water flushes were 30ml q 6 hours. On [2185-5-17] his free water flushes were increased to 100ml q 4 hours. On [2185-5-23] his free water flushes were decreased to 100mg q 6 hours. Today, [2185-5-25], his free water flushes were decreased to 50mg q 6 hours. Serum osm were 276 on [2185-5-17]. Urine sodium on [2185-5-18] was 71. Urine osm on [2185-5-18] were 292. Subsequent urine osm 400s [5-23]. . He has also been anemic during this admission. He was admitted with a hct of 45% last admission, and it has been mostly in the mid 20's to mid 30's since that time. It has gotten as low as 19.9% on [2185-5-11]. He has been transfused 2 units [2185-5-3], two units on [2185-5-11], and 1 unit on [2185-5-15]. Per report, he has been having diarrhea, and is guaiac positive, though no clear melena. He has never had a scope in our system. He has not had any iron studies during this admission. . He has had several infectious issues, he was treated with meropenem from [5-3] to [5-13] for resistant E. coli UTI and pneumonia. He has had several negative c.diff cultures, and was treated with flagyl empirically for several days. This has been stopped. On [5-23] he was started on cipro for an e.coli UTI (found [5-27] to be cipro resistent), and on [5-25] he was started on vanco for coag. negative staph in [3-13] blood culture bottles. . Review of Systems: Currently, he only c/o headache, frustration at not being able to get out of bed, unable to speak w/o PMV. Past Medical History: Hyperlipidemia HTN Embolic stroke in 10/97 with 7 since then (most recent [11-11]) CAD/MI x 3 AAA - infrarenal 4.8cm s/p repair PVD CRI CHF (depressed EF) Afib s/p ablation [12-10] SDH fall in [10-15] Right fem [Doctor Last Name ] in situ (93) s/p Left fem [Doctor Last Name ] in situ (93) Vein angioplasty of left femoral artery 01 ERCP stent [84] Hearing impairment Ischemic bowel s/p SB resection [4-16] EtOH abuse Social History: Heavy drinker, 1ppd tobacco, used to work as a lawyer (real estate property) and retired in his 50s Family History: NC Physical Exam: Admission Physical Exam: T Afebrile; BP 110/67 . General: intubated, sedated HEENT: NCAT, moist mucous membranes Neck: supple, no carotid bruit Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Carotids: no blood flow murmur Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. . Neurological Exam: Mental status: intubated sedated, not responding to verbal stimuli. . Cranial Nerves: PERRL, 4-->2mm with light. blinks to threat. face symmetric. + VOR. . Motor/[Last Name (un) ] does not withdraw to painful stimuli. . Reflexes: Bic T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes upngoing bilaterally. . Physical exam on transfer to medicine service: . Vs- 98.3 82 110/46 15 100% (40% TM) FS 140 Gen- Elderly, frail appearing male lying in bed with trach collar on, PMV not in place, NAD Heent- MM dry, anicteric, no oral lesions, EOMI, PERRL Neck- JVP flat, tracheostomy site C/D/I, supple CV- RRR, no M/R/G appreciated, though loud sounds from trach mask Chest- Diffuse expiratory wheeze anteriorly, equal Abd- soft, NT, no HSM, Gtube in place without surrounding erythema, pos BS Ext- No edema. Pneumoboots and multipodus boots in place. Neuro- AAO x 2, EOMI, decreased motor strength throughout Skin- Site of former R. subclavian line CDI (line pulled prior to exam), g-tube site CDI. Dry skin. Pertinent Results: Admission Labs: [2185-4-23] 04:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.035 [2185-4-23] 04:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2185-4-23] 04:15PM URINE RBC-[3-14]* WBC-[3-14] BACTERIA-FEW YEAST-NONE EPI-0-2 [2185-4-23] 04:15PM URINE HYALINE-0-2 [2185-4-23] 04:10AM GLUCOSE-100 UREA N-8 CREAT-0.7 SODIUM-138 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-22 ANION GAP-12 [2185-4-23] 04:10AM ALT(SGPT)-10 AST(SGOT)-21 ALK PHOS-82 [2185-4-23] 04:10AM %HbA1c-5.9 [2185-4-23] 04:10AM TRIGLYCER-170* HDL CHOL-28 LDL(CALC)-8 CHOLEST-70 [2185-4-23] 04:10AM PHENYTOIN-6.5* [2185-4-23] 04:10AM WBC-16.9* RBC-2.97* HGB-8.7* HCT-27.4* MCV-92 MCH-29.4 MCHC-31.9 RDW-15.1 PLT COUNT-591* [2185-4-23] 04:10AM PT-12.9 PTT-28.8 INR(PT)-1.1 [2185-4-23] 02:07AM GLUCOSE-86 NA+-137 K+-5.5* CL--109 TCO2-22 [2185-4-23] 02:06AM UREA N-9 CREAT-0.8 [2185-4-23] 02:06AM ALT(SGPT)-13 AST(SGOT)-40 CK(CPK)-131 ALK PHOS-86 TOT BILI-0.5 LIPASE-62* [2185-4-23] 02:06AM CK-MB-3 cTropnT-0.02* [2185-4-23] 02:06AM ALBUMIN-2.4* [2185-4-23] 01:50AM FIBRINOGE-307 . CTA Head and neck and CT perfusion [4-23]: 1. No evidence of intracranial hemorrhage or edema. No asymmetry identified on the CT perfusion study. 2. Atherosclerotic calcifications involving the origins of the great vessels from the aortic arch. Atherosclerotic calcifications at the origins of the vertebral arteries bilaterally and stenosis involving these origins cannot be excluded. 3. No hemodynamically significant stenosis involving the carotid arteries throughout their course bilaterally. 4. Unremarkable CTA of the circle of [Location (un) 431]. . MRI/MRA Head [4-23]: 1. Scattered, tiny foci of diffusion-weighted imaging abnormality involving the cerebral hemispheres and the left thalamus which could represent subacute infarction. 2. Signal dropout involving the supraclinoid right internal carotid artery which is likely secondary to atherosclerotic calcified plaque causing moderate stenosis as seen on the previous CT angiogram. . EEG [4-23]: This is an abnormal EEG in the waking and drowsy states due to the runs of rhythmic slowing in the right central region and posterior quadrant with superimposed sharp waves and persistent intermixed theta and delta slowing. These abnormalities suggest brief electrographic seizures in the right posterior quadrant with evidence of underlying subcortical dysfunction . EEG [4-25]: This telemetry captured six pushbutton activations. Two of those and several of the automated seizure detection segments showed clinical seizures. At baseline, there was high voltage right hemisphere and especially right frontal sharp wave discharges that were not particularly rhythmic but recurred at about 1.5-2 Hz throughout the recording. When these became more rhythmic or when there was still faster activity with spread of slowing to the left, there appeared to be clinical seizures. Many of these clinical seizures were primarily jerking of the left body, but with bilateral EEG changes there was jerking activity on the right, as well. The tracing suggests frequent clinical seizures along with a persistent and active epileptogenic lesion in the right hemisphere, likely anteriorly . CT Chest, Abd, Pelvis [4-25]: 1. Postoperative appearance to the abdomen after small bowel resection. Small inflammatory change with extraluminal gas adjacent to the distal small bowel, which is likely post-surgical change. However, because of the recent ischemic event and persistent small bowel wall thickening, close clinical follow up is recommended. 2. Moderate amount of ascites, small to moderate bilateral pleural effusions with associated atelectasis. Small pericardial effusion. 3. Compression deformities of T11 and L1 vertebral bodies, stable. 4. Patent aorto-biiliac graft. . CT abd/pelvis [2185-5-23]: 1. Postop changes within the abdomen up to small bowel resection. Interval resolution of the extraluminal gas seen adjacent to the distal small bowel with unchanged soft tissue density with few foci of increased density within it, which may represent dystrophic calcification. The surrounding fat stranding is likely represents scarring from postoperative change, attention to this region on followup examinations is recommended. 2. Interval resolution of the small bowel wall thickening seen on prior exam. 3. Patent SMA stent. 4. Interval resolution of bilateral pleural effusions and bibasilar atelectasis with residual sub segmental atelectasis at the right lung base. . TTE [2185-4-29]: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. LV systolic function appears depressed (cannot quantitate); the anterior septum and anterior free appear hypokinetic. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. Suboptimal image quality - patient unable to cooperate. No atrial septal defect seen on bubble study (2 rest injections). . EEG [5-16]: This 24-hour video EEG telemetry captured no electrographic seizures or interictal epileptiform discharges. The background was slow and disorganized throughout the recording representative of a mild to moderate encephalopathy. Compared to the prior day's recording, the degree of encephalopathy appeared slightly less . CXR [2185-5-26]: Tracheostomy tube and [Month/Day/Year 1106] catheter are in standard position. Cardiac and mediastinal contours are within normal limits and unchanged. Lungs remain grossly clear, and no pleural effusions or pneumothoraces are identified on this portable projection. . [2185-6-1] Left hip plain films: Comparison is made to a CT from [2185-5-23]. There are marked arterial [Year (4 digits) 1106] calcifications, as seen previously. There are bilateral degenerative changes at the hip joints with osteophytes but no fracture, dislocation, or bony destruction. IMPRESSION: No evidence of fracture. Brief Hospital Course: The patient presented as a code stroke; tPA was not given due to his recent surgery. He was admitted to the neuro-ICU intubated and loaded on dilantin. He was soon extubated without subsequent respiratory difficulty and continued to be monitored for seizure activity. From [Date range (1) 102156], he had continuous EEG monitoring, which was positive for at least 6 seizures, some of which spread contralaterally, and for right-sided discharges and sharp activity. He was started on keppra 500mg [Hospital1 ] on [4-25], which was increased to 750mg [Hospital1 ] on [4-25], at which point he was transferred to the neurology floor. MRI showed scattered, tiny foci of diffusion-weighted imaging abnormality involving the cerebral hemispheres and the left thalamus which could represent small subacute infarction, but no large territorial infarcts were seen. LP is negative for meningitis. His antihypertensives were initially held, then restarted after stroke was ruled out. His lipid panel was significant for LDL of 8 and lipitor was discontinued (due to malabsorption? poor nutrition?). . Pt. was monitored on the floor from [4-25]- [4-28]. EEG continued to show frequent R sided discharges and he continued to have continuous left arm and leg twitching c/w EPC. Keppra was titrated up to 1500 [Hospital1 ] and Dilantin 300 QD was continued. He was also started on Depakote which was titrated up to 500 TID, Phenobarbital which was titrated up to 100 [Hospital1 ], and Ativan 0.5 Q8. TMS was attempted on [4-28] and [4-29] and was unsucessful at stopping the seizures. Given that all of these intervention, pt. was transferred to the ICU for 48hr burst suppression with propofol on [4-28]. His Keppra was titrated further to [2178] [Hospital1 ], Depakote to 900 mg Q3H, and Dilantin to 55 mg IV Q6H. Propofol was discontinued after 2 days, and discharges on EEG and clinical seizures resolved, although the patient continued to be deeply encephalopathic. Repeat head CT was negative and encephalopathy has improved slowly with discontinuation of phenobarbital. His ICU course was complicated by ESBL E coli PNA/UTI and the patient was treated with a 10-day course of meropenem. . Extensive workup for causes of epilepsia partialis continua was negative (apart from a weakly positive 14-3-3, which can be falsely elevated by acute infarction). The acute infarct seen on MRI was thought to be the cause. . On [5-13], the patient was transferred to the floor for continued treatment. His encephalopathy had lightened with reduction of his anticonvulsant levels and cessation of phenobarbital. His AEDs were weaned over the next week, and eventually Depakote was weaned off, Keppra was weaned down to 1000 mg [Hospital1 ] (level high in 70s on [2178] [Hospital1 ]), Ativan was weaned off, and Phenobarbital was weaned. . Other issues include an elevated PSA and the patient should be seen by urology as an outpatient. . He was transferred to the medicine service on [2185-5-27] for continued management of his multiple medical problems and course is outlined as below: . # UTI: ESBL E. Coli resistent to multiple abx; sensitive to zosyn, meropenem, imipenem, nitrofurantoin. Given his weakness and inability to use urinal on his own at this point and concern for skin breakdown, foley was changed, but maintained in place. At rehab, he should have his foley catheter discontinued as soon as possible for voiding trial as this is the second E. Coli UTI for which he is being treated during this hospitalization. He will need to complete a 14 day course of zosyn last day [2185-6-10]. . # ? Bacteremia: Blood cultures drawn on [2185-5-23] revealed [2-13] sets positive for coagulase negative staph. He was started on vancomycin by the neurology team at that time. Surveillance cultures were not drawn after [5-23] until [5-28] and subsequent daily surveillance cultures have shown NGTD. His right SC line was d/c'd on [5-27] as a possible source. Given [2-13] cultures positive for coagulase negative staph (normal skin flora) it is not entirely clear whether this represents contaminant vs. true bacteremia. Additionally, he developed an absolute eosinophilia while on vancomycin, thus it was felt reasonable to hold the vancomycin and observe clinically and with daily surveillance blood cultures. As his vancomycin was originally supratherapeutic, it took several days to trend downward below therapeutic range, but consistently, surveillance cultures since the original positive have shown no growth thus far. Final cultures should be followed up and his clinical status should be monitored closely in this setting. . # Leukocytosis: With significant eosinophilia as discussed below. Given E. coli UTI and E. coli in sputum (likely representing tracheitis/tracheobronchitis as no clear infiltrate on CXR), WBC count elevation is likely in this setting. Although he does have persistent diarrhea, C. diff has been negative on multiple checks. A C. diff toxin B was sent and is pending and should be followed up on. He is being treated with a 14 day course of zosyn for the above infections. . # Eosinophilia: Absolute eosinophilia (mild noted prior to vancomycin, but significant increase after vanco initiation) with vancomycin initiation although differentials not followed consistently upon initiation. There were no other clear medication causes as absolute eosinophil count had previously been normal when new antiepileptic medications were started. Vancomycin was supratherapeutic upon transfer to medicine service and given not entirely clear whether [5-23] blood cultures represent true infection, vancomycin was held with daily surveillance blood cultures drawn. His renal function remained stable so as not to suggest AIN and he was without rashes. His CBC/diff should be monitored on discharge to assess for resolution of eosinophilia off vancomycin (absolute eosinophilia maxed at 3700 and is 1100 on day of discharge). . # Respiratory secretions: Significant amount of secretions requiring suctioning has been ongoing since trach placement, but have improved significantly (no longer requiring frequent suctioning) following initiation of zosyn. He does, however, have a strong cough and has been able to clear much of these secretions on his own. CXRs did not reveal focal infiltrates to suggest pulmonary infection as cause of increased secretions. Thus, likely tracheitis/tracheobronchitis causing the substantial secretions. His most recent sputum culture showed oral flora as well as ESBL E. coli (sparse growth). As above, he will be treated with a 14 day course to which his infection is susceptible (complete course [2185-6-8]). He has an appointment scheduled with pulmonary medicine at [Hospital1 18] to address his question of trach reversal. He will be discharged on 40% O2 via trach mask with O2 saturation 98-100%. . # Anemia/GI bleed: Baseline hematocrit prior to this extended hospitalization is unknown, but hct reached a low of 20 during this admission in the setting of guaiac + brown stool and he required prbc transfusions during his stay (last on [2185-5-25]). Post transfusion, his hematocrit remained stable in the high 20s to low 30s (29.4 on day of discharge). His anemia is normocytic with elevated RDW. Iron and TIBC low, ferritin normal so certainly element of ACD with iron deficiency. GI evaluated him here and thought GI bleed as well as anemia was multifactorial. He likely has ongoing ischemia given significant h/o ischemic disease and has malabsorption given recent small bowel resection [2-11] to gut ischemia. Also, it was thought that he may have some small amount of oozing from PEG site as this was placed post bowel resection. Given his multiple other medical matters and stable hematocrit, it was decided not to pursue endoscopy/colonoscopy while inpatient, but this should be pursued upon discharge. He has a follow up appointment with gastroenterology at [Hospital1 18] to further discuss his diarrhea and GI bleed as will likely need outpatient scope. . # Diarrhea: C. diff and stool studies were negative on repeat checks. C. diff toxin B was sent and is pending. He has had ongoing diarrhea since his small bowel resection for ischemic gut, but it has been worsened during this stay. As above, her GI evaluated him and thought that much of his diarrhea was secondary to "short gut" and thus malabsorption post resection. Additionally, he may have continued element of ongoing ischemia contributing. Per GI recommendations, he was started on bile acid sequestrant cholestyramine. Tube feeds were originally held as they were thought to be exacerbating his diarrhea, with some improvement while off. Glutamine was started per nutrition's recommendation in the setting of short gut syndrome. They were reinitiated with continued improvement in his diarrhea (please seen FEN section below). As above, C. diff toxin B should be followed up on and if negative, can use loperamide and tincture of opium as written below. . # Hyponatremia: Originally evaluated by medicine consult while on the neurology service for worsening hyponatremia. He had been getting increased free water flushes since [2185-5-17] in an attempt to volume resuscitate him, which likely contributed to his hyponatremia. Of note, he was also on lasix [Hospital1 ] during the entire time, which with free water administration contributed. His renal response to the hyponatremia suggested impaired ability to dilute the urine, with elevated UrOsm. This could suggest SIADH, either from recent surgery/ventilation, less likely from CNS process as his seizures have been well controlled. Free water flushes were changed to normal saline and IV medications were mixed with NS instead of sterile water. He was taken off standing lasix with close monitoring of his fluid status and prn dosing; this should be monitored upon discharge as well. With the above changes, his sodium normalized and has remained stable. . # Weakness: Diffuse and unable to assess focal deficits. Given prolonged MICU course and illness, likely representative of deconditioning and even ICU neuropathy/myopathy although he did not have formal studies including EMG. He does, however, have h/o multiple CVAs, but given no clear focal deficits, seems less likely [2-11] to CVA although possible. He did not have further MRI imaging while here as his weakness, especially in upper extremities, has been improving. . # Seizures: Please see discussion as above per neurology. He has been maintained on keppra alone since transfer out of the ICU without seizure activity while on the floor. His keppra was transitioned from IV dosing to delivery via his PEG. He has follow up with neurology scheduled. . # Left hip pain/low back pain: Onset of left hip pain was after having been moved from bed to chair. Plain films did not reveal dislocation nor fracture. His low back pain is chronic in nature (preceded well before AAA diagnosis and has lasted beyond repair) and has increased with immobility and with transfers from bed to chair. Pain has been well controlled with dilaudid. He should be transitioned off IV pain meds as possible while at rehab. . # FEN: Tube feeds were held briefly as they were thought to be playing a role in his diarrhea. They were then started at half strength and worked back up to full strength. He is still, however, not meeting protein goal at full strenth Vivonex at 80cc/hour. He is receiving glutamine per nutrition recs to aid in absorption in setting of short gut and cholestyramine per GI recommendations for his diarrhea. Speech and swallow should evaluate the patient with trach in place at rehab to assess for ability to supplement tube feeds with PO intake. . # Proph: Venodynes and SC heparin. . # Access: Right subclavian line was removed on [2185-5-27]. He has a right PICC line placed on [2185-5-31]. Foley was last changed on [5-28]. . # Communication: Son is health care proxy [Name (NI) ] [Name (NI) 31365] [Telephone/Fax (1) 106724]. . # Code: FULL (discussed w/ HCP) Medications on Admission: Meds obtained from [2185-4-21] discharge summary: 1. Albuterol 90 mcg/Actuation Aerosol [Month/Day/Year ]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Aspirin 325 mg Tablet [Month/Day/Year ]: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol [Month/Day/Year ]: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 4. Oxycodone-Acetaminophen 5-325 mg Tablet [Month/Day/Year ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Acetaminophen 325 mg Tablet [Month/Day/Year ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Do not exceed 4 grams of Acetaminophen per day when also giving Percocet. 6. Metoprolol Tartrate 50 mg Tablet [Month/Day/Year ]: One (1) Tablet PO TID (3 times a day). 7. Clonidine 0.2 mg/24 hr Patch Weekly [Month/Day/Year ]: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Clopidogrel 75 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. Psyllium 1.7 g Wafer [Last Name (STitle) ]: [1-11] Wafers PO DAILY (Daily). 11. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day (2) ]: One (1) Injection twice a day. 12. Lipitor 80 mg Tablet [Month/Day (2) ]: One (1) Tablet PO once a day. Discharge Medications: 1. Piperacillin-Tazobactam 4.5 g Recon Soln [Month/Day (2) ]: 4.5 grams Intravenous Q8H (every 8 hours): NOTE: Course to be completed on [6-10]. 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Month (only) ]: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Albuterol 90 mcg/Actuation Aerosol [Month (only) ]: Three (3) Puff Inhalation Q4H (every 4 hours). 4. Aspirin 325 mg Tablet [Month (only) ]: One (1) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol [Month (only) ]: Two (2) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q4-6H:PRN hold for sedation, confusion, rr<10 7. Acetaminophen 500 mg Tablet [Month (only) ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Metoprolol Tartrate 50 mg Tablet [Month (only) ]: Two (2) Tablet PO Q6H (every 6 hours). 9. Pantoprazole 40 mg IV Q12H 10. Clopidogrel 75 mg Tablet [Month (only) ]: One (1) Tablet PO DAILY (Daily). 11. Psyllium 1.7 g Wafer [Month (only) ]: [1-11] PO once a day. 12. Atorvastatin 80 mg Tablet [Month/Day (2) ]: One (1) Tablet PO once a day. 13. Cyanocobalamin 100 mcg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 14. Cholestyramine-Sucrose 4 g Packet [Month/Day (2) ]: One (1) Packet PO BID (2 times a day). 15. Glutamine 10 g Packet [Month/Day (2) ]: One (1) Packet PO DAILY (Daily). 16. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 17. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day (2) ]: One (1) Injection three times a day. 18. Levetiracetam 100 mg/mL Solution [Month/Day (2) ]: 1000 (1000) mg PO bid (). 19. Lorazepam 1-2 mg IV PRN FOR GENERALIZED SEIZURE>5MIN OR >3 SEIZURES/HR 20. Nitroglycerin 0.3 mg Tablet, Sublingual [Month/Day (2) ]: One (1) Tablet, Sublingual Sublingual PRN (as needed). 21. Opium Tincture 10 mg/mL Tincture [Month/Day (2) ]: Fifteen (15) Drop PO Q4-6H (every 4 to 6 hours) as needed. 22. Loperamide 2 mg Capsule [Month/Day (2) ]: One (1) Capsule PO QID (4 times a day) as needed. 23. Miconazole Nitrate 2 % Powder [Month/Day (2) ]: One (1) Appl Topical TID (3 times a day) as needed for skin redness. 24. Acetylcysteine 10 % (100 mg/mL) Solution [Month/Day (2) ]: One (1) ML Miscellaneous Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital 106725] Hospital of [Location (un) ] and Islands Discharge Diagnosis: Primary diagnosis: Seizures E. coli UTI Tracheitis Anemia Diarrhea Eosinophilia Hyponatremia Weakness Elevated PSA . Secondary diagnosis: Peripheral [Location (un) 1106] disease Congestive heart failure, systolic Chronic renal insufficiency Discharge Condition: WBC count normalized, afebrile. Discharge Instructions: You were admitted to the neurology service with seizures that required intubation in order to deliver enough medications to control. They are now controlled on keppra alone. You were transferred to the medicine service for further management of your multiple medical problems. . You were treated for infection in you bladder and respiratory secretions. You were found to have an elevated PSA of 9 with enlarged prostate and should follow up with your primary care doctor regarding this matter. . Please call your doctor or return to the emergency room if you develop fevers, chills, worsening cough/secretions, abdominal pain, worsening of diarrhea, blood in your stool or dark/tarry colored stool, trouble or discomfort urinating or any other symptoms that concern you. Followup Instructions: 1. NEUROLOGY: You have an appointment with Dr. [Last Name (STitle) 2442] on [6-8] at 1:00 pm at the [Hospital1 18] [Hospital Ward Name 23] building, [Location (un) ]. If you have any questions, please call ([Telephone/Fax (1) 5563]. . 2. GASTROENTEROLOGY: ([Telephone/Fax (1) 106726] with Dr. [Last Name (STitle) ] on [6-16] at 12pm at [Last Name (NamePattern1) 439]. This appointment is to evaluate your diarrhea and anemia. . 3. PULMONARY: Regarding your prolonged intubation and trach placement and your questions regarding trach reversal. Your appoitment is on [6-28] at 2:30pm in the [Hospital Ward Name 23] building ([Hospital Ward Name ]) on the [Location (un) 436]. This appointment is with Dr. [Last Name (STitle) 2171] ([Telephone/Fax (1) 513]. . 4. UROLOGY: ([Telephone/Fax (1) 772] [6-23] at 3pm with Dr. [Known firstname ] [Last Name (NamePattern1) 3748] in [Hospital Ward Name 23] building on [Hospital Ward Name ] on the [Location (un) 470]. This is regarding your enlarged prostate and elevated PSA. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "428.20", "041.10", "787.91", "348.30", "579.3", "790.93", "790.7", "434.91", "V09.81", "288.3", "345.71", "585.9", "482.82", "427.31", "464.10", "599.0", "276.1", "557.1" ]	icd9cm	[ [ [] ] ]	[ "96.72", "99.04", "96.6", "31.1", "99.07", "03.31" ]	icd9pcs	[ [ [] ] ]	27526, 27619	11324, 23572	287, 299	27908, 27942	4800, 4800	28764, 30014	3386, 3390		25023, 27503		27640, 27640		23598, 25000			27966, 28741									3430, 3733																		2675, 2783				3752, 3752	229, 249						327, 2656	3839, 4781		27778, 27887		4817, 11301	27659, 27757			3767, 3822						2805, 3252	3268, 3370
885	146,961	1899	Discharge summary	report	Admission Date: [2161-10-10] Discharge Date: [2161-10-12] Service: MEDICINE Allergies: Lipitor Attending:[First Name3 (LF) 330] Chief Complaint: melena Major Surgical or Invasive Procedure: endoscopy History of Present Illness: 83F w/ CAD s/p CABG, anemia, who reports "fainting and waking up incontinent of black liquid stool". She got up, cleaned up in bathtub, but continued to have a couple more episodes of small liquid, black stool yesterday. Her last BM was this day of adm. She also notes some lightheadedness, + nausea and diaphoresis. She does take aspirin and aleve 4 pills daily X 4-5 days for back pain. . In [Hospital1 18] ED, 98.4, 102, 166/78. She was in NAD, abd benign, euvolemic, melena on rectal. NG lavage negative. EKG unchanged. . In the unit, she reports feeling well with no chest pain, SOB, LHD, dizzyness, abd pain. Per daughter, pt has never had seizure like activity, syncope, GIB bleed before. She has never had a colonoscopy. She received 2 U PRBC so far. Past Medical History: 1. Venous insufficiency. 2. CAD status post acute MI [2148]. 3. Hypertension. 4. Cataract OS. 5. Hyperlipidemia. 6. Dysfunctional uterine bleeding. 7. Cystocele complicated by mixed incontinence. 8. Anemia. 9. DJD, right knee. PAST SURGICAL HISTORY: 1. Status post cataract extraction, OS. 2. Status post excision of [Initials (NamePattern4) ] [Last Name (NamePattern4) 4675] cyst, right knee. 3. Status post CABG, four vessels. . GYNECOLOGIC HISTORY: Gravida 3, para 2, two vaginal deliveries. Menarche in her teens. Menopause at age 53. Last Pap smear 5/[2160]. Last mammogram 2/[2159]. . Social History: She grew up in [Location (un) ]. She is widowed. She worked as a stitcher but was mostly a housewife. No tobacco use. She did smoke but quit many years ago. Social alcohol use, no drug use. Family History: Positive for diabetes in her sister. Positive for CAD in her brother, questionable malignancy in an aunt. [Name (NI) ] family history of hypertension. Physical Exam: VITALS: 98.7 115/78 85 16 100% 2LNC HEENT: PERRL, EOM intact, MM moist PULM: CTAB HEART: well-healed midline scar, RRR, [1-27] HSM LPSA ABD: soft, NT/ND, normoactive BS EXT: no edema, +DP blaterally; hypersensitive to light touch NEURO: AAoX3 RECTAL: guaiac positive, black stool in rectal vault Pertinent Results: Labs on discharge: [2161-10-12] WBC-11.8* Hct-29.4* Plt Ct-221 . PT-12.3 PTT-21.2* INR(PT)-1.0 . Glucose-139* UreaN-15 Creat-0.8 Na-146* K-3.9 Cl-114* HCO3-25 . . Endoscopy: Esophagus: Mucosa: Normal mucosa was noted in the whole esophagus. Stomach: Excavated Lesions There were 3 ulcers found in the pre-pyloric area ranging from 3mm to 1cm. All ulcers had clear bases. There was no active bleeding noted. Duodenum: Mucosa: Normal mucosa was noted in the first part of the duodenum and second part of the duodenum. Impression: Normal mucosa in the whole esophagus; Ulcer in the pre-pylorus Normal mucosa in the first part of the duodenum and second part of the duodenum; Otherwise normal EGD to second part of the duodenum Brief Hospital Course: 83 y/o F hx CAD s/p CABG now with 10 point HCT drop and melanotic stools concerning for GIB . # GIB: She presented with likely UGI source in the settig of taking aspirin, plavix, and NSAIDS. She received 2UPRBCs and Hct remained stable in 28-30 without need for further transfusions. Endoscopy showed three well healed pre-pyloric ulcers with no active bleeding. H pylori was checked and pending at discharge. She was advised to stop all NSAID use. Aspirin was restarted at discharge. She will need repeat endoscopy 6 weeks after discharge. . # Syncope: Suspect [12-26] hypovolemia and orthostasis in setting of blood loss although in the MICU, pt was not orthostatic (after reciving fluids and blood in ED). Pt was ruled out with 2 sets of cardiac enzymes and was monitored on tele. On the morning after admission to MICU, pt developed SVT (aflutter) to 140-150s which slowed with 3 doses of metoprolol 5mg iv. EKG after iv metoprolol was sinus with PVCs and APCs. Pt was started on metoprolol 12.5mg TID which will need uptitration (pt was on atenolol 75mg daily at home) . # CAD: s/p CABG. Patient was still taking plavix although her CABG was 1.5 years ago. Her primary cardiologist, Dr. [Last Name (STitle) ], confirmed that she should no longer be on plavix any more. This was clarified with patient. She can still continue aspirin. . # ARF: Baseline 0.9, now 1.2. Suspect prerenal azotemia and improved with fluids/blood . # HTN: BP meds intially held in setting of GIB. By day of discharge, she restarted BB and ACEi. . # Hypersensitivity in LE: Unclear etiology; ?RSD or restless leg, but not an active issue during this admission. . # FEN: diet was advanced after endoscopy. . # PPX: pneumoboots, PPI . # ACCESS: PIV X 2 . # CODE: Full, discussed with patient and HCP Medications on Admission: - Aspirin 81 mg once daily - atenolol 75 mg once daily - enalapril 5 mg once daily - furosemide 20 mg once daily - Plavix 75 mg once daily (per daughter, not sure of taking) - simvastatin 80 mg once daily, - nitroglycerin p.r.n. - calcium with vitamin D t.i.d. - MVI - aleve and tylenol PRN Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: please start taking this on Thursday, [10-15]. 3. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day. 4. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Calcium + Vitamin D 600-200 mg-unit Tablet Sig: One (1) Tablet PO once a day. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 doses. Discharge Disposition: Home Discharge Diagnosis: Primary: - duodenal ulcers - atrial flutter - anemia: [12-26] GI bleed - HTN Secondary: - CAD s/p MI [2148] - hyperlipidemia - DJD Discharge Condition: well Discharge Instructions: You came in with blood in your stool and a fainting episode. You received two units of blood in the emergency department and were admitted to the ICU. Your blood levels stabilized. You underwent an EGD which showed three ulcers in your duodenum. These were not bleeding. Please continue to hold your plavix. You can restart your aspirin on Thursday, [10-15]. We also are starting prilosec 20mg twice daily. Please take this at least until your repeat EGD and colonoscopy in [5-1] weeks. We restarted all your other medications (except the plavix). . Please monitor for any dizziness, bloody or black stools, or abdominal pain. If so, please stop your aspirin and return to the emergency department. Please contact your PCP if you experience chest pain, shortness of breath, constipation/diarrhea. . Please followup with your PCP to see if you have H. Pylori. . Please do NOT take Advil, motrin, Aleve, or other NSAIDs. . Please take metoprolol 25mg x1 tonight at 7pm. Then you can resume your atenolol normally in the morning. Followup Instructions: Please followup with GI: Dr. [Last Name (STitle) ] on Monday, [11-23]. Please arrive at 9:30am. Plan for a pickup at around 12:30. Your appointment is on the [Hospital Ward Name ]: [Hospital Ward Name 1950] entrance, [Location (un) ]. You will receive information by mail regarding your preparation for the EGD and colonoscopy. Number: [Telephone/Fax (1) ] . Please followup with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] on Tuesday, [10-20] at 11:15am. . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], MD Date/Time:[2161-12-1] 11:30 Provider: [First Name11 (Name Pattern1) 10588] [Last Name (NamePattern4) 10589], [MD Number(3) 1240]:[Telephone/Fax (1) 10590] Date/Time:[2162-1-5] 11:15	[ "414.00", "401.9", "427.32", "531.40", "276.52", "285.1", "E849.9", "584.9", "E935.9", "280.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.13" ]	icd9pcs	[ [ [] ] ]	6056, 6062	3143, 4936	223, 234	6245, 6252	2387, 2387	7345, 8154	1894, 2051		5278, 6033		6083, 6224		4962, 5255			6276, 7322								1305, 1665	2066, 2368																							177, 185				2406, 3120		262, 1028															1050, 1282	1681, 1878
4,166	103,317	25310	Discharge summary	report	Admission Date: [2156-7-26] Discharge Date: [2156-9-3] Date of Birth: [2104-3-28] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Ciprofloxacin / Morphine Sulfate / Ativan / Piperacillin Sodium/Tazobactam Attending:[First Name3 (LF) 6346] Chief Complaint: Transfer from Outside Hospital with sepsis and bowel leakage after two laparotomies Major Surgical or Invasive Procedure: Exploratory laparotomy, extensive lysis of adhesions, small bowel resection with enteroenterostomy, cecal primary closure, abdomen washout and gastrojejunostomy tube placement. History of Present Illness: [Known firstname 17] is a 52-year-old female who was transferred from an outside hospital after being admitted inearly [Month (only) 205] with diverticulitis. The patient was treated withantibiotic therapy and then underwent exploratory laparotomy and segmental colectomy with primary anastomosis on [2156-6-30]. She spent 10 days in the hospital postoperatively and was discharged home. She returned shortly thereafter with increasing abdominal pain and fevers. The patient had a pelvic abscess with an anastomotic leak and was taken to the operating room a second time on [2156-7-20] for exploratory laparotomy and abscess drainage. Enterotomies were made during this exploration and they were repaired with interrupted silk sutures. The patient was given an end colostomy and mucous fistula. Postoperatively on [2156-7-26], succus was actively drainging from the wound. A CT scan was performed which showed extravasation of contrast from the bowel into the pelvis and out the wound. The patient was transferred to the [Hospital1 346] for tertiary care after that finding. The patient was initially accepted by Dr. [Last Name (STitle) ] and then transferred to Dr. [First Name (STitle) 2819] on the Blue Surgery service. The patient was seen in the surgical intensive care unit in on arrival. There was bilious drainage from the abdominal incision and feculent drainage from [Initials (NamePattern4) ] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain that had been placed in the pelvis by the previous surgeon. The patient was explained the risks and benefits of operative procedure and it was deemed appropriate to operate as there was significant drainage and it probably would not be controlled adequately with nonoperative therapy. The grave situation was explained to the patient and the patient's daughter, and the patient agreed to proceed and signed a surgical consent for exploration. Bowel resection, diverting ostomy and requirement to leave the abdomen open were all discussed and a consent was signed. Past Medical History: Recurrent Diverticulitis HTN Benign colon polyp h/o EtOH abuse Fiberoid uterus s/p TAH BSO s/p Laproscopic cholecystectomy Social History: quit smoking in [6-/2156] at the time of her admission for diverticulitis 1.5ppd X 30 yrs History of EtOH and marijuana abuse Family History: non-contributory Physical Exam: temp:101.6, HR 123, BP 125/47, RR 19, SaO2 97% Gen: frail thin caucasion woman in NAD, HEENT: NCAT EOMI CV: RR, tachy, nl S1, S2 Pulm: CTA b/l Abd: BS present, tender to palp, drains intact, midline inscision Ext: no pedal edema, MAE Pertinent Results: [2156-7-26] 07:58PM GLUCOSE-83 UREA N-10 CREAT-0.5 SODIUM-131* POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-24 ANION GAP-15 [2156-7-26] 07:58PM ALT(SGPT)-9 AST(SGOT)-16 LD(LDH)-212 ALK PHOS-142* AMYLASE-103* TOT BILI-0.3 [2156-7-26] 07:58PM WBC-15.6* RBC-3.44* HGB-10.3* HCT-31.3* MCV-91 MCH-30.0 MCHC-33.0 RDW-14.7 [2156-7-26] 07:58PM NEUTS-72.6* LYMPHS-16.1* MONOS-5.6 EOS-5.5* BASOS-0.2 [2156-7-26] 07:58PM PLT SMR-VERY HIGH PLT COUNT-645* Brief Hospital Course: The patient was admitted to the Blue surgery service and underwent an emergent operation on [2156-7-27] (see Dr.[Name (NI) 11471] op note). Postoperatively, her wound healed secondarily with wet to dry dressing changes twice daily. She underwent CT-guided drainage of a pelvic abscess with placement of a pigtail catheter. A G tube and JP drain were also placed. She was administered antibiotics for organisms isolated from her wound cultures. One week [Last Name (LF) ], [Known firstname 17] developed a fever/rash and renal failure thought to be a reaction to an antibiotic, most likely Zosyn. She also developed a severe skin rash and was briefly transferred to the SICU for fluid resuscitation. She recovered from the drug reaction, was transferred back to the floor. Repeat CT scans of her abdomen showed no new collections, and she continued to improve. The JP drain was removed on [8-31]. She was deemed ready for discharge to rehab on [9-3]. Medications on Admission: Atenolol vancomycin levofloxacin metronidazole Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:qs x 1 month packet Refills:0 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:qs x 1 month packet Refills:0 3. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 4. Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN PICC line - Inspect site every shift 5. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 6. Diazepam 2.5 mg IV BID PRN 7. Hydromorphone 0.5-4 mg IV Q3-4H:PRN pain Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Small bowel leakage and cecal leakage enterocutaneous fistula Allergic reaction to pipericillin with severe rash/renal failure Sepsis Discharge Condition: Stable. Discharge Instructions: Please call your doctor if you experience fever >101.5, redness or purulent drainage from wounds, persistent nausea/vomiting, or any other concerns. No heavy lifting for 8 weeks. Please take all medications as prescribed. Followup Instructions: Please see Dr. [First Name (STitle) 2819] in 1 week. Upon discharge, please call Dr. [Name (NI) 63323] office at [Telephone/Fax (1) 2998] for an appointment. Completed by:[2156-9-3]	[ "E930.8", "693.0", "309.28", "567.2", "995.92", "038.8", "997.4", "288.3", "288.0", "584.9", "568.0", "790.4", "569.81", "998.59", "562.11", "112.5", "518.82" ]	icd9cm	[ [ [] ] ]	[ "54.59", "99.15", "46.79", "38.91", "54.91", "46.32", "38.93", "45.62" ]	icd9pcs	[ [ [] ] ]	5547, 5619	3807, 4782	440, 619	5797, 5807	3319, 3784	6077, 6276	3031, 3049		4879, 5524		5640, 5776		4808, 4856			5831, 6054									3064, 3300																							317, 402						647, 2721															2743, 2868	2884, 3015
18,846	123,369	6079	Discharge summary	report	Admission Date: [2137-5-11] Discharge Date: [2137-5-15] Date of Birth: [2074-2-1] Sex: F Service: MEDICINE Allergies: Penicillins / Ceftriaxone Attending:[First Name3 (LF) 613] Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Ms. [Known lastname ] is a 63yo F living at [Hospital3 2558] with multiple medical problems including DM, HTN, diastolic CHF, hyperlipidemia, pulm HTN, ESRD on HD, h/o AV graft infections, morbid obesity, lower extremity DVT, b/l IJ vein thromboses on coumadin, and OSA. She has recently been admitted several times to [Hospital1 18] for tachycardia most recently on [2-25] to the [Hospital Unit Name 196] service which she was found to be in atrial tachycardia. Today, she presents directly from HD. She has been needing more HD sessions for fluid removal in the past week. Today, she had 2kg fluid removed and was hypotensive at HD and metoprolol was held. Shortly afterwards, she began to notice palpitations with HR 120-130's. She was sent in directly from HD to [Hospital1 18]. In our ED, initial vitals were 96.9 128 133/112 20 100%RA. One hour in ED, her BP then decreased to 64/60, which improved to 110's after receiving 1500 cc NS. She was mentating throughout and stated that BPs normally run 80-90's. She then received lopressor 5mg IV X 3 with no change in HR. She had a low grade T 100.4, CXR negative, blood and urine cx drawn, but no antibiotics started. She was admitted to the ICU, where she reported feeling well. She is still noticing some fluttering sensation in chest, but denies CP. She did note a left shoulder twinge during HD which prompted her to ask RN at HD to check her HR. Since then, she has not had any more twinges. She attributes increased need for HD to eating more fruit at NH (watermelon and grapes). She has been to HD last Tues, Wed, [Last Name (un) ], and today. Also, she is recently s/p 7d levoquin for pneumonia. She denies fever, chills, N/V/D, no PND/orthopnea/LE swelling Past Medical History: PAST MEDICAL HISTORY: - hemorrhagic pericardial effusion - Bilateral internal jugular thromboses, restarted on coumadin [8-24] - h/o bilateral lower extremity DVT's - ESRD on HD T, Th, Sat - IDDM - Diastolic heart failure - Pulmonary hypertension - Hypercholesterolemia - OSA, noncompliant with CPAP as outpatient - OA - h/o C. Diff - GERD - Depression - Morbid obesity - Fibroid uterus; vaginal bleeding - h/o Osteomyelitis at the T9 Vertebrae [5-24]; tx with Vanc - h/o Multiple line infections [2135-12-17]: Providencia, treated with 4 wk course of aztreonam [2135-4-17]: Staph coag positive, sensitive to both vancomycin and gentamicin [2136-5-17]: Staph bacteremia tx with vanc x 6 weeks [2136-8-17]: Proteius mirabilis and MSSA, treated with ceftaz and vanc . PAST SURGICAL HISTORY: - L forearm radial-basilic AV graft, s/p infection, thrombosis and abandonment ([12-21]) - Multiple lines in L upper arm with AV graft - 1/07 L femoral PermaCath placed - L upper arm thrombectomy, revision, of LUE AV graft ([3-23]) - [4-23] Excision of left upper arm infected AV graft; associated MRSA bacteremia treated with 6 weeks vancomycin. - Right upper extremity AV fistula creation [10-23] s/p revision - [2135-12-14] Right AV fistula repair, Right IJ PermaCath rewiring and IVC filter removed Social History: Patient denies tobacco, alcohol or illicit drug use. She lives in a nursing home. She is separated from her husband. She has 5 children in [Location (un) 86] [Doctor Last Name ] area. Family History: Not obtained. Physical Exam: General: Pleasant woman in no acute distress, obese; left HD line in place Neck: No JVD appreciated Lungs: Wheezes clearing with cough, otherwise clear Cardio: distant soft HS, RRR, no m/r/g appreciated Abd: + BS, soft, obese, no HSM Extremities: No edema Neuro: AA, Ox3, CN II - XII intact, moving all limbs Pertinent Results: Discharge Labs: [2137-5-15] 08:50AM BLOOD WBC-5.0 RBC-3.09* Hgb-10.0* Hct-32.2* MCV-104* MCH-32.4* MCHC-31.2 RDW-14.4 Plt Ct-273 [2137-5-15] 08:50AM BLOOD PT-22.9* PTT-35.1* INR(PT)-2.2* [2137-5-15] 08:50AM BLOOD Glucose-107* UreaN-29* Creat-4.9# Na-136 K-4.1 Cl-97 HCO3-29 AnGap-14 [2137-5-12] 04:19AM BLOOD CK-MB-NotDone cTropnT-0.06 [2137-5-11] 01:20PM BLOOD cTropnT-0.06* [2137-5-12] 04:19AM BLOOD CK(CPK)-38 [2137-5-11] 01:20PM BLOOD CK(CPK)-90 [2137-5-15] 08:50AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.2 Imaging: Echo [2137-5-13] The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Diastolic dysfunction. No significant valvular abnormality seen. Compared with the prior study (images reviewed) of [2136-10-4], findings are similar. Microbiology: [2137-5-11] 1:20 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST. Brief Hospital Course: 63 yo F with ESRD and atrial tachycardia admitted initially to MICU for hypotension/tachycardia. 1) Atrial Tachycardia: The patient was started on IV Diltiazem and converted to PO Diltiazem and Metoprolol after rule out of myocardial infarction. EP was consulted to advise and her Diltiazem was stopped, replaced with Amiodarone load to complete [2137-6-13]. At this time, metoprolol will be discontinued. The patient had an echo with no significant change from prior. 2) Hypotension: The patient has chronic BP in the 80s-90s especially post-dialysis. The goal of therapy above is to remove her Diltiazem & Metoprolol to avoid the hypotensive side effects of her rate control medications. She was given fluid rescusitation but did not develop sepsis during this admission. Although she had 1 bottle positive for Coag negative Staph and received 2 dose of Vancomycin, therapy was discontinued as this is a likely contaminant. 3) Chronic Diastolic CHF: The patient remained euvolemic on exam and on her baseline 1.5-2L oxygen by nasal cannula. Echo confirmed no signficant change. 4) Venous Thromboembolism: The patient has a history of multiple DVTs. She was maintained on warfarin 2.5mg intermittently during this admission as her INR often increased over 3.0. She will be discharged on 1mg daily given the addition of Amiodarone and followed closely at [Hospital3 2558]. 5) ESRD: The patient was continued on her renal vitamins and HD Tuesday/Thursday/Saturday. 6) Depression: Continued Paxil 7) DM: Continued Home NPH with additional sliding scale coverage. Medications on Admission: Aspirin 81 mg daily Simvastatin 10 mg daily Warfarin 2.5 mg daily Diltiazem HCl 30 mg QID B Complex-Vitamin C-Folic Acid 1 mg daily Zinc Sulfate 220 mg daily Sevelamer Carbonate 1600 mg TID Paroxetine HCl 40 mg daily Folic Acid 1 mg daily Acetaminophen Ascorbic Acid 500 mg [Hospital1 ] Bisacodyl/Senna Metoprolol Tartrate 25 mg TID NPH 20 Units QAM Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty (20) Units Subcutaneous QAM. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 1 months: Last dose [2137-6-13]. 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 6 days: Last 400mg [Hospital1 ] Dose 5/7 PM dose. 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks: To begin [5-24] until [2137-6-14]. 16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: To begin [2137-6-14]. Please stop metoprolol when starting this dose. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: 1. Atrial tachycardia 2. chronic kidney disease stage V, on hemodialysis 3. chronic diastolic Heart failure Discharge Condition: Hemodynamically Stabile, afebrile, tolerating POs Discharge Instructions: You have been admitted to the hospital because of your fast heart rate/arrythmia. While you were here we had our Electrophysiology (heart rhythm) doctors [Name5 (PTitle) 788] [Name5 (PTitle) ], and they recommended changing your medications. You also continued on dialysis while admitted. Please note the following changes to your medications: Amiodarone 400mg by mouth twice daily until Tuesday [5-21] afternoon dose. After that, your dose will change to 200mg by mouth twice daily for 3 weeks (until [2137-6-11]). Thereafter, continue on Amiodarone 200mg by mouth every day. You may stop the metoprolol once you are the Amiodarone 200mg every day. Please stop your diltiazem. We have changed your Warfarin dose to 1mg daily. Please have [Hospital3 2558] follow your coumadin levels. Please call your doctor or 911 if you experience Fever >100, chest pain, difficulty breathing, confusion or any other concerning medical symptom. Followup Instructions: Dr. [First Name (STitle) ] will follow you at [Hospital3 2558]. Dr. [Last Name (STitle) ], your cardiologist, will contact you at [Name (NI) ] to set up an appointment within one month. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "403.91", "278.01", "327.23", "585.6", "428.0", "416.0", "428.32", "V58.61", "V12.51", "311", "250.00", "427.89" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	9234, 9304	5732, 7319	296, 310	9455, 9506	4043, 4043	10515, 10841	3684, 3699		7723, 9211		9325, 9434		7345, 7700			9530, 9856				4059, 5552				2933, 3458	3714, 4024						5596, 5709											9885, 10492						245, 258						338, 2090															2134, 2910	3474, 3668
27,691	102,900	12849	Discharge summary	report	Admission Date: [2180-10-19] Discharge Date: [2180-11-1] Date of Birth: [2106-4-19] Sex: M Service: MEDICINE Allergies: Lopressor / Keflex Attending:[First Name3 (LF) 2901] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 39530] is a 74 yo M with history of CAD s/p MI, 3V CABG [2167], CHF (EF 25% in [2179]), VF arrest s/p ICD [2179], who presented to [Hospital 1281] Hospital on [10-19] with dyspnea. Of note, he had been discharged approximately 12 hours before from [Hospital 487] Hospital, where he had a 30 day admission for CHF exacerbation. Per the daughter, he was still "full of fluid" upon discharge from [Hospital1 487]. He returned home to his assissted living facility Wednesday evening [10-18], and his daughter stayed over with him. She reports that he was experiencing sever SOB and DOE, and that he was barely able to walk the length of the hallway without becoming SOB. She notes that he sounded wheezy and "couldn't pee." When the VNA nurse came on Thursday morning, he recommended that he go straight to the hospital "or he will die." Was brought to [Hospital 1281] Hospital for temporary stabilization before transfer to [Hospital1 18] for continuity of care with patient's cardiologist Dr. [Last Name (STitle) 5686]. . At [Hospital 1281] Hospital found to have O2 sat 84% on RA improved to 100% on 40% O2 NRB. Exam showed bibasilar crackles, LE edema to knees and edema in arms. Given ASA, Lasix 80mg IV, nitropaste, SL nitro x 3. Put out 300cc urine. OSH labs significant for HCT 28, K 5.0, Cr 2.0, alb 3.0. . In the [Hospital1 18] ED t 97.5, HR 71, BP 89/49 rr 24 02 98% venti mask. Nitropaste removed. BP 75-80s and dopamine started with good effect. CPAP placed. Had an episode of "VT" and ICD fired in ED. Admitted to CCU for CHF exacerbation. . Per daughter, patient has not had chest pain. He has dyspnea on exertion as well as orthopnea and ankle edema. No syncope or presyncope Has no history of stroke, TIA, deep venous thrombosis, or pulmonary embolism. No recent fevers, chills, rigors, or sick contacts. [Name (NI) ] of the other review of systems were negative. Past Medical History: hypertension hyperlipidemia CAD s/p CABG in [2167] ICD placement [2179] [2-18] VF arrest CHF (EF 20-30% on this admission) h/o of chronic A-fib on Coumadin h/o Colon ca with remote surgery and uptodate colon-ca screening Depression/anxiety/ mild dementia h/o of RBBB Social History: Lives in Sunrise Senior [Hospital3 400] in [Location (un) 16848]. Has meds dispensed and administered to him there. Social history is significant for the absence of current tobacco use. Former smoker with 20-40 year pack history, quit 20 years ago. Family History: There is a + family history of premature coronary artery disease: brother died of MI at 38, dad died when pt was 17 (? of CAD), son died of stroke @47 Physical Exam: VS: T 97.1, BP102/87 , HR 76, RR14 , O2 100 % on CPAP 50% FIO2 Gen: WDWN elderly male in NAD, resp or otherwise. CPAP in place, awakens, but does not want to participate in exam. HEENT: NCAT. Sclera anicteric. Eyes closed, mask overlying edges of eyelids. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple Neck veins engorged with apex of JVP unseen while patient laying in bed at approx 60 degrees. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Intermittent s3 with 3/6 holosystolic murmur at LLSB, soft diastolic murmur at LLSB, Distant heart sounds. No rv heave Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Coarse breath sounds bilaterally, crackles at bases Abd: Obese, soft, NTND, + hepatomegaly with pulsatile liver. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: Has ecchymoses on UE, stasis dermatitis on LE, 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 CBC: WBC-6.1 RBC-3.33* Hgb-9.8* Hct-30.1* MCV-90 MCH-29.3 MCHC-32.4 RDW-16.8* Plt Ct-128* . CHEM: Glucose-80 UreaN-54* Creat-2.0# Na-134 K-5.0 Cl-101 HCO3-26 AnGap-12 . COAGS: PT-17.5 PTT-36.5* INR(PT)-1.6* . LFTs: ALT-16 AST-24 LD(LDH)-324* CK(CPK)-42 AlkPhos-123* TotBili-1.4 . LIPIDS: Triglyc-54 HDL-57 CHOL/HD-2.2 LDLcalc-60 Total Chol 128 . CEs: cTropnT-0.10* cTropnT-0.09* . Digoxin-0.9 . TFTs: TSH-1.1 Free T4-1.4 . Random cortisol Cortsol-19.5 . [2180-10-19] CXR: IMPRESSION: 1. CHF with bilateral pleural effusions, worse than on [2179-4-3]. 2. Retrocardiac opacity may represent atelectasis, pulmonary consolidation or combination of both. . [2180-10-19] EKG 7PM: Ventricular paced rhythm with wide QRS complexes. Compared to the prior tracing of [2179-5-19] there is a marked diminution in QRS voltage. Clinical correlation is suggested. 10PM: Atrial fibrillation and increase in rate. As compared with prior tracing of [2180-10-19] right bundle-branch block is now evident. The limb lead voltage is markedly diminished. There was low limb lead voltage recorded on [2179-4-2] and it is further reduced. Followup and clinical correlation are suggested. . [2180-10-20] ECHO The left atrium is markedly dilated. The right atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20-30 %) secondary to severe hypokinesis/akinesis of the interventricular septum, anterior free wall, and apex. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Severe [4+] tricuspid regurgitation is seen. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. . [2180-10-25] CT Abd/Pelv IMPRESSION: 1. Bilateral rectus sheath hematomas. 2. Small focal dissection of the infrarenal aorta. 3. Large bilateral pleural effusions, trace ascites. 4. Diffuse calcified granulomata involving the visualized aspects of the lungs. 5. Diffuse edema and venous distention consistent with the provided history of CHF. A surgical staple line is seen in the region of the sigmoid colon, suggesting prior surgery in this region, although a radiopaque anastomotic suture line is not identified. . Brief Hospital Course: #. CHF - Presented in decompensated heart failure with hypotension and respiratory distress. Was placed on dopamine and CPAP in the ED. In the CCU we began a lasix drip with eventual diuresis of almost >10 liters. His home CHF reg of carvedilol and lisinopril were held given his hypotension and ARF on presentation. Eventually weaned from dopamine gtt with marginal BPs (MAP in 50-60s). An echo confirmed systolic CHF with an EF of 20-30% as well as severe (4+) TR. Patient was eventually taken off lasix drip and begun on an oral diuresis regimen of budesonide and metolazone. For CHF, he was started on spironolactone and eventually a BB (Toprol XL) was restarted as well. He was also restarted on digoxin qMWF. His repsiratory status improved throughout his stay and he was in compensated heart failure at the time of discharge. On discharge, his diuretic regimen included spirnolactone and bumex. His ACE was held at discharge pending creatinine stabilization and blood pressure tolerance. This should be reassesses after discharge. . # Rhythm - Has a ventricularly paced rhythm with paroxysmal a-fib. Had pacer placed in [2179] after a VF arrest. The ICD fired in the OSH and he was restarted on amiodarone loading. In the ED here, the ICD reportedly fired again, but EP interrogation of the pacer revealed no VT/VF or discharges. We continued antiarryhthmic regimen with amiodarone loading (now down to maintenence of 400mg daily). There were no episodes of VT during this hospitalization. Of note, he was found to have bilateral rectus sheath hematomas on evalutation for palpable suprapubic mass, and for this reason anticoagulation was held during his stay. Coumadin should be restarted as an outpatient. . #. Persistent Hypotension - Patient presented to ED hypotensive and was started on doapmine drip. Was refractory to weaning for almost one week, but eventually able to wean off and maintain BPs in 90s SBP. The most likely etiology for his hypotension was cardiogenic shock. . #. CAD - gave medical secondary prevention with ASA, statin, but initially held BB and ACE in setting of hypotension and renal failure. Small troponin leak most consistent with CHF exacerbation. EKGs with no obvious ischemia. Eventually added on Toprol XL. . # Renal insufficiency - unclear baseline, diuresed to small creatinine bump (Cr 1.7). . # Dementia - continued aricept 5mg daily. Patient exhibited frequent disorientation and forgetfulness while int he hospital. He was also agitated at night, and so olanzapine 2.5mg qHS was added with good effect. . # Depression/Anxiety: appeared depressed and irritable throughout stay. Increased mirtazapine to 30mg po qHS . # Rectus Sheath Hematoma: stable during hospitalization. Coumadin and hep SC held pending resolution. Coumadin should be restarted on resolution of rectus sheath hematoma. . # FEN - FLUID RESTRICTION of 1200cc daily!! Low NA+ cardiac diet! . # Code: confirmed DNR/DNI . Medications on Admission: Aricept 5mg daily carvedilol 6.25mg [Hospital1 ] Lisinopril 5mg daily ASA 81mg daily Simvastatin 40mg daily digoxin 0.125mg qMWF potassium 20mEq [Hospital1 ] Remeron 22.5mg qHS amiodarone 400mg [Hospital1 ] Advair Diskus 1 puff inh [Hospital1 ] Tylenol 650mg q4h prn Kenolog 1% apply [Hospital1 ] Coumadin 1 mg daily Ativan 0.5mg q6h prn Milk of Magnesia 30mL prn Colace 100mg [Hospital1 ] Discharge Medications: 1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-18] Drops Ophthalmic PRN (as needed). 16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for itchiness. 17. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritis. 20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [Location (un) 14468] Nursing & Rehabilitation Center - [Location (un) 1456] Discharge Diagnosis: Primary: Congestive Heart Failure . Secondary: Coronary Artery Disease atrial fibrillation chronic renal insufficiency dementia Discharge Condition: improved, normotensive, no respiratory distess Discharge Instructions: You were admitted ot the hospital with an exacerbation of your congestive heart failure. We gave you diuretics ("water pills") to remove the excess fluid that was causing your shortness of breath. We also had to temporarily support your blood pressure with a medicine called dopamine until your body could regulate the blood pressure better on its own. . While you were here we also did a CT scan of your abdomen since we felt a mass there. It turns out that the mass was a hematoma (bleed) in the wall of an abdominal muscle. Your body will absorb the blood on its own. . You have a heart rhythm called atrial fibrillation, which puts you at an increased risk for having a stroke. To prevent strokes, most patients with atrial fibrilliation take a blood thinning medicine called coumadin. You will need to begin taking coumadin as an outpatient. We are not giving it to you right now due to the bleeding you had in your abdominal wall. Your primary care doctor should begin this medicine at a future date. . Please take all of your medicines as prescribed. Please keep all of your follow up appointments. If you experience any shortness of breath or chest pain please call your doctor or go to the ER. Followup Instructions: You have an appointment to see your Primary Care Physician [Name9 (PRE) 24576],[Name9 (PRE) 198] [Name Initial (PRE) ] [Telephone/Fax (1) 24579] on Wednesday, [11-8], at 3:15PM. . Please follow-up with your cardiologist Dr. [Last Name (STitle) 5686], [First Name3 (LF) ] , MD [Telephone/Fax (1) 11554], in [1-18] weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] Completed by:[2180-11-1]	[ "311", "584.9", "585.9", "403.90", "427.31", "785.51", "V58.61", "428.0", "290.0", "428.23", "414.01", "V45.81", "V10.05" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	12450, 12561	7227, 10167	300, 307	12732, 12781	4164, 7204	14032, 14548	2885, 3037		10631, 12427		12582, 12711		10193, 10608			12805, 14009									3052, 4145																							241, 262						335, 2293															2315, 2595	2611, 2869
55,360	184,704	48874	Discharge summary	report	Admission Date: [2111-12-25] Discharge Date: [2112-1-8] Date of Birth: [2057-3-22] Sex: F Service: SURGERY Allergies: Latex Attending:[First Name3 (LF) 1] Chief Complaint: Small bowel obstruction Major Surgical or Invasive Procedure: Exploratory laparotomy, extensive lysis of adhesions, small bowel resection, reanastomosis and repair enterotomy, revision of ileal urinary conduit loop History of Present Illness: 54F with h/o spina bifida with LE immobility, recurrent SBO, HCV p/w abdominal pain. She states that her last episode of SBO was 7 years ago. She developed severe abdominal pain in the afternoon after a large meal. The pain was severe constant, diffuse, improved somewhat with emesis. She developed the emesis for a couple of episodes, food, no blood. She presented to the ED and was found to have SBO on CT. She received morphine and 6mg ativan for anxiety. Her pain improved to [2113-5-1]. Surgetry saw the patient and placed NG tube, recommended IVF, NG tube suction, serial exams. She was admitted to hospitalist service for further evaluation. Past Medical History: 1. Osteomyelitis of L ischium [11-28] 2. Spina bifida 3. Small bowel obstructions 4. Chronic constipation 5. Recurrent Cellulitis 6. Panic disorder, agoraphobia 7. Vascular insufficiency 8. Chronic constipation 9. Iron deficiency anemia 10. Cystectomy at 12 yo, Urostomy tubes 11. Multiple UTIs PAST SURGICAL HISTORY: 1. Exploratory laparotomy times three; last one 20 years ago ([2-28] multiple adhesions). 2. Back surgeries. 3. Hip replacement 4. Ankle surgeries. 5. Right rotator cuff repair. 6. Ileoconduit neobladder. Social History: Denies ETOH, tobacco products, or drugs. Family History: Micro Pseudomonas from swab [2106-7-7] -pan sensitive KLEBSIELLA PNEUMONIAE, PSEUDOMONAS AERUGINOSA swab [2105-1-30] pan sensitive ULCER L ISCHEAL Ulcer MRSA,pseudomonas in path BONE LEFT ESCHIAL enteroccocus s to vanco Physical Exam: VS: Temp: 98.4 BP: 167/101 HR: 118 RR: 18 O2sat: 99 RA . Gen: appears somewhat uncomfortable, though no distress HEENT: PERRL, EOMI. No conjunctival injection. Neck: Supple, no LAD, no JVP elevation. Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal respiratory effort. CV: tachy, no murmurs, rubs, gallops. Abdomen: mildly firm and distended, diminished BS, mild TTP diffusely, no guarding Extremities: 1+ edema, erythema, no tenderness Neurological: alert and oriented X 3, No dysmetria on finger to nose. Skin: No rashes or ulcers. Psychiatric: Appropriate. Pertinent Results: [2111-12-25] 09:03AM PTH-32 [2111-12-25] 06:48AM GLUCOSE-158* UREA N-19 CREAT-0.6 SODIUM-143 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-20 [2111-12-25] 06:48AM estGFR-Using this [2111-12-25] 06:48AM ALT(SGPT)-31 AST(SGOT)-29 ALK PHOS-59 TOT BILI-1.8* [2111-12-25] 06:48AM CALCIUM-10.7* PHOSPHATE-2.4* MAGNESIUM-2.2 ABDOMEN (SUPINE & ERECT) Study Date of [2111-12-25] 7:13 AM FINDINGS: There is unconventional anatomy due to patient's history of spina bifida. Multiple dilated loops of bowel with small bowel measuring up to 4.4 cm in diameter are seen. In the left lateral decubitus view, multiple air- fluid levels are seen. Stool is noted within the distal portion of the colon. No free air is definitively seen. IMPRESSION: Dilated small bowel loops with multiple air-fluid levels suggestive of ileus versus small-bowel obstruction. CT ABDOMEN W/CONTRAST Study Date of [2111-12-25] 11:49 AM IMPRESSION: 1. High-grade obstruction with transition point located in the distal ileum. 2. Associated hydroureter in patient with prior ileal conduit and neobladder surgery. 3. Multiple hypoattenuating hepatic lesions likely hepatic cysts or hemangiomas, stable. 4. Left gluteal decubitus ulcer, stable. 5. Prominent perirectal/gluteal cleft soft tissue of unclear significance but stable since prior scan. Correlation with digital rectal exam could be done after resolution of patient's emergent issues. RENAL U.S. Study Date of [2111-12-27] 9:38 AM IMPRESSION: Markedly limited renal ultrasound as described above. No significant appreciable change in the degree of bilateral hydronephrosis and hydroureter from most recent CT examination. Portable TTE (Complete) Done [2111-12-30] at 11:29:34 AM 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%). 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 leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. 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 [2110-6-26], the estimated pulmonary artery systolic pressure is higher. (LV systolic function appeared normal on review of the prior study). . [2112-1-8] 05:54AM BLOOD WBC-14.2* RBC-3.17* Hgb-9.7* Hct-27.1* MCV-85 MCH-30.7 MCHC-35.9* RDW-15.8* Plt Ct-226 [2112-1-6] 06:26AM BLOOD WBC-13.1* RBC-3.52* Hgb-10.6* Hct-29.1* MCV-83 MCH-30.3 MCHC-36.5* RDW-14.6 Plt Ct-257 [2112-1-5] 06:08AM BLOOD WBC-13.2* RBC-3.76* Hgb-11.2* Hct-31.6* MCV-84 MCH-29.7 MCHC-35.4* RDW-14.3 Plt Ct-287 [2112-1-4] 04:48AM BLOOD WBC-10.7 RBC-3.23* Hgb-9.8* Hct-27.5* MCV-85 MCH-30.4 MCHC-35.7* RDW-14.5 Plt Ct-239 [2112-1-8] 05:54AM BLOOD Glucose-155* UreaN-22* Creat-0.6 Na-144 K-5.5* Cl-118* HCO3-21* AnGap-11 [2112-1-6] 06:26AM BLOOD Glucose-107* UreaN-13 Creat-0.3* Na-146* K-3.4 Cl-112* HCO3-29 AnGap-8 [2112-1-5] 06:08AM BLOOD Glucose-120* UreaN-11 Creat-0.4 Na-146* K-3.5 Cl-109* HCO3-31 AnGap-10 [2112-1-4] 04:48AM BLOOD Glucose-100 UreaN-10 Creat-0.4 Na-145 K-4.0 Cl-108 HCO3-31 AnGap-10 [2111-12-25] 06:48AM BLOOD Glucose-158* UreaN-19 Creat-0.6 Na-143 K-4.0 Cl-102 HCO3-25 AnGap-20 [2112-1-2] 05:03AM BLOOD ALT-15 AST-20 LD(LDH)-169 AlkPhos-34* TotBili-1.1 [2112-1-8] 05:54AM BLOOD Calcium-10.8* Phos-4.2 Mg-3.0* [2111-12-29] 05:01AM BLOOD Albumin-2.2* Calcium-7.9* Phos-3.1 Mg-1.9 Brief Hospital Course: 54F with h/o spina bifida with LE immobility, recurrent SBO, HCV now with SBO and acute renal failure . 1. SBO/Sepsis: High grade small bowel obstruction in imaging. SBO was performed with the removal of 3 feet of necrotic small bowel. Within 12 hours of the procedure, the patient was noted to be hypotensive and required aggressive hydration and a short interval of pressor support. She was initally treated with vanc/cipro/flagyl but there was concern for allergy to one of these medications and so the patient was switched to vanc/zosyn for coverage of abdominal flora. Once patient was transferred to floor (Stone 5), SBP's remained elevated 140 to 170's. Over several days, her blood pressures stablized and returned back to her baseline ranging between 100-110 systolic. She continues with IV Lopressor, and should be transistioned to oral Lopressor once tolerating oral medications. . # Hypoxic Respiratory Failure: Pt was intubated for sugery but continued to require up to POD#8. Barriers to her immediate extubation pulmonary edema in the setting of aggressive fluid resusitaion and labile hypertension. The patients respiratory status stabilized, and remained stable during her hospital course. . # Anxiety: Patient has significant anxiety at baseline and typically takes 2mg xanax every 8 hours at home. While intubated, the patient required versed and peri-extubation, was treated with haldol to minimize agitation. Once on the floor ([Hospital Ward Name 1950] 5), her she appeared somnolent with intermittent delirium & hallucinations. All Benzo's and Narcotics were held for 2-3 days. At this time, Psych was consulted for furhter management, and per the husband's request. The husband had been giving the patient xanax from home. This was discussed with him, and stopped. Her delirium waxed and waned. Home xanax regimen was resumed per Psych recommendation. Currently, her mental status has been much improved with mild confusion occurring overnight. She is easily re-oriented, and non-combative. . # ARF: Renal following. Multiple causes possible. Received IV contrast for CT scan on [12-25]. Also noted to have bilateral hydonephrosis on CT scan, confirmed and unchanged on renal u/s on [12-27]. -Renal and urology services followed patient during admission. -She was adequately volume rescuscitated, Creatinine was followed with marked improvement back to baseline. Her urostomy appliance was completely changed on [2112-1-7]. U/A C+S was sent on [2112-1-6] for slight elevation in WBC to 13. Culture with no growth. UA-negative. Urine clear, yellow. . # ID: She will continue with another 3 days of IV Vanco and Zosyn for a total of 10days to treat post-op fever which occurred in the ICU. WBC slightly elevated for past few days from 13-14. Patient does not exhibit any other symptoms of infection. Vitals are stable. Cognitive status improved, and abdominal incision without signs of infection. . # Skin: Midline abdominal incision OTA with staples. Occasional serosanguinous drainage. Apply ABD pad as needed. Staples to be removed in [1-28] weeks at follow-up appointment with Dr. [Last Name (STitle) ]. Patient requires aggressive skin care due to mobility deficits. Miconazole powder to skin folds-rash improved. Continue to monitor old decubitus site back of left thigh. Apply Duoderm for protection. . # spina bifida: - no active issues . # Nutrition: Diet advanced to regular food. Continues with poor appetite and occasional N/V. Calorie counts initiated. TPN started in ICU, and continued to present day due to poor PO intake. TPN cycled over 12 hours. Electrolytes titrated based on daily labwork. Discontinued TPN once PO intake meets daily caloric needs. . # Access: Right DL PICC placed on [2112-1-4] . # Code: Full Code Medications on Admission: alprazolam 2 TID, hiprex 1gm [Hospital1 ], vitamin C 1000 QD Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day): To affected area. 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 4. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QAM AND QNOON (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Hiprex 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 3 days. 12. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 3 days. 13. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q4H (every 4 hours). 14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for Dyspnea. 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Small bowel obstruction Ischemic bowel Hypoxic respiratory failure Acute renal failure Post-op hypotension Post-op delirium . Secondary: ileoconduit multiple SBO spina bifida chronic constipation HCV recurrent UTI Panic disorder, agoraphobia Osteomyelitis of L ischium [11-28] Discharge Condition: Stable Tolerating clear liquids, and some regular food Pain well controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Apply DSD/ABD pad to incision PRN for serosanguinous drainage. -Your staples will be removed at your follow-up appointment. Steri strips will be applied. -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Urostomy to gravity. Tap water enemas daily, then to twice weekly once bowel function returns to baseline. Calorie counts. Followup Instructions: 1. Please follow-up with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 9] in 2 weeks. Call to arrange appointment. 2. Follow-up with PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) ] [Telephone/Fax (1) 250] in 1 week OR as needed. Completed by:[2112-1-8]	[ "276.8", "995.91", "741.90", "591", "518.5", "038.9", "557.0", "998.59", "584.9", "300.21", "276.0", "564.09", "276.4", "E878.2", "V13.02", "293.0", "560.81", "280.9" ]	icd9cm	[ [ [] ] ]	[ "54.59", "99.04", "99.15", "56.52", "45.62", "96.72", "38.93" ]	icd9pcs	[ [ [] ] ]	11933, 11999	6383, 10183	286, 441	12333, 12411	2606, 6360	14218, 14532	1767, 1996		10298, 11910		12020, 12312		10209, 10275			12435, 13577							13592, 14195	1476, 1693	2011, 2587																							223, 248						469, 1123															1145, 1453	1709, 1751
9,579	125,444	9635	Discharge summary	report	Admission Date: [2168-6-20] Discharge Date: [2168-6-25] Date of Birth: [2138-11-27] Sex: M Service: ICU CHIEF COMPLAINT: Airway obstruction. HISTORY OF PRESENT ILLNESS: The patient is a 29 year old male with a history of childhood asthma with occasional albuterol use, allergic rhinitis and question of obstructive sleep apnea with tonsillar hypertrophy, who presented on the day of admission for an elective tonsillectomy. The procedure was done without any operative events. Postoperatively, the patient developed bleeding from his left tonsillar pole. ENT evaluated the patient and noticed that there was swelling of the uvula and epiglottis with frank bleeding from the left tonsillar pole. The increased bleeding necessitated a return to the Operating Room for a cautery. Estimated total blood loss was 250 to 300 cc. Concern for airway edema and loss of airway led to elective intubation, using an intubating LMA. Intubation was difficult and took 20 minutes to achieve. Transient episodes of hypoxia were noted as well as transient hypotension. The patient was transferred to the Fenard Intensive Care Unit. In the Operating Room the patient was started on propofol, vecuronium, given 2.5 liters of volume resuscitation. PAST MEDICAL HISTORY: 1. Status post left lower extremity gunshot wound complicated by cellulitis in [2165]. 2. Irregular heartbeat. 3. Childhood asthma with occasional post upper respiratory infection reactive airways disease. 4. Allergic rhinitis. 5. Gallstones. 6. Obstructive sleep apnea with tonsillar hypertrophy. 7. History of Helicobacter pylori status post treatment. 8. Status post open reduction and internal fixation of left tibia in [2167-5-11]. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Albuterol MDI with occasional p.r.n. use. SOCIAL HISTORY: The patient works as a cook. He denies smoking. The patient has a history of alcohol abuse and in the past has had two to four 40 ounce beers per day. He denied any evidence of withdrawal symptoms. Currently, he uses about one 40 ounce bottle of malt liquor every two to three days. He does admit to smoking THC every two to three days. FAMILY HISTORY: No history of coronary artery disease, diabetes mellitus or cancer. There is a history of alcohol abuse. PHYSICAL EXAMINATION: The patient arrived to the [Last Name (un) 6608] Intensive Care Unit intubate on assist control 600 by 10, PEEP of 5, 100% FIO2. Temperature was 37.1 F., with a heart rate of 103, blood pressure of 91/22; respiratory rate of 10 and oxygen saturation of 98%. On general examination, the patient was a fairly well appearing male in no apparent distress. He was sedated and intubated. HEENT: The patient was intubated with scant dried blood in clots in the anterior oral cavity. Neck examination revealed mild to moderate neck swelling. Cardiac examination revealed a regular tachycardia, normal S1, S2, no murmurs, rubs or gallops. Pulmonary examination revealed decreased breath sounds at the left base. Abdominal examination revealed the belly was soft, nondistended, with normal bowel sounds and no hepatosplenomegaly. Extremity examination revealed no edema. Neurological: The patient was sedated and paralyzed. LABORATORY: Pertinent laboratory findings were that the patient had a white blood cell count of 16.7, hematocrit of 36.0, and platelets of 241 with an INR of 1.3 and a fibrinogen of 268. EKG with normal sinus rhythm at 96; normal axis, left ventricular hypertrophy with normal intervals. Otherwise no significant ST-T or acute changes. Chest x-ray with discoid atelectasis, right middle lobe, patchy opacity with air bronchograms consistent with pneumonia, versus pneumonitis, versus hemorrhage. SUMMARY OF HOSPITAL COURSE: The patient is a 29 year old male with a history of asthma, ATP, question of obstructive sleep apnea with tonsillar hypertrophy, who presented for a elective tonsillectomy and whose course is complicated by airway edema and hemorrhage requiring intubation for airway protection. 1. ENT: The patient is status post elective tonsillectomy for tonsillar hypertrophy, complicated by severe airway edema and hemorrhage thought secondary to trauma from surgery, necessitating intubation for airway protection. An underlying disorder such angioedema was also of concern. The patient was intubated for a period of 24 to 48 hours while airway edema was stabilized using dexamethasone 10 mg intravenously q. eight hours. The patient was treated with Clindamycin 600 mg intravenously q. eight hours for antibiotic coverage. This was to cover oral flora as well as anaerobes. ENT followed the patient throughout the patient's Intensive Care Unit stay. Laboratory work for angioedema was sent including C4, C1Q, C1 inhibitor, functional assay and trypticase. Serial hematocrits were monitored and the patient's hematocrit remained stable throughout admission. The patient was initially sedated and paralyzed in order to maintain his airway as the intubation was quite difficult. The patient was eventually weaned off steroids and discharged home on Clindamycin 450 mg q. six hours for ten days. He was arranged to follow-up with Dr. [Last Name (STitle) ] as an outpatient. 2. PULMONARY: The patient with a history of asthma and obstructive sleep apnea status post tonsillectomy. Postoperatively the patient was found to have bilateral lower lobe consolidations with a lone temperature spike to 101.6 F. This was thought to be consistent initially with aspiration pneumonia versus pneumonitis. The patient was successfully extubated 48 hours after intubation. He was treated empirically with Clindamycin and Levofloxacin for a potential aspiration pneumonia. However. repeat chest x-ray the day prior to discharge revealed complete resolution of bilateral lower lobe processes and it was thought that these were likely more due to atelectasis than pneumonic process. Levofloxacin was discontinued the day prior to discharge. The patient had no further temperature elevations and a normal white blood cell count after steroids were discontinued. 3. GASTROINTESTINAL: The patient was covered with a proton pump inhibitor for stress ulcers and this was eventually transitioned to ranitidine p.o. when the patient was extubated. 4. HEMATOLOGIC: The patient had postoperative hemorrhage and his hematocrit was monitored and remained stable throughout his Intensive Care Unit stay. 5. PSYCHIATRIC: The patient with a history of alcohol withdrawal and was monitored per CIWA scale and given Ativan as needed. He required very little Ativan and did not undergo any withdrawal symptomology during his stay. The patient recently lost his brother and was told one day after extubation. The patient was very saddened by this news and requested discharge in time for the funeral. He had family present with him for support 6. INFECTIOUS DISEASE: The patient had two out of four bottles grow Gram positive cocci in pairs and clusters from the same set of blood cultures. This was around the time of extubation. Cultures subsequently returned coagulase negative Staphylococcus and this was most consistent with contamination. The patient was initially covered with Vancomycin until cultures came back with coagulase negative Staphylococcus. He remained afebrile with a normal white count after extubation. 7. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was initially n.p.o. while intubated and as he was extubated, he was given clears which were advanced to soft liquids which were eventually full liquids, which was eventually advanced to a soft solid and then a full diet. He did well without any evidence of aspiration. 8. PROPHYLAXIS: The patient was maintained on an intravenous proton pump inhibitor while intubated and this was switched to p.o. H2 blocker, once able to take p.o. He was maintained on Venodyne boots for deep vein thrombosis and pulmonary embolism prophylaxis throughout his hospital stay. He was also out of bed and ambulatory two days prior to discharge. 9. COMMUNICATION: Communication was maintained with the family as well as the patient's primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4569], on several occasions. 10. CODE STATUS: The patient was full code throughout his admission. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient was discharged home with follow-up with his primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4569] within one week of the discharge. The patient was also advised to follow-up with his ENT Surgeon, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], for follow-up after his procedure. The patient was arranged to have an echocardiogram to evaluate for pulmonary hypertension as he had a history of possible obstructive sleep apnea and enlarged pulmonary arteries on chest x-ray. He will follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the pulmonary department who specialized in pulmonary hypertension. The patient was also advised to speak to his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4569], for follow-up of his angioedema, labs including C1 esterase inhibitors, C1Q and tryptase. The day before admission, the patient showed satisfactory exercise capacity and was able to ambulate up and down the length of the unit with maintenance of an oxygen saturation of 95 to 96% on room air. Given this, he was thought to be stable for discharge and was discharged on [2168-6-25]. DISCHARGE MEDICATIONS: 1. Albuterol inhaler, two puffs inhaled every four hours as needed for wheezing. 2. Clindamycin 450 mg p.o. q. six hours. DISCHARGE DIAGNOSES: 1. Status post tonsillectomy. 2. Laryngeal edema and hemorrhage requiring intubation. 3. Respiratory failure, acute. DR.[Last Name (STitle) 39],[First Name3 (LF) ] 04-143 Dictated By:[Last Name (NamePattern1) 5246] MEDQUIST36 D: [2168-6-25] 15:56 T: [2168-6-25] 16:36 JOB#: [Job Number 32620] cc:[Last Name (NamePattern4) 32621]	[ "E878.6", "478.6", "998.11", "E849.7", "305.01", "474.11", "518.5", "780.57", "493.90" ]	icd9cm	[ [ [] ] ]	[ "33.22", "96.04", "28.7", "28.2", "96.71" ]	icd9pcs	[ [ [] ] ]							2229, 2336	9971, 10361	9825, 9950																											3819, 8439	2360, 3790											156, 177						207, 1275															1297, 1850	1868, 2211	8465, 9802
45,391	103,165	8749	Discharge summary	report	Admission Date: [2135-7-14] Discharge Date: [2135-7-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: GIB Major Surgical or Invasive Procedure: intubation (electively for EGD only; otherwise DNR/DNI) colonoscopy EGD History of Present Illness: 86M with h/o recent NSTEMI [1-17], and recent admission to OSH for GIB of unclear source (plavix stopped x5d, then restarted), presenting to [Hospital1 18]-N this morning for altered mental status, lethargy, and black stools. VS there 97.7 118 16 78/48 90%RA. Exam notable for guaic positive stool and lethargy. Labs revealed HCT 22, K 6.0 (hemolyzed), CRE 2.9. NG lavage revealed green gastric contents, no blood, no coffee grounds. He received 2 PIVs, nexium gtt, CTX 1 gm, azithromycin, and 2U PRBC, with BP improvement to 101/42 HR 89 at time of transfer to [Hospital1 18]. Of note, he was admitted to [Hospital ] Hospital [Date range (1) 30614] in the setting of weakenss and [Doctor Last Name ] large dark bowel movement, found to be anemic (HCT 21.3 on admission, up to 34.1 at discharge after total 5U PRBCs), and was admitted for evaluation of GIB with EGD, with course c/b respiratory failure requiring intubation (per family x3d) felt [3-14] CHF vs PNA. EGD at that time revealed esophagitis and duodenitis per discharge summary. In ED VS = 97.8 93 128/58 20 100%. Labs upon arrival notable for K 5.8, CRE 2.4 (baseline 1.3 at time of discharge [6-30]), HCT 25.6 (after 2U PRBC from OSH), WBC 20.1, INR 1.2. SBP dropped to 77/42 with HR 103, so CVL was placed and he was started on levophed, and received an additional . SBP improved to 120s after 1L NS and an additional 1U PRBC, which is still hanging. GI consult obtained, cardiology made aware. Past Medical History: - CAD s/p 2 vessel CABG in [2126], bioprosthetic AVR, NSTEMI [1-17] with DES to RCA (>90% stenosis), and PL, otherwise open SV grafts x 2 (LAD, DIAG), native 90% LCx dx. - CHF (EF= 30-44%), mod TR, LAE on TTE [6-18] at OSH. - PVD - known R SFA occlusion @ cath [1-17]. - HTN - DM2 - on oral meds. - Hyperlipidemia - h/o CVA in [5-19] with slurred speech, found to have (atrophy, small vessel ischemic changes, subtle chronic left pontine infarct) on CT HEAD at OSH [6-18]. Social History: Lives alone, 7 children. No tobacco, drinks [2-11] glasses of wine a week, denies IVDU. Family History: HTN, CAD, DM. Physical Exam: Vitals: 97.4 95 150/55 27 99%2L General: lethargic, oriented x1, no acute distress HEENT: MM dry, oropharynx clear, poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: Regular rate, normal S1 + S2, 2/6 SEM @ RSB, no rubs, gallops Abdomen: soft, non-tender, non-distended, hypoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2135-7-14] 08:35PM WBC-18.7* RBC-2.82* HGB-8.5* HCT-25.0* MCV-89 MCH-30.2 MCHC-34.1 RDW-18.7* [2135-7-14] 08:35PM PLT COUNT-214 [2135-7-14] 08:28PM GLUCOSE-232* UREA N-111* CREAT-2.0* SODIUM-142 POTASSIUM-5.5* CHLORIDE-112* TOTAL CO2-20* ANION GAP-16 [2135-7-14] 08:28PM CK(CPK)-152 [2135-7-14] 08:28PM CK-MB-23* MB INDX-15.1* cTropnT-0.63* [2135-7-14] 04:51PM TYPE-ART PO2-475* PCO2-40 PH-7.32* TOTAL CO2-22 BASE XS--5 [2135-7-14] 04:51PM LACTATE-0.8 [2135-7-14] 03:37PM WBC-17.6* RBC-2.66* HGB-8.3* HCT-23.5* MCV-88 MCH-31.1 MCHC-35.2* RDW-18.7* [2135-7-14] 03:37PM PLT COUNT-215 [2135-7-14] 01:03PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2135-7-14] 10:36AM LACTATE-1.4 [2135-7-14] 09:47AM HGB-9.0* calcHCT-27 [2135-7-14] 09:45AM GLUCOSE-231* UREA N-123* CREAT-2.4# SODIUM-136 POTASSIUM-5.8 CHLORIDE-104 TOTAL CO2-19* ANION GAP-19 [2135-7-14] 09:45AM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-43 TOT BILI-1.0 [2135-7-14] 09:45AM LD(LDH)-163 CK(CPK)-95 [2135-7-14] 09:45AM LIPASE-85* [2135-7-14] 09:45AM cTropnT-0.42* [2135-7-14] 09:45AM calTIBC-291 HAPTOGLOB-163 FERRITIN-94 TRF-224 [2135-7-14] 09:45AM WBC-20.1* RBC-2.83* HGB-8.6* HCT-25.6* MCV-90# MCH-30.4# MCHC-33.7 RDW-17.9* [2135-7-14] 09:45AM NEUTS-92.3* LYMPHS-5.7* MONOS-1.9* EOS-0.1 BASOS-0.1 [2135-7-14] 09:45AM PLT COUNT-245 [2135-7-14] 09:45AM PT-14.1* PTT-24.6 INR(PT)-1.2* STUDIES: [2135-7-14] ECG: LBBB (old), nl axis, no STE per sgarbossa criteria, STD and TWI in 1, avl, V4-6 c/w LVH. [2135-7-14] CXR: no obvious infiltrate, pulmonary edema. ?free air under right diaphragm. prior cabg and avr seen. [2135-7-15]: Colonoscopy: There was a very tight bend at the sigmoid colon which could represent previous anastomosis if patient has had prior surgery. There were a few areas of a few red drops of blood seen in the ascending colon which were washed without underlying lesion seen. Mucosa appeared very friable and occasional contact bleeding was seen. However, this was minimal and does not account for transfusion requirement. Polyp in the sigmoid colon Bile was seen in the terminal ileum and cecum without evidence of blood. Ileum was normal up to 25 cm. Otherwise normal colonoscopy to terminal ileum to 20 cm. [2135-7-15]: EGD: Impression: Mild gastritis. Otherwise normal EGD to second part of the duodenum [2135-7-15]: CT ABD/PELVIS 1. No retroperitoneal bleed. Right femoral venous catheter in expected position. 2. Two rim calcified infrarenal abdominal aortic aneurysms measuring up to 3 cm in diameter are chronic, without adjacent paraaortic abnormality. These may be the sequelae of prior penetrating ulcer or focal dissection. Dense calcification at the origin of the renal arteries and SMA; significant stenosis cannot be excluded. 3. Cholelithiasis without evidence for cholecystitis on this limited non-contrast exam. [2135-7-16] Echo The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior and infero-lateral akinesis with septal hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. 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 moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: # GIB - Patient having melanotic stools with hemodynamic instability requiring total of (6units, last transfusion on [2135-7-15]) of pRBCs at [Hospital1 18]. GI was consulted. EGD was negative for acute bleed. Colonoscopy was negative for acute bleed. CT scan was negative for RP bleed. Hemolysis labs were negative. Hct remained stable since last transfusion on [2135-7-15] # hypotension - Initially concerning for GIB given guaic positive stool, decreased HCT, and recent similar admission. ddx also included sepsis, so evaluated for possible sources with CXR, Bcx, and UCx. CXR was negative. Bcx and Ucx were negative Patient was given aggressive IVF and blood as above. After the colonoscopy he did require levophed briefly, but then was able to maintain BPs without pressor-support. # confusion - per family, confusion was typical of pt's hospitalizations, and likely multifactorial with contribution from poor neurologic reserve (h/o CVA, chronic vascular changes), hypotension, and possible septic picture. No evidence to suggest primary CNS infection (no meningismus, headache, kernig, brudzinki negative), no focal neurologic deficits on exam. Seroquel was held, then restarted at home dose. Pt returned alert and oriented x 3 once transferred out of ICU. # hyperkalemia - likely [3-14] ARF. no ECG changes c/w hyperkalemia. Resolved. . # ARF - likely [3-14] volume depletion. lactate negative. Resolved with IVF. . # CAD - s/p NSTEMI. denies chest pain or dyspnea, and EKG without frank evidence of ischemia though has old LBBB, and worsening TWI and STD in V4-6 in setting of sinus tach and anemia (likely reflects both LVH and some demand ischemia). feels ACS is unlikely, but given +troponin and recent NSTEMI, will proceed as follows: - held ASA and plaivx initially, then restarted when EGD revealed no active bleeding. - held metoprolol, lisinopril given initial hypotension, then restarted when pt actually became hypertensive on the floor - transfuse to maintain HCT > 27. - Echo done, result as above . # CHF - EF 40% at OSH in [6-18], on lasix at home. Held lisinopril and lasix initially, then restarted prior to discharge. # DM2 - on orals at home; covered with ISS during hospital stay. . # hyperlipidemia - held statin initially, then restarted prior to discharge. . # Code: DNR/DNI Medications on Admission: - metformin 500mg po bid - plavix 75mg po qdaily (stopped x5d during [6-18] admission) - glipizide 10mg po bid - metorolol 50mg po bid - isosorbide mononitrate 30mg po qdaily - lisinopril 20mg po qdaily - digoxin 125mg po qdaily - hydralazine 25 mg po tid - lipitor 20mg po qdaily - senna - colace - aspirin 81mg po qdaily - mvi - seroquel 25mg po bid (started [6-18]) - lasix 40mg po qdaily - prilosec 40mg po bid Discharge Medications: 1. Equipment 3-in-1 commode (diagnosis of CVA) 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO twice a day. 7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:30 Tablet Sustained Release(s) Refills:2 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Lipitor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 17. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 18. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for yeast infection on buttocks. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: GI bleed Acute renal failure . Secondary: Coronary artery disease Hypertension Chronic systolic heart failure Discharge Condition: Improved Discharge Instructions: You were admitted to the hospital for bleeding in the gastrointestinal tract. Upper and lower endoscopy was done however we could not find the source of the bleeding because it had stopped bleeding by then. . A capsule study has been scheduled for you. You will receive instructions by mail, but you should also call [Location (un) 13544] at [Telephone/Fax (1) 30615] to confirm the appointment and learn more about the procedure. . Some changes were made to your medications: - Stopped hydralazine (blood pressure medication) - Stopped Prilosec and instead started Ranitidine - Changed Seroquel from 25 mg twice a day to 25 mg once at bedtime - Added Nystatin cream as needed for fungal infection of the buttocks . CT scan of your abdomen and pelvis done during this hospitalization showed some changes that should be followed up with a repeat scan in 3 months ([Month (only) 216]-[2135-10-11]). Your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] this. . Please weigh yourself every morning and call your doctor if weight > 3 lbs. Please adhere to 2 gm sodium diet. . If you experience dizziness, palpitations, black tarry stools, red blood with stools, or any other symptoms concerning to you, please call your doctor or return to the emergency room. Followup Instructions: Please go to the following appointments as scheduled: Capsule study: [2135-7-26] 8:00 AM with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1982] Phone:[Telephone/Fax (1) 463] Follow up appointment with gastroenterology: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8718], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2135-8-2] 1:30 PM . Please call Dr.[Name (NI) 30616] office at [Telephone/Fax (1) 29110] to follow up in [4-13] weeks (sometime after your appointment with Dr. [Last Name (STitle) 4539]. Please mention that you were asked to get a repeat imaging of your abdomen for the findings seen on CT scan during your hospital stay. A summary of your hospitalization will be faxed to her office. Completed by:[2135-8-3]	[ "276.50", "272.4", "530.10", "535.50", "276.7", "401.9", "V43.3", "584.9", "250.00", "535.60", "443.9", "426.3", "428.0", "285.9", "V45.82", "412", "V58.67", "414.01", "428.22", "V12.54", "298.9", "288.60", "211.3", "578.9" ]	icd9cm	[ [ [] ] ]	[ "99.04", "33.23", "96.04", "38.93", "38.91", "45.23", "45.13" ]	icd9pcs	[ [ [] ] ]	11501, 11550	7178, 9518	265, 338	11713, 11724	3075, 7155	13068, 13875	2523, 2538		9992, 11478		11571, 11692		9544, 9969			11748, 13045									2553, 3056																							222, 227						366, 1875															1897, 2396	2412, 2507
50,050	169,097	42803	Discharge summary	report	Admission Date: [2102-12-6] Discharge Date: [2102-12-16] Date of Birth: [2032-12-19] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: [2102-12-12] 1. Urgent coronary artery bypass grafting x5 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the second obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the posterior descending coronary artery. 2. Endoscopic left greater saphenous vein harvesting. [2102-12-6] Cardiac Catheterization History of Present Illness: 69 yoM with h/o T2DM, HTN, and HL who presents with chest pain. Two days prior to admission he went for a walk and after about a mile, started to feel a substernal chest heaviness that eventually subsided and he walked another mile. That night he had an episode of chest pressure at rest. This morning, he got out of the shower and had similar chest pressure, now accompanied by fatigue, diaphoresis, and shortness of breath. He reports feeling so unwell that he couldn't get his clothes on. He went to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital at that time. . At OSH, labs showed trops 0.03-> .18->.76. ECG showed TWI in inferolateral leads. He was loaded with 300mg plavix yesterday. He was transferred to [Hospital1 18] for cardiac caheterization. In the cath lab, he was found to have 3 vessel disease with EF 45%. Heparin IV was restarted after cath. He was then referred to cardiac surgery for revascularization. Past Medical History: Diabetes mellitus Hypertension Hypercholesterolemia PSH: foot surgery as a child Social History: Lives with his wife in [Name (NI) 5028]. Has 5 kids, 10 grandkids. Works at [Hospital1 ] Airport. Denies current or previous tobacco use, alcohol use, or recreational drug use. Family History: Brother had MI at age 55, still living, also with DM. Father died of valvular heart disease at age 72. Mother died at age [Age over 90 ]. Physical Exam: Admission PEx: VS: T 97.0 BP 119/44 HR 76 RR 16 O2 Sat 98%RA Wt 108.7kg GENERAL: Awake, well-appearing male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7cm. CARDIAC: RRR, with normal S1, S2. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. CTAB except for scant crackles at left base that cleared with coughing. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Right groin dressing clean/dry/intact. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ femoral, DP, and PT pulses bilaterally. . Pertinent Results: Labs on Admission: [2102-12-6] 05:00PM BLOOD WBC-8.0 RBC-3.67* Hgb-11.9* Hct-32.8* MCV-89 MCH-32.3* MCHC-36.2* RDW-11.2 Plt Ct-193 [2102-12-6] 05:00PM BLOOD PT-13.0* PTT-32.0 INR(PT)-1.2* [2102-12-6] 05:00PM BLOOD Glucose-114* UreaN-15 Creat-0.8 Na-130* K-4.0 Cl-99 HCO3-25 AnGap-10 [2102-12-6] 05:00PM BLOOD ALT-32 AST-138* CK(CPK)-392* AlkPhos-63 Amylase-53 TotBili-0.4 [2102-12-6] 05:00PM BLOOD cTropnT-1.91* [2102-12-7] 07:05AM BLOOD CK-MB-25* MB Indx-10.7* [2102-12-6] 05:00PM BLOOD TotProt-5.8* Albumin-3.7 Globuln-2.1 [2102-12-7] 07:05AM BLOOD Calcium-9.2 Phos-2.4* Mg-1.9 Cholest-148 [2102-12-6] 05:00PM BLOOD %HbA1c-6.2* eAG-131* [2102-12-7] 07:05AM BLOOD Triglyc-106 HDL-37 CHOL/HD-4.0 LDLcalc-90 [2102-12-7] 04:51AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.023 [2102-12-7] 04:51AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2102-12-7] 04:51AM URINE [2102-12-7] 04:51AM URINE Hours-RANDOM UreaN-791 Creat-103 Na-38 K-26 Cl-34 [2102-12-7] 04:51AM URINE Osmolal-507 URINE CULTURE (Final [2102-12-8]): NO GROWTH. Staph aureus Screen (Final [2102-12-9]): NO STAPHYLOCOCCUS AUREUS ISOLATED. [Hospital1 18] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 6.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 5.0 cm Left Ventricle - Fractional Shortening: 0.17 >= 0.29 Left Ventricle - Stroke Volume: 62 ml/beat Left Ventricle - Cardiac Output: 3.43 L/min Left Ventricle - Cardiac Index: 1.69 >= 2.0 L/min/M2 Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.3 cm <= 3.0 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 6 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 3 mm Hg Aortic Valve - LVOT VTI: 18 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: 2.1 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Mitral Valve - E Wave deceleration time: 380 ms 140-250 ms Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized. No spontaneous echo contrast or thrombus in the body of the RA or RAA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. No atheroma in ascending aorta. Complex (>4mm) atheroma in the aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Moderate (2+) MR. Prolonged (>250ms) transmitral E-wave decel time. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. GENERAL COMMENTS: The patient was under general anesthesia throughout the procedure. No TEE related complications. Results Conclusions PRE-BYPASS: 1. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 2. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. 3. No atrial septal defect is seen by 2D or color Doppler. 4. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with hypokinetic inferior & inferolateral wall motion. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). 5. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Dr.[Last Name (STitle) 914] was notified in person of the results in the operating room. POSTBYPASS: The patient is in sinus rhythm on low dose epinephrine and moderate dosage of phenylephrine infusions. With inotropic support, the RV function is maintained, the LV function is improved with EF=45%. The inferior & inferolateral walls which were hypokinetic prebypass remain hypokinetic but improved from prebypass assessment. The MR is now trace. The TR is now trace. The remaining valves are unchanged. The aorta remains intact. [12-7] Cardiac Catheterization: 1. Selective coronary angiography of this right dominant system demonstrated severe 3 vessel coronary artery disease. The LMCA was without angiographically significant coronary artery disease. The LAD had a proximal 50% stenosis and a mid 75% stenosis after the first diagonal. The remainder of the LAD was without angiographically significant stenoses. The LCX had a mid 95% stenosis and a 70% stenosis at the ostium of OM1. The RCA was diffusely diseased with a 50% ostial lesion, and a long 75-80% stenosis in the mid segment. The RPDA had an ostial 70% stenosis. Right to left collaterals were noted. 2. Left heart catheterization revealed an elevated LVEDP of 25 mmHg. 3. Left ventriculography demonstrated a LV ejection fraction of 44.5% as calculated by LV plainimetry. The inferior wall was severely hypokinetic to akinetic, and there was moderate anteroapical hypokinesis. There was no mitral regurgitation. 4. Limited resting hemodynamics revealed a normal systemic arterial blood pressure with a central aortic blood pressure of 115/64. 5. Right femoral artery closed with 6 French AngioSeal. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Acute Non-ST elevation myocardial infarction. 3. LV systolic dysfunction. 4. Elevated LVEDP after angiography. 5. Normal systemic arterial blood pressure . 6. Arterial access closed with AngioSeal. [12-8] Carotid US 1. 60-69% stenosis in the right internal carotid artery with significant homogeneous plaque in the mid right internal carotid artery. 2. Less than 40% stenosis in the left internal carotid artery. [2102-12-16] 06:00AM BLOOD WBC-7.5 RBC-3.06 Hgb-9.9* Hct-28.0* MCV-91 MCH-32.4* MCHC-35.5* RDW-12.0 Plt Ct-180 [2102-12-16] 06:00AM BLOOD Glucose-79 UreaN-24* Creat-1.1 Na-131* K-4.5 Cl-94* HCO3-31 AnGap-11 Brief Hospital Course: 69 year old male with h/o T2DM, HTN, and HL who presents with chest pain and positive troponins consistent with NSTEMI, cardiac cath revealed severe 3 vessel coronary artery disease. Cardiac surgery consulted and patient deemed to be good surgical candidate. Since patient received plavix loading prior to cath, a 5 day washout period was instituted. Preoperative workup included transthoracic echo which revealed LVEF 40-45%, [12-11]+MR. Carotid ultrasound with R(60-65%), L(40%). The patient was brought to the operating room on [12-12] for coronary bypass grafting with Dr [Last Name (STitle) 914]. Please see operative report for details in summary he had: 1. Urgent coronary artery bypass grafting x5 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the second obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the posterior descending coronary artery. 2. Endoscopic left greater saphenous vein harvesting. His bypass time was 112 minutes, with a crossclamp time of 96 minutes. He tolerated the operation well and post operatively was transferred to the cardiac surgery ICU for recovery in stable condition on Neosynephrine infusion for hemodynamic support. He remained hemodynamcially stable in the immediate post-op period, anesthesia was reversed he woke neurologically intact and extubated. On POD1 he continued to be hemodynamically stable but continued to require low dose Neosynephrine infusion support and stayed in the ICU. On pOD2 he weaned from Neosynephrine infusion, was started on Bblockers and diuretics and transferred to the stepdown floor for continued recovery. All tubes, lines, and drains were removed per cardiac surgery protocol. He did have several short bursts of atrial fibrillation while in the ICU and was started on Amiodarone. The remainder of his hospital course was uneventful. He worked with nursing and physical therapy to improve his strength and mobility and on POD#4 was discharged home with visiting nurses. He is to follow up with Dr [Last Name (STitle) 914] in 1 month Medications on Admission: Lisinopril 5mg po daily Aspirin 81mg po daily Metformin 1000mg po bid MVI 1 tab po daily Fish Oil Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 mg [Hospital1 ] x 7 days, then decrease to 200 mg [Hospital1 ] x 7 Disp:120 Tablet(s) Refills:2 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:45 Tablet(s) Refills:2 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:14 Tablet(s) Refills:0 9. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 14 days. Disp:28 Tablet Extended Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: CAD s/p CABG x5 PMH: Diabetes mellitus Hypertension Hypercholesterolemia PSH: foot surgery as a child Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema (L)LE 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 one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks 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: [Hospital 409] clinic [Telephone/Fax (1) 1504] to be arranged. Surgeon: Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914] [Telephone/Fax (1) 1504] to be arranged. Cardiologist: Dr. [Last Name (STitle) 77919] [Telephone/Fax (1) 65733] to be arranged. Please call to schedule appointments with your: Primary Care Dr [Last Name (STitle) ],[First Name3 (LF) ] P. [Telephone/Fax (1) 82199] in [3-15] weeks Endocrinologist: Dr. [First Name4 (NamePattern1) 2092] [Last Name (NamePattern1) 92463] 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:[2102-12-16]	[ "427.31", "410.71", "E878.2", "401.9", "V17.3", "250.00", "997.1", "272.4", "414.01" ]	icd9cm	[ [ [] ] ]	[ "88.53", "88.56", "37.22", "39.61", "36.15", "36.14" ]	icd9pcs	[ [ [] ] ]	13802, 13885	10104, 12449	326, 950	14031, 14266	3208, 3213	15083, 15885	2266, 2412		12598, 13779		13906, 14010		12475, 12575		9400, 10081	14290, 15060									2427, 3189																							272, 288						978, 1943								3227, 9383							1965, 2048	2064, 2250
3,442	101,983	43189+58599	Discharge summary	report+addendum	Admission Date: [2178-12-25] Discharge Date: [2178-12-30] Date of Birth: [2139-10-26] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 759] Chief Complaint: DKA Major Surgical or Invasive Procedure: Cardiac cath: no CAD History of Present Illness: 39 yo f w/ h/o hypothyroid, type II DM who started to complain of flu-like sx with generalized malaise, headache, neck and [First Name3 (LF) 93073] pain approx 6d ago after going to a chinese restaurant where all of her family members got nausea/diarrhea. According to husband, [Name (NI) 93073] pain radiating around to abdomen in "bandlike" pattern. Remained in bed most of next two days. Had decreased p.o. intake, on Wed went to PCP, [Name10 (NameIs) ] on NSAIDS, flexaril, vicodin. Pt still complained of increased lethargy that evening and brought to OSH ED where her glucose was 744, ag 28, bicarb 5, ph 6.9. Amylase 99, lipase 656 and ARF w/ cr 1.4. Also WBC 18.7 w/ 17% bandemia. She was started on insulin gtt, sodium bicarb, and IVF. CXR was clear, RUQ u/s w/o evidence of cholelithiasis, of dilated CBD. Head CT neg. Started on cefotax and levoflox on [12-25]. TTE reported to show anterior and lateral and apical HK w/ EF 40%. Lipase peaked at 1649. Glucose difficult to control and pt transferred to [Hospital1 18]. Past Medical History: hypothyrodism DM II- not taking meds for last 3 months. Social History: Marries w/ 2 children Works at Catholic charity Denies Etoh Denies Tobacco Denies IVDU. Family History: Father DM Paternal GM DM Mother died of MI at 69. No h/o pancreatitis. Physical Exam: t 97.2, bp 106/68, p 124, r 17, 100% ra Middle aged woman, resting in bed, w/ fluctuating ability to hold a conversation. PERRL. OP clear. No JVD Dry mucous membranes LCA b/l Bony protrusion of R cervical area of c6-7 area. Minimally tender, no surrounding erythema, no flocculence. +bs. soft. nt. nd. Horizontal stretch marks on both sides of her abdomen. No le edema. Pertinent Results: [2178-12-26] 04:24AM BLOOD WBC-13.8* RBC-3.55* Hgb-11.8* Hct-31.4* MCV-89 MCH-33.2* MCHC-37.5* RDW-13.6 Plt Ct-127* [2178-12-26] 04:24AM BLOOD Neuts-75.6* Lymphs-20.8 Monos-3.0 Eos-0.3 Baso-0.3 CXR: no acute cardiopulm dz CT ABD/PELVIS: Small amount of nonspecific free fluid within the pelvis and minimal right sided pleural effusion. Otherwise, normal CT of the abdomen and pelvis. CATH: a right dominant system with no angiographically apparent flow limiting stenoses. The LMCA, LAD, and RCA had minimal luminal irregularities. The patent LCX supplied 2 OMs. The cardiac index was normal (3.5 l/min/m2). Left ventriculography showed global hypokinesis (EF 40 to 45%) with no mitral regurgitation. Brief Hospital Course: 1) [Name (NI) 75996] Pt has a hx of Type II DM with no requirement of insulin and was only on oral hypoglycemic [Doctor Last Name 360] previously. Pt presesnted to the OSH with DKA and was managed in the ICU with insulin drip, fluid resuccitation, and electrolyte replacement. [Last Name (un) ] was following her and started the patient on insulin (15 units glargine qhs, and humalog ISS). She may have a late onset of Type I DM, or this could be secondary to pancreatitis with beta cell dysfunction. She will be discharged with insulin and a follow up with [Last Name (un) ]. 2) GPC bacteremia- Pt presented with 1/1 bottle GPC +blood cx at OSH. It was most likely contaminant since it grew out staph. epi at OSH. Vancomycin was initially started but discontinued once repeat blood cultures were negative. 3) Pancreatitis-unclear diagnosis given relatively benign presentation. Enzymes elevated out of proportion to clinical symptoms but trended down on it's own. At OSH, triglycerides and calcium were normal. Pt has no history of alcohol abuse and denies any recent binge. CT of the abdomen/pelvis were normal. It only showed small amount of nonspecific free fluid within the pelvis and minimal right sided pleural effusion. Since pt had a flu-like sx several days prior to these events, pancreatitis could be from viral infection as well. 4) Systolic dysfunction- At OSH, TTE was ordered which showed EF of 40%. The repeat TTE showed EF of 35%, moderate regional left ventricular systolic dysfunction with focal hypokinesis of the distal half of the septum and anterior walls and apex. The remaining segments contract well. Right ventricular chamber size is normal with mild global free wall hypokinesis consistent with possible mid-LAD disease. Pt was taken to cath which showed clean coronaries. Work up for cardiomyapathy including SPEP/UPEP, iron studies, [Doctor First Name ], rheumatoid factor, Lyme titer. HIV study was not sent since she is does not have any risk factor. Given the hx of flu-like sx, it could be from viral etiology such as coxsacke virus which could also cause pancreatitis which may have led to DKA. Pt should be seen by Dr.[Name (NI) 23312] [Hospital 1902] clinic and should have a follow up echo in few months. Pt was discharged with Toprol 25 mg qd, lisinopril 2.5 mg qd, and ASA 81 mg qd. Lisinopril was not titrated since sBP runs in 80's-90's at baseline. 5)Hypothyroid: Pt's TSH and free T4 level were consistent with hypothyroid. She was continued on Synthroid 150 mcg po qd. 6)Spine mass: Pt reports having painful spine bony protusion for the last 2 years. She says that the pain is intermittent and is paraspinal. On exam, she has a mass that is firm consistent with bone, nontender to palpation that is at C5-C6 level. She has never gotten a work up for this. Pt should get an outpatient MRI of the spine for further evaluation. Medications on Admission: On transfer: Cefotaxime Levoflox Insulin gtt 7 units/h Diflucan 100mg iv q24h Synthroid 150mcg qday Discharge Medications: 1. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 3. insulin Take Glargine insulin 15 units at bedtime, and take Humalog sliding scale as printed 4. insulin syringes and needles Please give 120 syringes and needles, with 2 refills 5. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. ketone strips Sig: One (1) as needed. Disp:30 Refills:2 7. Outpatient Lab Work Serum Potassium within 2 weeks of discharge 8. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO at bedtime. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 9. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: Per sliding scale. Disp:1 vial Refills:2 10. Lantus 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. Disp:10 ml Refills:2 Discharge Disposition: Home With Service Facility: [Hospital6 486] Discharge Diagnosis: Primary: 1. diabetic ketoacidosis 2. depressed ejection fraction/systolic dysfunction Secondary: 1. hypothyroidism 2. tachycardia Discharge Condition: stable, tolerating po, ambulating Discharge Instructions: Please keep all of your appointments and take all of your medicine. You should have your potassium checked within 2 weeks. You will need to check your sugars 4 times a day and give yourself insulin as prescribed on the insulin sliding scale. You should call the [Hospital ] clinic with any questions. You should call your doctor or come to the hospital if you experience chest pain, shortnes of breath, fevers or other concerning symtpoms. Followup Instructions: 1)[Last Name (un) ] -Thursday [1-7] MB [Name8 (MD) 46218] RN -[1-15] 9:30am Dr. [Last Name (STitle) ] 2) Cardiology: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 1401], M.D. Where: [Hospital 273] CARDIAC SERVICES Phone:[Telephone/Fax (1) 2386] Date/Time:[2179-1-14] 2:00 Please call to make an appointment with a primary care doctor. The number for the clinic is ([Telephone/Fax (1) 1300].Provider: [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2179-1-13] 2:00 Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16701] [Hospital 1902] clinic to make an appointment in [2-6] weeks. [Telephone/Fax (1) 3512] Completed by:[2178-12-30] Name: [Known lastname ] [Known lastname 1063],[Known firstname ] [Last Name (NamePattern1) ] Unit No: [Numeric Identifier 14682] Admission Date: [2178-12-25] Discharge Date: [2178-12-30] Date of Birth: [2139-10-26] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2544] Chief Complaint: Major Surgical or Invasive Procedure: Brief Hospital Course: Anemia: Pt noted to be anemic with Hct 27-28 with mild thrombocytopenia Plt 120's. Hct initially in high 30's but it was in a setting of hypovolemia during DKA. This could be from the recent viral infection causing bone marrow suppression as well as cardiomyopathy and pancreatitis. No source of internal or external bleed. Pt needs a follow up of Hct and plt as an outpatient. If her cound does not show improvement, she may need further study including possible BM biopsy for aplastic anemia or MDS. PCP needs to follow up with her iron studies. Discharge Disposition: Home With Service Facility: [Hospital6 1066] Discharge Diagnosis: Discharge Condition: Discharge Instructions: Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2545] MD [MD Number(2) 2546] Completed by:[2178-12-30]	[ "425.4", "577.0", "250.13", "244.9", "287.5", "276.5", "428.20", "285.9" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.23", "88.53" ]	icd9pcs	[ [ [] ] ]	9621, 9672	9044, 9598	9021, 9021	9718, 9718	2073, 2786	9798, 9927	1595, 1667		5887, 6894		9695, 9695		5762, 5864			9744, 9744									1682, 2054																							8981, 8981						329, 1394															1416, 1474	1490, 1579
5,544	116,545	489	Discharge summary	report	Admission Date: [2123-11-10] Discharge Date: [2123-12-3] Date of Birth: [2047-10-15] Sex: M Service: MEDICINE Allergies: Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit Extracts / Nafcillin / cefazolin Attending:[Doctor First Name 3298] Chief Complaint: fever, rigor, vomiting Major Surgical or Invasive Procedure: TEE [11-12], no vegetations, EF 40-45% DCCV: [11-16], converted to NSR PICC line placed R arm Temporary HD line placed R IJ [2123-11-26], removed [2123-12-3] History of Present Illness: Mr. [Known lastname 23] is a 76 yo M with h/o CAD, CHF, a-fib, AVR, DM, HTN, HLD, p/w one day of fever, rigor, nausea and vomiting. Pt felt sudden onset rigor one day ago, with fever to 100, and BP reportedly to 220/120 at home. He had some valium and was able to sleep. He Of note, pt did not have recent sickness, no weight loss, night sweats. He did report some exercise intolerance recently in the gym, which he attributed to hypoglycemia. Of note, pt had a PCI with 2 drug eluting stents placed in LAD and R-PDA. Pt had no recent dental work and never had colonoscopy. Pt went to [Hospital1 ] [Location (un) ] today, where he had VS: 102.1 HR: 101 BP: 123/49 Resp: 23 O(2)Sat: 100%. Lab showed WBC of 11.3 with 7% Bands, INR 3.2, Cr 2.4, CK 1400, CK-MB 6, Trop 0.035; and moderate hepatocellular transaminitis. Pt underwent noncontrast CT-head, which did not reveal acute intracranial bleed. Blood culture later grew GPC in pairs and clusters. Pt received 2L IVF and one dose ceftriaxone / zosyn, and transferred to [Hospital1 ] [Location (un) ]. In [Hospital1 ] [Location (un) ], patient was switched to nafcillin once cultures showed MSSA. After starting nafcillin, his urine output diminished significantly and his creatinine bumped. At this time, the patient presented to our service. Past Medical History: IDDM c/b neuropathy HTN HLD CAD s/p CABG in [2113] and [2119] and multiple stents s/p biologic AVR [2119] c/b transient heart block post op treated with pacer insertion ([Company 1543] Sensia dual-chamber pacemaker). Paroxysmal Atrial Fibrillation (last pacer interrogation demonstrated no episodes of AF) Chronic Systolic Heart Failure (EF 35% to 40% in [2119]) BPH Hypothyroidism CKD Social History: Exercises at the gym 2-3 times per week. Has a bachelor's degree, previously worked as a pharmacist and a small business owner, and is currently retired. Married and lives with his wife. [Name (NI) 4084] smoked. Rarely drinks a single drink. No illicits Family History: Notable for a mother who died at 81 and had a brain tumor and a sibling with Alzheimer disease. There is also thyroid, lung cancer in other family members. Brother: pancreatic and liver cancer in his brother. [Name (NI) ] family history of CAD or sudden cardiac death. Physical Exam: PHYSICAL EXAM ON ADMISSION Vitals: 97.2, 78, 108/57, 19. 97% on RA General: Alert & oriented X3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no r/rh/w CV: Regular rate and rhythm, soft S1, S2, no m/r/g Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses bl, no clubbing, cyanosis or edema, no splinter hemorrhage NEURO: MMS notable for poor memory and normal attention, CN2-12 grossly intact, slight pronator drift on the right, otherwise no focal neurological findings, normal strength throughout. On Discharge: VS: 97.5, 142/73, 82, 18, 97RA BG 62, 95, 45 Physical Exam: General: pleasant this morning, easy to arouse HEENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous membranes, no ulcers / lesions / thrush CV: RRR, normal S1, S2, Pul: CTAB BACK: no focal tenderness, no costovertebral angle tenderness GI: normoactive bowel sounds, soft, non-tender, distended, no hepatosplenomegaly Extremities: warm and well perfused, 2+ DP pulses palpable bilaterally, bilateral nonpitting edema of hands and feet LYMPH: no cervical, axillary, or inguinal lymphadenopathy SKIN: the original skin reaction to the antibiotic is resolvign with some lingering drying ulcers. However, there is a new petechial rash on the back of his right leg . No excoriations. The same petechial rash is present on the back of his left elbow, but in a more limited area. I did not notice the rash there yesterday but I may have missed it. NEURO: resting tremor in arms bilaterally, awake, slightly sedated but oriented x3, CN 2-12 intact, 5/5 strength, sensation in /tact bilaterally, no asterixis PSYCH: non-anxious, normal affect, frustrated with length of stay Pertinent Results: On Admission: [2123-11-10] 04:15PM BLOOD WBC-9.2 RBC-3.42* Hgb-9.9* Hct-29.7* MCV-87 MCH-29.1 MCHC-33.5 RDW-13.3 Plt Ct-199 [2123-11-10] 04:15PM BLOOD Neuts-42* Bands-40* Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-1* Metas-11* Myelos-0 Promyel-2* [2123-11-10] 04:15PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ [2123-11-10] 04:15PM BLOOD PT-34.2* PTT-43.1* INR(PT)-3.4* [2123-11-10] 04:15PM BLOOD Glucose-388* UreaN-40* Creat-1.8* Na-136 K-4.2 Cl-102 HCO3-19* AnGap-19 [2123-11-10] 04:15PM BLOOD ALT-195* AST-185* CK(CPK)-1240* AlkPhos-103 TotBili-0.8 [2123-11-10] 04:15PM BLOOD CK-MB-7 cTropnT-0.03* [2123-11-10] 04:15PM BLOOD Albumin-3.3* Calcium-8.0* Phos-2.3* Mg-1.8 [2123-11-14] 04:12AM BLOOD Free T4-4.5* [2123-11-14] 04:12AM BLOOD TSH-0.042* Imaging: Portable TEE (Complete) Done [2123-11-12] 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 patent foramen ovale is present. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and complex atheroma n the descending thoracic aorta. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis or abscess seen. Normal functioning aortic valve bioprosthesis. Mildly depressed left ventricular function. Mild spontaneous echo contrast in the left atrium without evidence of thrombus in the left atrium or left atrial appendage. CT HEAD W/O CONTRAST Study Date of [2123-11-15] CONCLUSION: 1. No finding to suggest acute vascular territorial infarct; in this setting, MRI with DWI (if feasible) would be more sensitive. 2. Evidence of chronic small vessel ischemic disease. 3. Chronic inflammatory disease involving the bilateral sphenoid air cells with superimposed acute inflammation involving the left sphenoid air cell; correlate clinically. CHEST (PA & LAT) Study Date of [2123-11-17] IMPRESSION: 1. Left lower lobe opacity worrisome for pneumonia in the right clinical setting, less likely atelectasis. 2. No pulmonary vascular congestion. RENAL U.S. Study Date of [2123-11-23] IMPRESSION: Normal renal ultrasound. 2.4 cm exophytic left lower pole renal cyst. CHEST (PA & LAT) Study Date of [2123-11-24] IMPRESSION: 1. Interval development of mild interstitial pulmonary edema and enlargement of still small layering bilateral pleural effusions. 2. Persistent retrocardiac opacification that could either represent atelectasis though pneumonia is also a possibility in the correct clinical setting. ABDOMEN (SUPINE ONLY) Study Date of [2123-11-24] IMPRESSION: No ileus or obstruction. Labs on Discharge: [2123-12-2] 04:24AM BLOOD WBC-13.0* RBC-2.91* Hgb-8.2* Hct-26.0* MCV-89 MCH-28.2 MCHC-31.5 RDW-17.1* Plt Ct-630* [2123-11-30] 06:00AM BLOOD Neuts-79* Bands-1 Lymphs-8* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* [2123-11-30] 06:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL [2123-12-3] 04:44AM BLOOD PT-19.3* PTT-29.7 INR(PT)-1.8* [2123-12-3] 04:44AM BLOOD Glucose-42* UreaN-138* Creat-5.5* Na-141 K-4.4 Cl-99 HCO3-27 AnGap-19 [2123-11-28] 05:06AM BLOOD CK(CPK)-87 [2123-11-29] 06:19AM BLOOD CK-MB-7 cTropnT-0.49* [2123-12-3] 04:44AM BLOOD Calcium-8.6 Phos-7.4* Mg-2.6 [2123-12-3] 04:44AM BLOOD Vanco-22.8* Brief Hospital Course: 76 y/o M with a history of CHF, afib, DM2, CAD with a history of CABG s/p recent PCI in early [2123-10-19] with DES to LAD and distal PDA presented to [Hospital1 ] with fever, malaise, R arm weakness and was found to have transaminitis, bandemia, and ARF. The patient was put on nafcillin for MSSA but developed anuria and increase in creatinine. The patient was stabilized and started on steroids, at which point the patient was presented to our service. ##MSSA Bacteremia presenting as sepsis. Likely source thought to be due to introduction of skin bacteria during recent coronary angiogram/PCI. TEE on [11-12] did not show vegetation. Pt was followed by ID with plan to treat with 4 week course of naficillin until [12-8].The patient became anuric and his creatinine bumped on nafcillin, so he was switched to cefazolin, on which he developed a rash. It is unclear if the rash was from the nafcillin or the cefazolin. In any case, we switched him to vancomycin to be safe. He is to complete his course on [12-8]. Goal trough is 15-20. Given his poor kidney function, he will require daily trough with dosing daily to maintain that trough. The course will complete on [12-8]. . #Acute renal failure d/t AIN Pt developed progressive renal failure, which was concerning for probable AIN due to nafcillin. Nafcillin was discontinued, and Nephrology was consulted. Due to worsening renal function, pt became progressively fluid overloaded. Diuresis was attepted with aggressive diuretics (Metolazone 5 mg followed by Lasix 120 mg IV, BID), with minimal response. Pt became nearly anuric, and pt subsequently developed uremia with asterixis. Pt was also symptomatic from volume overload, with mild dyspnea at rest, cough, nausea, early satiety, and poor appetite (likely d/t bowel edema). Pt was started on empiric steroids on [2123-11-25] for presumed AIN after discussion with both Nephrology and ID. He will continue on Prednisone, and will taper over the next 30 days. His discharge dose is 50mg /day and it will be tapered by 5mg every 3 days until the course is completed. Urgent HD access was obtained by Interventional Radiology, as pt is anticoagulated on Warfarin for atrial fibrillation, as well as aspirin and plavix. Pt underwent his first round of HD on [2123-11-26]. The patient required dialysis until [2123-11-29] at which point his urine output increase significantly and we would evaluate him daily, both in terms of his I/Os, and in terms of his electrolytes and kidney function labs. The patient did not require any further HD, and his catheter was pulled and the patient was discharged. The patient is to have CBC and Chem7 drawn and faxed to the nephrologists on Monday [12-6] for follow up. #NSTEMI: type 2 MI due to demand in setting of sepsis presenting with arm discomfort. Troponin peak to 0.46 on [11-13]. Cardiology recommended continued medical management of known CAD with ASA/plavix (recent PCI in early [Month (only) ]). His dose of statin reduced in context of use of amiodarone. On discharge, we decided to increase his statin dose to 80mg (home dose), given his history of recent MI in [Month (only) ]. #Diabetes Type 2: uncontrolled with complications (MI): he is on aggressive insulin regmin including parandial humalog and basal lantus at home. [Last Name (un) ] was consulted and helped up titrate his SS and basal insulin for better glucose control. [Last Name (un) ] continued to follow and make recommendations. On 2 occasions, the patient was found to have a glucose aroudn 50-60. On one occasion, the patient was difficult to arouse, but was easily reversed with dextrose. On the second occasion, he was completely asymptomatic, though dextrose was given anyways. The patient's sliding scale and daily NPH dose has been adjusted based on [Hospital1 4087] recs. The patient should have his glucose monitored and his insulin should be adjusted according to his glucose trends. It is likely that his insulin requirements will change as his prednisone is tapered. #Afib: paroxysmal afib known on history with afib and RVR during ICU stay requiring a combination of betablockers and CCB as well as initiation of amiodarone. He underwent DCCV on [11-16] with return of NSR. Since then he has been on toprol XL and amiodarone 400mg TID. As of [11-21] he received 9300mg loading dose of amiodarone and was transitioned to 200mg amiodarone daily with f/u with cardiology to decide on any further need of admiodarone. He was anticoagulated with coumadin. His INR should be trended daily and his coumadin dose should be adjusted accordingly, as his coumadin requirements may be different now with his diminished kidney function. He was discharged at a dose of 3mg per day and INR 1.8. #Question of stroke: presented to [Hospital Unit Name 153] at [Hospital1 18] with aphasia and R upper extremity weakness with old strokes on non-contrast head CT done at OSH. Seen by neurology in ICU who felt that symptoms could be due to recrudescence of previous stroke or possibly a small new stroke in setting of sepsis. An MRI was not possible because he has a pacemaker. A repeat CT performed 72 h after CT done at [Location (un) 620] did not show evidence of stroke. He reamined on anticoagulation given afib and high risk of stroke given CHADS2>=4. His speech returned to baseline and he did not have further extremity weakness other than L shoulder due to suspected rotator cuff tear. #Rotator cuff tear: inability to comfortable move L shoulder with discomfort in upper arm. Xray showed degenerative joint disease. Ortho consult suspected partial rotator cuff tear on physical exam and recommended ROM as tolerated with outpatient f/u in the sports medicine clinic. His shoulder improved during the course of the hospitalization. #Thyroid function abnormalities: PMH documents history of hypothyroidism and home med included levothyroxine, but dose of 20mcg is very low for someone his size. TSH low at 0.042, free T4 slightly high at 4.5. Rather than repeat TFTs in acute setting which could be abnormal for sick euthyroid, his dose of levothyroxine was discontinued and recommend close outpatient monitoring of TSH, free T4 as he is now on amiodarone. #R cephalic vein clot noted on U/S of R upper arm, not a DVT #Transitional Issues: Please follow daily INR and vancomycin trough. His vancomycin and coumadin doses need to be adjusted accordingly. His goal INR is [1-21]. His goal trough is 15-20 until [12-8]. If the patient's trough is less than 16, he is to get a dose of 500mg of vancomycin. If the trough is greater than 16, the dose is to be held for that day. He should also have a full CBC/Chem7 done on Monday [12-6] and the results should be faxed to [Numeric Identifier 4088]. Thank you Medications on Admission: AMITRIPTYLINE 25MG - One every evening ASPIRIN 81MG - ONE EVERY DAY ATORVASTATIN 80 mg - once a day CLOPIDOGREL 75 mg - once a day DIAZEPAM 5 mg - at bedtime as needed for prn FUROSEMIDE 20 mg - once a day HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg - one by mouth qd prn INSULIN GLARGINE - 52 units every AM INSULIN LISPRO [HUMALOG] - sliding scale L-THYROXINE 25MCG - ONE EVERY DAY LISINOPRIL 30 mg - once a day METFORMIN 500 mg - twice a day METOPROLOL SUCCINATE 100 mg - twice a day NEURONTIN 300MG - EVERY EVENING NITROGLYCERIN 0.4 mg -sublingually qd prn chest pain TAMSULOSIN 0.4 mg Capsule - 2 Capsule(s) by mouth at bedtime WARFARIN - as directed by coumadin clinic CHOLECALCIFEROL 2,000 unit - once a day MULTIVIT-IRON-MIN-FOLIC ACID [CENTRUM] - 1 Tablet daily . Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every other day: give dose at night. 6. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day). 7. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ONCE MR2 (Once and may repeat 2 times). 10. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Disp:100 ML(s) Refills:0 11. 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. 12. 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. 13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 16. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [Hospital1 ] (2 times a day). 17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): discontinue once patient is mobile. 19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 21. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 22. vancomycin 500 mg Recon Soln Sig: [12-20] Intravenous see details for 5 days: Please follow vanco trough for goal 15-20 daily. If patient is below 16 vanco trough, please administer 500mg that day. 23. prednisone 5 mg Tablet Sig: 1-10 Tablets PO once a day for 30 days: please start with 10 pills (50mg) for 3 days, then decrease dose by 5mg (1 pill) every three days for a total of thirty days. 24. insulin lispro 100 unit/mL Solution Sig: One (1) dose Subcutaneous as directed by sliding scale: 1 dose as directed by sliding scale. 25. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 26. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 27. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 28. Lab Please check CBC and Chem7 and fax results to [Telephone/Fax (1) 4089] (c/o Dr. [Last Name (STitle) 4090] 29. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: adjust per INR. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: MSSA bacteremia NSTEMI ARF/AIN requiring initiation of hemodialysis rotator cuff tear uncontrolled type 2 diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were hospitalized for a blood stream infection with staph aureus (MSSA). You will need to complete a long course of antibiotics ending on [12-8]. Please have your INR checked daily and have the coumadin dose adjusted accordingly. Please also have your vancomycin trough checked daily and have the vancomycin dose adjusted daily until your course is complete on [12-8]. Please have full chem7 and CBC with INR checked on Monday [12-6] to make sure that your electrolytes are fine. [Month/Year (2) ] changes start Vancomycin IV until [12-8] start Amiodoarone start calcium acetate start prednisone stop lisinopril stop metformin stop diazepam stop hydrocodone-acetaminophen . Dose changes coumadin Insulin regimen Followup Instructions: Department: INFECTIOUS DISEASE When: TUESDAY [2123-12-28] at 9:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4091], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NEUROLOGY When: FRIDAY [2124-1-14] at 11:00 AM With: [First Name11 (Name Pattern1) 4092] [Last Name (NamePattern1) 4093], MD [Telephone/Fax (1) 2574] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 1951] Campus: EAST Best Parking: [Known lastname 23] Garage Name: [Last Name (LF) ],[First Name7 (NamePattern1) 2946] [Initial (NamePattern1) ] [Last Name (NamePattern4) 4094]: INTERNAL MEDICINE Location: [Hospital1 ] HEALTHCARE - [State 3753]GROUP Address: [State ], [Apartment Address(1) 3745], [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 2205] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Completed by:[2123-12-5]	[ "038.10", "585.9", "410.71", "275.41", "995.91", "428.22", "285.1", "584.5", "693.0", "E879.0", "428.0", "V42.2", "V45.81", "V58.61", "342.90", "357.2", "414.00", "275.3", "403.10", "564.00", "244.9", "300.00", "E930.5", "286.9", "V45.82", "348.30", "V45.01", "250.62", "996.61", "427.31", "276.2", "451.82", "580.9", "584.9", "784.51" ]	icd9cm	[ [ [] ] ]	[ "88.72", "39.95", "99.62", "38.95", "38.97" ]	icd9pcs	[ [ [] ] ]	19639, 19733	8820, 15187	383, 558	19892, 19892	4797, 4797	20841, 22080	2633, 2909		16510, 19616		19754, 19871		15716, 16487			20075, 20818									3699, 4778														3639, 3684		15208, 15690							321, 345				8044, 8797		586, 1912								4811, 8025	19907, 20051						1934, 2341	2357, 2617
52,996	141,450	41140	Discharge summary	report	Admission Date: [2162-4-19] Discharge Date: [2162-4-27] Date of Birth: [2076-10-2] Sex: F Service: CARDIOTHORACIC Allergies: trazodone Attending:[First Name3 (LF) 165] Chief Complaint: chest pain Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram [2162-4-20] Coronary artery bypass graft x3 (left internal mammary artery > left anterior descending artery, saphenous vein graft > obtuse marginal, saphenous vein graft > diagonal) [2162-4-22] History of Present Illness: This 85 year old female presented to the Emergency Room with chest pain. She had a coronary intervention on [2162-2-10] with a bare metal stent to the prox-mid LAD and mid-distal LCx/OM1 and had been participating in reportedly rigorous cardiac rehab, using the exercise bike and treadmill without any symptoms including chest pain or shortness of breath. However, 3 weeks prior to admission, she began experiencing sub-sternal chest pressure and tightness which occurred both at rest and with significant exertion (carrying heavy groceries, vaccuming 4 rooms), which was relieved in [2-6] minutes with rest and with Nitro. She was started in Isosorbide Mononitrate last week for her chest pain and her metoprolol dose was increased from 25mg to 50mg, with initial improvement of her symptoms. However, her symptoms subsequently returned and became progressively more frequent, occurring on a daily basis in the past several days. She reports associated burning pain but denies dyspnea, nausea, lightheadedness, arm or jaw pain. She does report that in the past several days, she has been experiencing "soreness" between her shoulder blades with the onset of chest pain which does not vary with movement and is relieved in [2-6] minutes with rest or Nitro when the chest pain abates. Of note, her pre-intervention symptoms were similar in that she experienced substernal chest pressure and tightness also both on significant exertion and at rest and lasting [5-11] minutes, but reports her symptoms at that time were associated with dyspnea and a burning "indigestion-like pain" of a different nature than her current symptoms. She was symptom-free initially following the intervention and reports compliance with all of her medications. . She presented to OSH after speaking with her outpatient physician, [Name10 (NameIs) ] reports being chest pain free since this morning when she had an episode at the OSH and was given full dose ASA and Nitro SL and Nitro paste with relief. Initial troponin at OSH was negative. She was found to be bradycardic but asymptomatic, hemodynamically stable, and was transferred to [Hospital1 18] for further evaluation. . In the ED, initial vitals were 45 160/70 20 100% 4L NC She remained bradycardic but chest pain free in the ED. . On arrival to the floor, she reported an episode of chest tightness and burning similar to her episodes at home which occurred after straining to have a bowel movement in the bathroom. EKG was obtained during the episode, which self-resolved after ~5 minutes. She denied any associated symptoms and looked comfortable at the time. Past Medical History: coronary artery disease s/p coronary intervention Dyslipidemia Hypertension Hypothyroidism Total hysterecotomy for fibroids in [2111] gastroesophageal reflux Macular Degeneration Social History: She lives at home by herself and performs all of her ADL's. She has a friend near by ([Name (NI) ]), and is close with her daughter [Name (NI) ], who accompanies her here today. -Tobacco history: quit 56yrs ago -ETOH: very rarely, a few drinks per year -Illicit drugs: denies Family History: Brother with CABG at 68yo, Mother with history of angina. Physical Exam: VS: 97.5 173/64, repeat 180/74 48 18 97%RA 63kg GENERAL: Alert, interactive, appropriate, well appearing, HOH, NAD. HEENT: Sclera anicteric. Pupils equal and round. MMM. NECK: Supple with JVP <9cm. CARDIAC: RRR, normal S1/S2, GII systolic murmer at RUSB, GII holosystolic murmer at LSB. No thrills, lifts. No S3 or S4. LUNGS: 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: WWP, no c/c, trace pitting edema b/l. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ Left: DP 2+ Pertinent Results: [2162-4-26] 04:00AM BLOOD WBC-8.5 Hct-30.5* Plt Ct-255 [2162-4-25] 05:10AM BLOOD WBC-10.3 RBC-3.32* Hgb-9.8* Hct-28.9* MCV-87 MCH-29.7 MCHC-34.0 RDW-14.7 Plt Ct-224 [2162-4-26] 04:00AM BLOOD UreaN-12 Creat-0.8 Na-137 K-4.1 Cl-103 HCO3-20* AnGap-18 [2162-4-25] 05:10AM BLOOD UreaN-14 Creat-0.7 Na-139 K-5.2* Cl-106 [2162-4-26] 04:00AM BLOOD Mg-2.2 [2162-4-25] 05:10AM BLOOD Mg-2.3 [2162-4-22] TEE Conclusions Prebypass 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 thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 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 descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Postbypass The patient is A-paced and is on no infusions. Biventricular systolic function continues to be normal. Mitral and tricuspid regurgitation is now mild. The thoracic aorta is intact post decannulation. Dr. [Last Name (STitle) ] was notified in person of the results at the time of the study. Brief Hospital Course: She was admitted on [2162-4-19] from the Emergency Room after presenting with chest pain. She ruled out for a myocardial infarction. She underwent a cardiac catheterization which revealed in-stent restenosis and was referred for surgical evaluation. She underwent routine preoperative workup and on [4-23] was brought to the Operating Room for coronary artery bypass grafting tow three vessels. Please see operative note for details. She received vancomycin and cefazolin for perioperative antibiotics. Post operatively she was transferred to the intensive care unit for post operative management. In the first twenty-four hours she was weaned and extubated without complications. She continued to progress and on postoperative day one chest tubes were removed, she was started on betablockers and diuretics and was transferred to the step down unit for further recovery. Pacing wires were discontinued without complication. The physical Therapy service was consulted for assistance with her strength and mobility. She was gently diuresed towards her preoperative weight. She developed atrial fibrillation which responded to an increase in her beta blockade. Medications were titrated for hypertension. Amlodipine was added, and home dose of Lisinoopril 40mg was resumed. Heart rate did not allow room for additional Lopressor. The patient should be monitored on the current regimen for a few days, and if additional anti-hypertensive is needed, consider resuming Imdur. She continued to make steady progress and was discharged to [Doctor First Name 391] [Hospital ] rehabilitation on postoperative day 5. Medications on Admission: - Aspirin 325mg daily - Plavix 75mg daily - Atorvastatin 80mg daily - Levothyroxine 25 mcg qod - Ranitidine 150mg [Hospital1 ] - Metoprolol succinate 50 mg Extended Release daily - Coenzyme Q10 - Nitroglycerin 0.3 mg Sublingual prn - Lisinopril 40 mg daily - Imdur ER 30 mg PO daily - HCTZ 25 mg PO daily - Sertaline 50 mg PO daily Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay Skilled Nursing & Rehabilitation Center - [Hospital1 392] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass Dyslipidemia Hypertension Hypothyroidism Gastroesophageal reflux disease Macular Degeneration Discharge Condition: Alert and oriented x3, nonfocal Ambulating with assistance Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. Edema -trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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. [First Name (STitle) ] ([Telephone/Fax (1) 170]) on [2162-5-17] at 1:45 pm Cardiologist/PCP: [Last Name (NamePattern4) ]. [Last Name (STitle) ] ([Telephone/Fax (1) 4475]) on [2162-5-21] at 1:00 pm Wound check - [Hospital ] Medical Building, [Apartment Address(1) ] A ([Telephone/Fax (1) 170]) on [2162-5-4] at 11 am 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:[2162-4-27]	[ "414.01", "V45.82", "411.1", "V70.7", "244.9", "530.81", "272.4", "362.50", "427.89", "427.31", "401.9" ]	icd9cm	[ [ [] ] ]	[ "39.61", "37.22", "88.56", "36.15", "36.12" ]	icd9pcs	[ [ [] ] ]	8054, 8174	6034, 7668	286, 538	8363, 8592	4468, 6011	9515, 10222	3718, 3778				8195, 8342		7694, 8031			8616, 9492									3793, 4449																							236, 248						566, 3193															3215, 3400	3416, 3702
31,260	171,190	2716	Discharge summary	report	Admission Date: [2108-1-5] Discharge Date: [2108-1-18] Date of Birth: [2045-4-2] Sex: F Service: MEDICINE Allergies: Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 6378] Chief Complaint: SOB, hypoxia Major Surgical or Invasive Procedure: Thoracentesis Intubation Bronchial Blockade placement and removal Central Line placement History of Present Illness: 62 y/o F with PMHx of biventricular heart failure and pulm hypertension presents with hypoxia and pleuritic chest pain. Pt first developed cough with sputum production 2 weeks prior to admission. She was treated with Azithromycin for 5 days and had some initial improvement in symptoms. However, after completing the course, she began to have worsening cough, DOE and developped a pleuritic chest pain. The chest pain began on her left side while lying down 3 nights ago. She denies CP with exertion, symptoms seem to come on when lying down. She denies any fever, chills, nausea, vomiting, diarrhea or [Month (only) ] po intake. She has significant DOE and some increase in ankle edema. Orthopnea is at baseline of 3 pillows and denies PND. She was being seen in clinic on thursday morning and was sent to ED for O2 sats in the 80s and tachypnea. . VS on arrival to ED: 96.6 72 128/62 18 87 %on RA. Pt underwent CTA that was negative for PE but showed small to moderate right sided pleural effusion and R basilar atelectasis. EKGs were essentially unchanged from prior with non-specific ST-T wave changes. Pt received Lasix 40mg IV, Aspirin 325mg, Levofloxacin 750mg and combivent nebs. on arrival to floor, pt was feeling comfortable at rest but reports DOE with minimal exertion. . ROS on admission: 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. On the floor, a right sided diagnostic and therapeutic thoracentesis was done. Within minutes, she became hypoxic and had hemoptysis. She remained hemodynamically stable throughout, however a code blue was called for emergent intubation. She was transferred to the MICU for intubation and bronchoscopy, with possible endobronchial blockade. Past Medical History: (1) Ulcerative colitis. (2) Alcohol use. (3) Hypertension. (4) Hypercholesterolemia. (5) Status post ventral hernia repair. (6) Status post back surgery at [Hospital3 2358] Medical Center. (7) Atrial fibrillation. (8) Diastolic dysfunction & Biventricular heart failure,mild global hypokinesis, mitral regurgitation,moderate to severe tricuspid regurgitation with moderate pulmonary artery systolic hypertension. (9) GI bleed in [10-28] with 5cm duodenal ulcer Social History: The patient is married. She does have an abusive partner but states that she feels safe at home. She has very supportive children and 17 grandchildren. She drinks ETOH socially and denies smoking Family History: Father with MI at age 68. Mother with breast cancer at 52 Physical Exam: VS: 96.9 BP 126/72 HR 90 RR 20 Sats 97% on 2L NC GEN: Female in NAD, awake, alert, no resp distress HEENT: EOMI, sclera anicteric, malar distribution of erythema, no precervical LN appreciated NECK: Supple, JVD elevated to mid neck sitting at 60 degrees CV: irreg/irreg, Gr 2-3 SEM over LUSB, no r/g CHEST: CTAB, no wheezes or rales apprec, [Month (only) ] BS over RLL ABD: Soft, NTTP, NABS, ND EXT: [12-23]+ pitting edema bilaterally Pertinent Results: [2108-1-5]: CT Chest: IMPRESSION: 1. No pulmonary embolism. 2. Cardiomegaly with layering large right pleural effusion and compressive right lower lobe atelectasis. 3. Apparent skin thickening over the right breast. Please correlate with clinical exam. [2108-1-10]: TTE The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. 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. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-23]+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2107-11-16], findings are similar. [2108-1-5] 05:00PM BLOOD WBC-6.2 RBC-4.09* Hgb-11.8* Hct-36.0 MCV-88 MCH-28.9 MCHC-32.8 RDW-14.6 Plt Ct-312 [2108-1-6] 07:25AM BLOOD WBC-4.5 RBC-3.53* Hgb-10.0* Hct-31.0* MCV-88 MCH-28.2 MCHC-32.1 RDW-14.3 Plt Ct-242 [2108-1-9] 10:14PM BLOOD Hct-27.1* [2108-1-10] 04:03AM BLOOD WBC-6.5 RBC-3.36* Hgb-9.6* Hct-28.2* MCV-84 MCH-28.5 MCHC-33.9 RDW-15.0 Plt Ct-294 [2108-1-11] 03:16AM BLOOD WBC-8.5 RBC-3.11* Hgb-8.8* Hct-26.1* MCV-84 MCH-28.4 MCHC-33.8 RDW-14.9 Plt Ct-267 [2108-1-16] 07:10AM BLOOD WBC-5.6 RBC-3.25* Hgb-9.2* Hct-27.5* MCV-85 MCH-28.3 MCHC-33.3 RDW-14.5 Plt Ct-335 [2108-1-5] 05:00PM BLOOD Glucose-80 UreaN-13 Creat-1.1 Na-136 K-5.6* Cl-98 HCO3-25 AnGap-19 [2108-1-16] 07:10AM BLOOD Glucose-99 UreaN-34* Creat-1.1 Na-136 K-3.2* Cl-96 HCO3-32 AnGap-11 [2108-1-5] 05:00PM BLOOD CK(CPK)-84 [2108-1-6] 07:25AM BLOOD CK(CPK)-29 [2108-1-5] 05:00PM BLOOD cTropnT-<0.01 [2108-1-6] 07:25AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2108-1-5] 05:00PM BLOOD CK-MB-NotDone proBNP-2419* [2108-1-9] 08:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [1-9] Blood culture negative [1-9] Urine culture 10-[Numeric Identifier 4856] Coag negative staph [1-14] Sputum culture: contaminated [1-17] C. diff negative [1-12] CXR The current study demonstrates newly developed opacification of the right lower lung with a relatively straight upper margin, findings that are suspicious for atelectasis of the right middle and right lower lobe with still present pleural effusion. The left pleural effusion is unchanged, but the aeration of the left lower lung has improved. The upper lungs are unremarkable. No evidence of pneumothorax is present. [2108-1-18] 10:50AM BLOOD WBC-6.2 RBC-3.05* Hgb-8.8* Hct-25.8* MCV-85 MCH-28.9 MCHC-34.2 RDW-14.5 Plt Ct-366 [2108-1-18] 10:50AM BLOOD Glucose-101 UreaN-34* Creat-1.5* Na-135 K-3.5 Cl-95* HCO3-31 AnGap-13 [2108-1-5] 05:00PM BLOOD CK-MB-NotDone proBNP-2419* [2108-1-5] 05:00PM BLOOD cTropnT-<0.01 [2108-1-6] 07:25AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2108-1-9] 08:00AM BLOOD TSH-5.4* Brief Hospital Course: 62 y/o F with PMHx of biventricular heart failure and moderate pulm hypertension presents with pleuritic chest pain, hypoxia and DOE transferred to the MICU for hemoptysis following thoracentesis. 1. Hemoptysis: Patient was intubated on arrival to the MICU for airway protection and ease of bronchoscopy with central line and arterial line placed. Bronchoscopy showed RLL bleeding, however not brisk and bronchial blockade placed to tamponade bleeding. She was fluid rescusciated and on levophed as needed to maintain blood pressure. Bleeding stopped with stable hematocrit and the blockade was removed. Prior to extubation on [2108-1-12] a short course of methylprednisolone was given for concern of laryngeal edema that did not develop post extubation. Hematocrit was stable for the rest of the hospitalization, and there was no further evidence of hemoptysis. 2. Hypoxia/DOE: The patient remained hypoxic through her admission to the MICU secondary to volume overload. She tolerated diureses with Lasix drip and bolus well and was transferred to the floor on 5L NC. She was diuresed on the floor with IV lasix 80mg [Hospital1 ]. On discharge she had been not requiring supplemental oxygen for over 48 hours, with good oxygen saturations > 92% at rest. With physical therapy, she desaturated to 85%. Thus she will be discharged with supplemental oxygen for activity, and will be maintained on 80mg po lasix [Hospital1 ]. 3. Atrial fibrillation: The patient has a history of Atrial fibrillation rate controlled on metoprolol. She was not anticoagulated previously secodnary to recent diagnosis of Duodenal Ulcer. Anticoagulation was not started secondary to bleed. Her metoprolol was restarted at 50mg PO TID before transfer to the floor. 4. Chest pain: Most likely pleurtic in nature. Resolved. EKGs unchanged, CE's ruled out and cardiac cath in [10-28] was normal. Medications on Admission: Furosemide 20 mg TID alternating with 20mg [Hospital1 ] Toprol 125 mg daily Albuterol QID Fexofenadine 180 mg daily Folic acid 1 mg daily Gabapentin 100 mg qhs Iron daily Asacol 800 mg TID Prilosec 20 mg [Hospital1 ] Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet Sustained Release 24 hrs PO once a day. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 3. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for cough for 10 days. Disp:30 Lozenge(s) Refills:0 10. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 6549] Medical Services Discharge Diagnosis: Primary diagnosis: 1. Acute on chronic diastolic heart failure 2. Hemoptysis secondary to thoracentesis Secondary diagnosis: Atrial fibrillation Hypertension Discharge Condition: Stable. O2 saturation 95% on Room air at rest. 85% with activity. Discharge Instructions: You were admitted because you had fluid in your lungs that made breathing difficult. You had a thoracentesis, and started coughing up blood thereafter. You were transferred to the ICU and intubated. You had a bronchoscopy that showed bleeding, and interventional pulmonology stopped it. Your blood count remained stable thereafter. After you were extubated, we continued to diurese you to remove fluid from your lungs. On discharge, you didn't require supplementary oxygen for 24 hours. You were evaluated by physical therapy, and you didn't require supplementary oxygen with activity. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500mL/day Followup Instructions: MD: Dr. [Last Name (STitle) 838] Date and time: [2108-1-26] @ 1445 Location: [Location (un) ] Phone number: ([Telephone/Fax (1) 3346] You have an appointment with Dr. [Last Name (STitle) 497] on [2108-1-20]. The clinic phone number is [Telephone/Fax (1) 1582]. You also have an appointment with Dr. [First Name (STitle) 437] in Cardiology on [1-23] at 10am. The clinic phone number is [Telephone/Fax (1) 2037]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6384] MD, [MD Number(3) 6385] Completed by:[2108-1-25]	[ "401.9", "428.33", "E878.8", "272.0", "427.31", "556.9", "584.9", "519.19", "518.81", "998.11", "428.0", "511.9" ]	icd9cm	[ [ [] ] ]	[ "34.91", "96.71", "96.04", "39.98", "33.22" ]	icd9pcs	[ [ [] ] ]	10251, 10318	7025, 8921	325, 415	10520, 10588	3600, 7002	11354, 11966	3062, 3121		9197, 10228		10339, 10339		8947, 9174			10612, 11331									3136, 3581																							273, 287						443, 1736			10464, 10499			10358, 10443		1750, 2340							2362, 2832	2848, 3046
15,441	172,756	12636	Discharge summary	report	Admission Date: [2169-2-17] Discharge Date: [2169-2-23] Date of Birth: [2139-11-26] Sex: F Service: [Company 191] MEDICINE HISTORY OF THE PRESENT ILLNESS: This is a 28-year-old female patient with a history of ALL status post chemotherapy, radiation therapy, and BMT, pancreatitis secondary to gallstones, status post cervical esophageal patch after esophageal perforation from dilation of a stricture, Barrett's esophagus, esophageal dysmotility, GERD, history of aspiration pneumonia, diabetes mellitus, hypertension, hypothyroidism, who presents with hypoxia and a new oxygen requirement after endoscopy. The patient was scheduled for an upper endoscopy under general anesthesia because of a history of an apneic episode during attempted procedure in [2168-11-17] which was determined to be secondary to aspiration pneumonia. During the procedure, the patient had notable bronchospasm and before the esophagus was intubated, the scope was pulled for desaturation and hypotension considered secondary to inadequate sedation. The patient's hypoxia and hypotension resolved and sedation was increased by anesthesia. The patient then underwent an uncomplicated EGD but postprocedure had noted decreased breath sounds and a chest x-ray which was significant for a right main stem bronchus intubation. Given a low oxygen saturation and rhonchorous breath sounds, the patient was transferred to the MICU for observation after extubation. PAST MEDICAL HISTORY: 1. ALL, status post chemotherapy, radiation therapy, and a bone marrow transplant as a young child. 2. Pancreatitis. 3. Status post cholecystectomy. 4. Esophageal dilation for stricture complicated by perforation, status post esophageal patch. 5. Barrett's esophagus. 6. Esophageal dysmotility. 7. GERD. 8. Aspiration pneumonia. 9. Pneumococcal pneumonia. 10. Diabetes mellitus. 11. Hypothyroidism. 12. Hypertension. 13. Depression. 14. Gout. 15. Neuropathy. 16. Asthma. 17. Obstructive/restrictive lung disease. 18. Left apical nodule noted on chest CT at [Hospital6 8866]. ALLERGIES: Morphine, erythromycin, and Compazine. ADMISSION MEDICATIONS: 1. Neurontin 800 mg q.a.m., 1,500 mg q.p.m. 2. Paxil 10 mg p.o. b.i.d. 3. Metformin 500 mg p.o. b.i.d. 4. Actos 15 mg p.o. q.d. 5. Aciphex 20 mg p.o. b.i.d. 6. Metoprolol 25 mg q.a.m., 50 mg q.p.m. 7. Zestril 2.5 mg q.d. 8. Spironolactone 25 mg p.o. q.d. 9. Biaxin 250 mg p.o. q.d. 10. Zyrtec 10 mg p.o. q.d. 11. Amitriptyline 75 mg p.o. q.d. 12. Ativan 1 mg p.o. q.d. 13. Colchicine 0.6 mg p.o. q.d. 14. Allopurinol 100 mg p.o. q.d. 15. Levoxyl 75 micrograms p.o. q.d. 16. Reglan 10 mg p.o. b.i.d. 17. Meperidine 50 mg b.i.d. p.r.n. 18. Lantus 150 units subcutaneously b.i.d. 19. Humalog sliding scale. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 101.3, BP 117/60, heart rate 125, respiratory rate 30, oxygen saturation 92% on 6 liters nasal cannula plus 0.4% FI02 on shovel mask. General: The patient is awake, alert, and oriented in mild respiratory distress, cooperative. HEENT: Left surgical pupil. Right pupil round and reactive to light. Extraocular movements intact. Dry mucous membranes. The oropharynx was clear. There were dentures present in the upper mouth. Pulmonary: There were bibasilar rales and diminished breath sounds at the bases bilaterally. Cardiovascular: Tachycardiac, regular rhythm, normal S1, S2. No evidence of murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, multiple surgical scars, well-healed normoactive bowel sounds. Extremities: No evidence of clubbing, cyanosis, or edema. There were palpable pulses, 2+ bilateral DP pulses. Neurologic: Alert and oriented times three. Muscle strength was [3-22] throughout. Sensation: Intact to light touch. LABORATORY/RADIOLOGIC DATA: None on admission. Chest x-ray revealed right main stem ET tube, bilateral basilar atelectasis, right worse than left, low lung volumes. HOSPITAL COURSE: 1. HYPOXEMIA: The patient was admitted to the Medical Intensive Care Unit Service after an EGD that was complicated by a right main stem bronchus intubation and subsequent hypoxemia and increased oxygen requirement. The etiology of the patient's hypoxemia was considered most likely related to atelectasis secondary to the right main stem bronchus intubation versus aspiration pneumonia. The patient was started on Albuterol and Atrovent for underlying obstructive lung disease and placed on supplemental oxygen as needed for oxygen saturations over 90%. The patient did not require any noninvasive positive pressure ventilation but continued to require oxygen by nasal cannula to maintain adequate oxygen saturation. The patient was transferred to the Medicine [Hospital1 ] on hospital day number three and was started empirically on levofloxacin and Flagyl for concern of aspiration pneumonia given continued low-grade fevers as well as crackles more significant in her left lung field and a questionable infiltrate on chest x-ray. Over the course of her stay on the Medicine Floor, the patient defervesced and had a decreasing oxygen requirement. Incentive spirometry was encouraged for possible atelectasis. The patient complained of left-sided pleuritic chest pain and given her concomitant tachycardia, tachypnea, and decreased oxygen saturations, a chest CTA was performed to rule out pulmonary embolism. The chest CTA showed no evidence of PE but was significant for multiple mediastinal supraclavicular and hilar lymphadenopathy with ground glass opacities in the lingula and an apical left nodule measuring 1.3 by 0.9 cm. The Pulmonary Consult Service was contact[Name (NI) ] and evaluated the patient for her continued hypoxemia and CTA findings. They felt that the patient's increased oxygen requirement and hypoxemia was likely multifactorial and related to her elevated right hemidiaphragm, left lingular ground glass opacity, mild obstructive disease, and moderately severe restrictive disease by recent PFTs. The patient's records from [Hospital6 1708] were obtained and notable for the left apical nodule. A speech and Swallow study was ordered, the results of which are pending at the time of dictation and it is anticipated that the patient will follow-up with her pulmonologist at [Hospital6 15291] for a possible right diaphragm fluoroscopy to rule out paralysis as well as PFTs pre and post bronchodilators. The patient's oxygen requirement decreased throughout her hospitalization and she was saturating 95% on 1 liter on the day of discharge. Given a desaturation to 83% on room air with ambulation the patient was discharged with home oxygen and close follow-up with her pulmonary physician. 2. ESOPHAGEAL DYSMOTILITY: The patient presented originally for an EGD that was significant for diffuse erythema and congestion of the mucosa in the whole stomach, nodules in the stomach body, Barrett's esophagus, and an otherwise normal EGD. Biopsies were performed, the results of which are pending at the time of dictation. The patient was continued on her outpatient doses of Reglan and Pantoprazole for reflux symptoms. 3. TACHYCARDIA: The patient was noted to be tachycardiac on transfer to the Medicine Floor from the ICU. This was considered likely secondary to dehydration and the patient was given IV fluids with improvement in her tachycardia. EKGs were obtained which showed no evidence of ischemic changes. It is notable that the patient has a baseline tachycardia. 4. DIABETES MELLITUS: The patient was continued on pioglitazone, insulin sliding scale on her home regimen for neuropathy. Given some labile blood sugars, standing doses of Glargine insulin were adjusted throughout this admission. The patient was also maintained on a diabetic diet with blood sugars monitored q.i.d. She was continued on her pioglitazone and Metformin. 5. HYPOTHYROIDISM: The patient was continued on her outpatient dose of levothyroxine. 6. GOUT: The patient was continued on colchicine and Allopurinol per her outpatient regimen. 7. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS: The patient has a prior diagnosis of MRSA and was kept on precautions until nasal and rectal swabs were sent that were negative for MRSA. The MRSA precautions were subsequently discontinued. CONDITION ON DISCHARGE: Stable. Oxygenating well on 1 liter per minute of oxygen by nasal cannula. DISCHARGE STATUS: The patient is discharged to home. DISCHARGE DIAGNOSIS: 1. Aspiration pneumonia. 2. Barrett's esophagus. 3. Esophageal dysmotility. 4. History of ALL, status post chemotherapy, radiation therapy, and bone marrow transplant. 5. Gastroesophageal reflux disease. 6. Diabetes mellitus. 7. Hypothyroidism. 8. Hypertension. 9. Gout. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg p.o. q.d. times nine days. 2. Flagyl 500 mg p.o. t.i.d. times nine days. 3. Reglan 20 mg p.o. q.i.d. 4. Humalog insulin sliding scale. 5. Glargine 50 units q.a.m., 35 units q.p.m. 6. Metformin 500 mg p.o. b.i.d. 7. Senna one tablet b.i.d. p.r.n. 8. Colace 100 mg b.i.d. 9. Lisinopril 2.5 mg p.o. q.d. 10. Metoprolol 25 mg p.o. q.a.m., 50 mg p.o. q.p.m. 11. Meperidine 25-50 mg p.o. b.i.d. p.r.n. 12. Zyrtec 10 mg p.o. q.d. 13. Clarithromycin 250 mg p.o. q.d. 14. Aldactone 25 mg p.o. q.d. 15. Levoxyl 75 micrograms p.o. q.d. 16. Allopurinol 100 mg p.o. q.d. 17. Colchicine 0.6 mg p.o. q.d. 18. Atorvostatin 10 mg p.o. q.d. 19. Lorazepam 1 mg q.h.s. p.r.n. 20. Amitriptyline 75 mg p.o. q.h.s. 21. Pantoprazole 40 mg p.o. q.d. 22. Pioglitazone 15 mg p.o. q.d. 23. Paroxetine 10 mg p.o. b.i.d. 24. Gabapentin 1,800 mg p.o. b.i.d. FOLLOW-UP:The patient has a follow-up appointment with her primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 11894] [Last Name (NamePattern1) 39037] at [Hospital6 8866] on [2169-3-2] at 11:30 a.m. The patient's pulmonary physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7111], [First Name3 (LF) ] contact the patient to schedule a follow-up appointment. It is hoped that the patient will be evaluated with a right diaphragm fluoroscopy to rule out paralysis. The patient should also have a follow-up chest CT to examine her left upper lobe nodule. The patient should also have PFTs pre and post bronchodilators to evaluate her obstructive and restrictive lung disease. The patient is not being discharged with Albuterol MDI in order to avoid its effects on her PFTs. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 21723] Dictated By:[Last Name (NamePattern1) 4950] MEDQUIST36 D: [2169-2-23] 10:11 T: [2169-2-22] 22:22 JOB#: [Job Number 39038]	[ "530.5", "276.5", "V42.81", "518.0", "530.85", "496", "997.3", "530.81", "507.0" ]	icd9cm	[ [ [] ] ]	[ "45.16" ]	icd9pcs	[ [ [] ] ]									8826, 10816		8522, 8803			4001, 8344				2167, 2802																																												2817, 3983							1504, 2144		8369, 8501
48,217	174,325	38924	Discharge summary	report	Admission Date: [2118-9-27] Discharge Date: [2118-10-4] Date of Birth: [2047-1-19] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3021] Chief Complaint: Acute renal failure, severe hyperkalemia. Major Surgical or Invasive Procedure: Bilateral nephrostomy tubes, [2118-9-27]. History of Present Illness: 71yo male with castrate resistant metastatic prostate cancer and stage III CKD presents after being found to have acute renal failure and hyperkalemia on routine labs at OSH. Per pt, went to oncologist yesterday with complaint of general weakness and increased SOB at rest with resultant labs. The patient states he had noted no urine output for the last 5 days. He also admits to a productive cough for the last 8 weeks as well as new SOB. He is not on any home oxygen. He also reports intermittent nausea and occasional vomiting. He was sent to [Hospital1 6687] ED where he received kayexelate and lisinopril 40mg prior to transfer to [Hospital1 18]. . In ER, initial VS: T- 98.5, HR- 72, BP- 143/89, RR- 24, SaO2 89% on RA. Labs pertinent for BUN/Cr 107/13.7 with potassium of 6.7. UA showed small leukocytes, 56 WBC, large blood and >182 RBCs. CXR demonstrated mild pulmonary edema. EKG with low voltages but sinus rhythm at a rate of 80, NA/NI, no peaked T-waves. Bedside u/s revealed a small pericardial effusion with no tamponade physiology. U/S also demonstrated bilateral massive hydronephrosis. He was noted to have minimal foley output. For hyperkalemia, he was given dextrose, insulin, calcium gluconate, and he received duonebs for SOB. Urology was consulted and recommended CT to assess for level of ureteral obstruction and to continue foley decompression of the bladder. Renal agreed with CT and urgent decompression of obstruction, with no indication for urgent dialysis but to give kayexelate for hyperkalemia and expect post-obstructive diuresis. Oncology was consulted and stated they would follow along. IR agreed to take patient for urgent bilateral percutaneous nephrostomy placement. Vital signs on transfer were HR 90, afebrile, satting 92-94% on 2L NC, 88% on RA, BP 141/78. . In the ICU, initial vital signs were T- 97.3, HR- 85, BP 127/70, RR- 17, SaO2- 91% on NC. Patient reports symptom improvement after IR procedure. Denies fevers, chills with some shortness of breath that has also improved. Past Medical History: - Metastatic prostate cancer, first diagnosed in [2110] s/p cryotherapy; increasing PSA noted, then put on hormonal therapy, recently completed 8 cycles of taxotere; has known spinal metasteses - Hypertension - Hyperlipidemia - Stage III CKD, baseline Cr 1.5 in [2116] Social History: He lives in [Hospital1 6687] with his wife. [Name (NI) ] is retired, but had previously worked as a controller of a company. - Tobacco: less then 10 cigarettes per day - Alcohol: less than 2 drinks per day - Illicits: Denies Family History: NC Physical Exam: Admission Exam: Vitals: T- 97.3, HR- 85, BP 127/70, RR- 17, SaO2- 91% on NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, NC in place Neck: supple, JVP not elevated, no LAD Lungs: Bibasilar crackles with wheezes, good respiratory effort. 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 GU: bilateral nephrostomy tubes in place, draining well Ext: warm, well perfused, 2+ pulses, with 1+ edema bilaterally Pertinent Results: Admission Labs . CBC: [2118-9-27] 05:00PM WBC-8.2 RBC-4.03* HGB-12.6* HCT-37.3* MCV-93 MCH-31.4 MCHC-33.8 RDW-15.7* [2118-9-27] 05:00PM NEUTS-84.9* LYMPHS-10.3* MONOS-3.9 EOS-0.3 BASOS-0.5 [2118-9-27] 05:00PM PLT COUNT-311 . CHEM-7: [2118-9-27] 05:00PM GLUCOSE-98 UREA N-107* CREAT-13.7# SODIUM-140 POTASSIUM-6.7 CHLORIDE-102 TOTAL CO2-20* ANION GAP-25* [2118-9-28] 03:30PM BLOOD Calcium-9.3 Phos-6.8* Mg-2.1 . Renal function: [2118-9-27] 05:00PM BLOOD UreaN-107* Creat-13.7# [2118-9-28] 04:24AM BLOOD UreaN-98 Creat-11.5# [2118-9-28] 03:30PM BLOOD UreaN-83 Creat-8.4# . LFTs: [2118-9-28] 04:24AM BLOOD ALT-14 AST-13 LD(LDH)-184 AlkPhos-68 TotBili-0.2 . URINE STUDIES: [2118-9-27] 07:30PM URINE Color-Pink Appear-Hazy Sp [Last Name (un) ]- [2118-9-27] 07:30PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-SM [2118-9-27] 07:30PM URINE RBC->182 WBC-56* Bacteri-FEW Yeast-NONE Epi-0 . CXR [2118-9-27]: IMPRESSION: 1. Moderate right pleural effusion. 2. Bibasilar opacities at the lung bases, likely atelectasis, cannot exclude superinfection. 3. Engorgement of the vessels centrally. 4. Enlarged cardiac silhouette. . [2118-9-27] CT ABD/PELVIS: IMPRESSION: 1. Worsening moderate-to-severe bilateral hydronephrosis and proximal hydroureter, with the ureters compressed and/or encased by extensive retroperitoneal lymphadenopathy which may be slightly increased in size compared to prior. 2. Bilateral large pleural effusions, worse on the right with bibasilar atelectasis. 3. Small amount of free fluid in the pelvis with presacral edema. 4. T12 and L1 vertebral body sclerotic osseous metastases, similar to outside CT from [2118-7-19]. Mild loss of height of T12 vertebral body is stable compared to [2118-7-19]; however, is new from [2117-11-11]. 6. Cholelithasis. 7. Diverticulosis. . [2118-9-28] CXR: IMPRESSION: Worsening of pleural effusions and pulmonary edema that may be due in part to technical differences between this and the prior study. . [2118-9-30] CXR: IMPRESSION: 1. Stable bilateral pleural effusions, moderate on the right and small on the left. Improved pulmonary edema. 2. Stable mediastinal widening corresponding with known adenopathy. . [2118-9-30] ECHO: Mild symmetric left ventricular hypertrophy, LVEF>55%, mildly dilated RV, ascending aorta is mildly dilated, at least mild pulmonary artery systolic hypertension. . DISCHARGE LABS: [2118-10-4] 07:02AM BLOOD WBC-8.9 RBC-3.79* Hgb-11.8* Hct-35.8* MCV-94 MCH-31.1 MCHC-32.9 RDW-15.6* Plt Ct-321 [2118-9-30] 06:40AM BLOOD PT-12.2 PTT-29.3 INR(PT)-1.0 [2118-10-4] 07:02AM BLOOD Glucose-89 UreaN-27* Creat-1.6* Na-143 K-3.6 Cl-107 HCO3-28 AnGap-12 [2118-10-4] 07:02AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.9 [2118-10-4] 07:02AM BLOOD ALT-25 AST-18 AlkPhos-63 TotBili-0.3 Brief Hospital Course: 71yo man with metastatic prostate CA and stage III CKD who was transferred from OSH for [Last Name (un) ] and hyperkalemia due obstructive uropathy. Bilateral percutaneous nephrostomy tubes were placed [2118-9-28]. . # Acute kidney injury due to obstruction: Resolved s/p bilateral nephrostomy tube placement [2118-9-28]. Urology and Nephrology consulted. Post-obstructive diuresis slowing. Aspirin held because of macroscopic hematuria post-nephrostomy placement. . # Hyperkalemia: Resolved s/p Kayexylate, insulin/glucose, calcium. . # Prostate CA: Started abiraterone [2118-9-26]. Leuprolide given last week. XRT started Monday [2118-10-3], finishes Friday [2118-10-7]. Continued prednisone, but dose increased for COPD exacerbation, plant to taper down slowly to baseline 5mg [Hospital1 ]. Restarted abiraterone (Zytiga) 1000mg PO daily [2118-10-3] per primary oncologist. . # Hypoxia and right-sided pleural effusion: CXR with moderate new right pleural effusion and vascular congestion. Cough x6wks. Sputum culture grew Moraxella catarrhalis, started levofloxacin for possible pneumonia. Echo normal. COPD exacerbation given prominent wheeze, cough, and smoking history. O2 needs resolved since increase in prednisone. Continued prednisone taper. Changed nebs to prn and discharged with a nebulizer. Continued levofloxacin, renally dosed, for Moraxella pneumonia. Held diuretics while auto-diuresing. . # Pulmonary edema: Improved with post-obstructive diuresis. Held on furosemide while auto-diuresing. Now off O2. . # Hypertension: Outpatient furosemide held with post-obstructive diuresis. PCP to restart next week as needed. . # Hyperlipidemia: Continued outpatient statin. . # Anemia: Continued vitamin B12 replacement. . # Hypernatremia: Due to free water deficit. Resolved. . # FEN: Regular low-sodium diet. Hypophosphatemia post-obstructive diuresis not repleted, but monitored. . # GI PPx: PPI and bowel regimen. . # DVT PPx: Heparin SC. . # Precautions: None. . # Lines: Peripheral IV, bilateral nephrostomy tubes. . # CODE: FULL. Medications on Admission: Abiraterone 1000mg PO daily, started 10/[2117]. Atorvastatin 20mg PO daily Dexamethasone 8mg PO daily Enalapril 10mg PO daily Furosemide 20mg PO daily Leuprolide (Lupron Depot) 7.5mg IM qmo Prednisone 5mg PO BID MVI 1 tab PO daily Aspirin 81mg daily Vitamin B12 KCl 20meq ER PO daily Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY. 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY. 3. Zytiga 250 mg Tablet Sig: Four (4) Tablet PO DAILY. 4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY. 5. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H x2 doses. Disp:2 Tablet(s) Refills:0 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H PRN wheezing, shortness of breath. Disp:30 neb Refills:1 7. ipratropium bromide 0.02 % Solution Inhalation Q6H PRN Dyspnea, wheeze. Disp:30 neb Refills:1 8. prochlorperazine maleate 10mg PO DAILY: Take 1hr prior to radiation. 9. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO q6hr PRN nausea. Disp:20 Tablet(s) Refills:1 10. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO q8HR PRN nausea. Disp:20 Tablet(s) Refills:1 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN Constipation. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN Constipation. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO Q24H. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 14. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY: Take 40mg daily x3d, then 20mg daily x4d, then return to your previous dose 5mg [Hospital1 ]. Disp:10 Tablet(s) Refills:0 15. Home nebulizer Home nebulizer Dx: COPD. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] - [Location (un) 538] Discharge Diagnosis: 1. Acute kidney failure. 2. Hyperkalemia (high potassium level). 3. Obstructive uropathy (kidney damage due to obstruction). 4. Metastatic prostate cancer to lymph nodes and bones/spine. 5. Hypoxemia (low oxygen levels). 6. Dyspnea (shortness of breath). 7. Acute COPD exacerbation (chronic obstructive pulmonary disease, emphysema). 8. Possible pneumonia. 9. Pulmonary edema and pleural effusion (fluid in lungs). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for acute kidney failure due to obstruction from metastatic prostate cancer. Your potassium level was also dangerously high, a result of the kidney failure. You were given medications to reduce the potassium level and catheter drains were placed into both ureters to bypass the obstruction. You immediately began excreting urine and over several days the kidneys returned to baseline. Once the potassium and kidney function began improving, you were transferred out of the Intensive Care Unit (ICU). Radiation Oncology decided that to relieve the obstruction and control cancer growth in the spine you should have radiation therapy, which started Tuesday [2118-10-4]. The nephrostomy tubes will need to stay in place until after radiation therapy and how long they are needed will be determined by Urology. Your breathing remained labored and you began needing oxygen support. Chest x-ray showed fluid on the lungs (pleural effusion and pulmonary edema). This fluid began coming off once your kidneys began working again. While the your urine output increased, your furosemide (Lasix) was held. In addition, you were started on an antibiotic for a bacteria that grew in your sputum (possible pneumonia) and steroids (prednisone) for acute COPD exacerbation (chronic obstructive pulmonary disease, emphysema). You will need to complete a course of the antibiotic and a slow taper of the steroids. Aspirin has been held due to bleeding from the nephrostomy tubes. . MEDICATION CHANGES: 1. Levofloxacin once daily x7 days total. 2. Prednisone as directed. 3. Hold aspirin until further notified. 4. Hold furosemide (Lasix) until directed by your primary care physician. 5. Stop enalapril and potassium supplements as both elevate potassium levels and your potassium level had been dangerously high. Your primary care physician may reinstitute these at a later date. Followup Instructions: Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 86355], MD Specialty: Internal Medicine When: Tuesday [10-11] at 1:45pm Address: [Street Address(2) ], [Hospital1 ],[Numeric Identifier 54491] Phone: [Telephone/Fax (1) 22442] [Doctor Last Name 2270] from Dr. [Last Name (STitle) ] office says that if this is not a convenient time for you, you can call the office to reschedule. . Department: SURGICAL SPECIALTIES When: WEDNESDAY [2118-10-12] at 3:15 PM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 164] Specialty: Urology Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "272.4", "196.2", "V87.41", "482.83", "V58.65", "799.02", "428.31", "428.0", "V10.46", "403.90", "198.5", "198.3", "491.21", "584.9", "593.4", "276.7", "305.1", "276.0", "276.2", "591", "285.9", "585.3" ]	icd9cm	[ [ [] ] ]	[ "92.29", "55.03", "99.25" ]	icd9pcs	[ [ [] ] ]	10447, 10569	6590, 8690	346, 393	11027, 11027	3655, 6151	13148, 13910	3043, 3047		9028, 10424		10590, 11006		8716, 9005			11209, 12724				6167, 6567					3062, 3636																				12744, 13125			265, 308						421, 2474									11042, 11185						2496, 2774	2790, 3027
48,351	194,788	41921	Discharge summary	report	Admission Date: [2107-10-24] Discharge Date: [2107-11-4] Date of Birth: [2041-12-26] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending:[First Name3 (LF) 2698] Chief Complaint: left leg infection Major Surgical or Invasive Procedure: Operative Debridement for Necrotizing fasciitis Cardiac Catheterization Upper Endoscopy with injection and clipping of esophageal bleed History of Present Illness: 65 y/o male with a history of sub total colectomy for colon cancer in [2101] who presented to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] hospital with pimple on left buttock. He was diagnosed with necrotizing fasciitis and was transferred to [Hospital1 18] where he underwent surgical debridement. His post-op course was complicated by developement of hypotension and a STEMI which is being treated medically. The patient is now extubated and hemodynamically stable and therefore is being transferred to the cardiology service for further management of STEMI. . On arrival to the floor, patient reports that he is doing well. He has some discomfort in the affected groin area that is well controlled with current pain regimen. He reports that his breathing has improved significantly from prior. . REVIEW OF SYSTEMS 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. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: colon cancer s/p sub-total colectomy [2101] s/p appendectomy Social History: - Tobacco: Quit 35 years ago. ~6 pack-years before that - EtOH: 2 beers/week - Illicits: denies Family History: Colon cancer. No early CAD Physical Exam: ACS Physical Exam on Admission to [Hospital1 18]: Vitals: T 103.6 P 142 BP 117/88 RR 36 O2 100% 2L GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding DRE: normal tone, no gross or occult blood Ext: No LE edema, LE warm and well perfused. large (6x6cm) area of necrosis at the left gluteal fold with surrounding erythema, induration and small amount purulent drainage. Pertinent Results: Admission Labs: [2107-10-24] 12:30AM BLOOD WBC-10.4 RBC-4.49* Hgb-12.9* Hct-37.6* MCV-84 MCH-28.7 MCHC-34.2 RDW-12.8 Plt Ct-142* [2107-10-24] 12:30AM BLOOD Neuts-71* Bands-22* Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2107-10-24] 12:30AM BLOOD PT-16.6* PTT-27.9 INR(PT)-1.5* [2107-10-24] 12:30AM BLOOD Glucose-111* UreaN-45* Creat-2.3* Na-137 K-4.0 Cl-106 HCO3-16* AnGap-19 [2107-10-24] 12:30AM BLOOD ALT-27 AST-38 AlkPhos-28* TotBili-1.3 [2107-10-25] 12:13PM BLOOD CK(CPK)-1055* [2107-10-24] 12:30AM BLOOD proBNP-2354* [2107-10-24] 12:30AM BLOOD cTropnT-<0.01 [2107-10-25] 12:13PM BLOOD CK-MB-101* MB Indx-9.6* cTropnT-1.67* [2107-10-24] 12:30AM BLOOD Calcium-7.7* Phos-1.4* Mg-1.1* [2107-10-24] 03:16AM BLOOD Type-ART pO2-118* pCO2-51* pH-7.22* calTCO2-22 Base XS--7 Intubat-INTUBATED [2107-10-24] 12:47AM BLOOD Glucose-93 Lactate-3.6* Na-138 K-3.8 Cl-108 calHCO3-19* . Discharge Labs: [2107-11-4] 05:39AM BLOOD WBC-6.7 RBC-3.27* Hgb-9.7* Hct-27.9* MCV-85 MCH-29.6 MCHC-34.7 RDW-14.1 Plt Ct-295 [2107-11-4] 05:39AM BLOOD Glucose-104* UreaN-12 Creat-1.0 Na-137 K-4.2 Cl-109* HCO3-21* AnGap-11 [2107-11-1] 06:24AM BLOOD ALT-20 AST-22 LD(LDH)-237 AlkPhos-39* TotBili-0.5 DirBili-0.3 IndBili-0.2 . Other Relevant Labs: [2107-10-28] 06:50AM BLOOD %HbA1c-5.9 eAG-123 [2107-10-28] 06:50AM BLOOD HDL-13 CHOL/HD-10.5 LDLmeas-<50 . Other Studies: Left buttock debridement path report([2107-10-24]): Soft tissue with extensive infiltrating suppurative inflammation and necrosis, consistent with necrotizing fasciitis. . TTE [2107-10-24]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There seems to be mild to moderate inferior lateral wall hypokinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 40 %). The estimated cardiac index is borderline low (2.0-2.5L/min/m2). The right ventricular cavity is moderately dilated The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . TTE [2107-10-25]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with near-akinesis of the inferolateral and basal lateral segments (left circumflex/OM distribution). The remaining segments contract normally (LVEF = 35-40%). 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. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Moderate to severe tricuspid regurgitation. At least mild pulmonary hypertension. . CT Abd/Pelvis w/o Contrast [2107-10-25]: 1. No collection or fistula identified. 2. Bibasilar consolidation and small bilateral pleural effusions. 3. Trace amount of free fluid within the right paracolic gutter. No drainable collections. [2107-11-1] EGD: Blood was seen in the esophagus. There was a linear erosion/ulceration from the GE junction to the extending proximally for 2cm. Active bleeding was seen from the proximal edge of the lesion. It was felt to be consistent with either a linear ulcer or [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear. (injection, endoclip) Furrowing of the mucosa was noted in the mid-esophagus. Blood in the whole stomach Blood in the second part of the duodenum Otherwise normal EGD to third part of the duodenum . [Hospital1 18] WOUND CULTURE (Final [2107-10-28]): BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH. Pansensitive . - OSH Blood Cultures- [2107-10-23] - Group G Beta Strep - 4/4 bottles - OSH Wound Cultures- [2107-10-23] - Wound cultures - Abundant growth Group G Beta Strep . Cardiac Cath (prelim report) [2107-10-31]: 1. Selective coronary angiography in this right dominant system revealed moderate multivessel coronary artery disease. The LMCA had a 20% ostial and 20% mid vessel lesion. The LAD had moderate calcification with a 30% ostial, 75% mid vessel occlusion after D2 involving the origin of S1. A mid vessel D2 with a 50% stenosis at the originas well as slow flow consistent with microvascular disease is also noted. The LCX had a proximal 30% tubual stenosis, a large OM2/LPL with a proximal 30% stenosis and tortuous terminal pole. A modest caliber AV grossve with 50% stenosis just after the origin of the OM2 and slow flow is also noted. The RCA was mildly calcified with diffuse plaquing throughout, a mid vessel 45% stenosis at a large AM2, a large tortuous AM2, a small toruous RPL1 and RPL2 arising from large distal AV groove RCA. Slow flow is likewise noted. 2. Limited resting hemodynamics revealed a normotensive systemic arterial pressure of 92/55 mmHg. FINAL DIAGNOSIS: 1. Moderate three vessel coronary artery disease without obvious culprit lesion in LCX or RCA to explain inferolateral STEMI. Incidental finding of complex bifurcation mid LAD lesions involving D2. Tortuous terminal branches consistent with hypertensive heart disease with diffuse slow flow consistent with microvascular dysfunction. 2. Low normal systemic arterial pressures. 3. Normal left ventricular diastolic function. Brief Hospital Course: Primary Reason for Hospitalization: 65M with history of Colon Ca (s/p hemicolectomy in [2101]) and no cardiac history who was transferred to [Hospital1 18] for operative debridement of necrotizing fasciitis and whose post-op course was complicated by STEMI and then upper GI bleed. . ACTIVE ISSUES: # Necrotizing Fasciitis: Upon transfer to [Hospital1 18] the patient was taken to the OR for operative debridement. Post-op course was complicated by hypotension requiring pressors. Initially he was covered broadly with Vancomycin and Zosyn until sensitivities became available. He was then switched to Penicillin and Clindamycin. The patient developed a diffuse erythematous rash which was likely related to penicillin. He was therefore switched to linezolid and instructed to add penicillin to his allergy list. He will complete a 2 week course of antibiotics from day of debridement ([2107-10-24]) with last dose given on [11-7]. Wound cultures at [Hospital1 18] grew Group A strep however blood and wound cultures from OSH grew group G strep. There was no obvious explanation for the discordance. Regardless, the antibiotics given are appropriate for both organisms. He will follow-up with Acute Care Surgery clinic on [11-15] for management of his wound vac. . # STEMI: On [2107-10-25] patient was noted to have ST elevations on telemetry. Subsequent 12 lead ECG showed inferior/posterior/lateral ST elevations. Troponin peaked at 3.15 and CK-MB peaked at 149. Echocardiography revealed near-akinesis of the inferolateral and basal lateral segments (left circumflex/OM distribution). However, cardiac cath performed 6 days later showed only moderate three vessel coronary artery disease without obvious culprit lesion in LCX or RCA to explain inferolateral STEMI. This was most likely a LCX lesion that was successfully managed medically. The echo findings were not consistent with a stress induced cardiomyopathy. Cardiac cath was not performed at the time of diagnosis because of his active infection and septic physiology. Lysis was not an option given his recent surgical debridement. He was therefore started on aggressive medical antiplatelet therapy with ASA, Plavix 600mg X1, heparin X72hrs, and Integrilin X 24hrs. After he was stabilized he was transferred to the cardiology service and underwent cardiac cath which showed the findings described above. The intensity of his medical regimen was decreased because of GI bleed requiring 5 units of blood and he was discharged on ASA 81mg daily. He was also started on Atorvastatin 80mg. He will follow-up in cardiology clinic with Dr. [Last Name (STitle) ] on [12-5]. Metoprolol will be started at that time if BPs tolerate. Of note the patient never had chest pain at any point during the hospitalization. . # Acute Systolic Heart Failure (EF: 35-40%): Due to STEMI as described above and exacerbated by fluid resuscitation during septic shock. He was diuresed with IV lasix initially but was stable and euvolemic for several days prior to discharge and therefore he was not discharged on any diuretic. However he may require a low dose diuretic in the future. He was started on lisinopril 5mg daily which will be uptitrated as BPs tolerate. Metoprolol not started prior to discharge because of low-normal BP. . # Upper GI Bleed: Patient with acute GI bleed on [2107-11-1], transferred to the MICU. Received 5 units pRBCs. Patient was intubated for airway protection during his EGD, which showed a linear ulcer at the GE junction, that may have been [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ] tear. The patient did not have any preceding history of vomiting however up to 50% of [Doctor First Name 329]-[Doctor Last Name ] tears have no antecedent vomiting. Bleeding was stopped with epi and clips. Patient was kept NPO for 24 hours and then diet slowly advanced. He will maintain a soft diet for a week after discharge. He was initially on a PPI drip and was discharged on Pantoprazole 40mg [Hospital1 ]. Duration of therapy to be decided at GI f/u appointment. A repeat EGD may be performed at that time as well because visibility was limited by active bleeding during inpatient EGD. . # Acute Kidney Injury: Creatinine was 2.3 on presentation to [Hospital1 18], most likely pre-renal from septic shock. Creatinine subsequently improved to 1.0. His baseline creatinine is unknown. . TRANSITIONAL ISSUES: - Duration of PPI therapy to be determined at [Hospital ] clinic f/u - CBC and chem-7 should be checked by PCP at post hospital f/u appointment - LFTs should be monitored by PCP as appropriate for new initation of statin therapy - Add penicillin to allergy list (rash) Medications on Admission: none Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:1 2. oxycodone-acetaminophen 5-500 mg Capsule Sig: One (1) Capsule PO once a day as needed for wound vac change: take 2 hrs before wound vac change. Disp:10 Capsule(s) Refills:0 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:1 4. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day: Last dose in evening on [11-7]. Disp:8 Tablet(s) Refills:0 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary - Necrotizing fasciitis - ST elevation Myocardial Infarction - Acute Systolic Heart Failure (EF 35-40%) - Upper GI Bleed - Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 60132], it was a pleasure taking care of you here at [Hospital1 18]. You were transferred here to have surgery for a life-threatening infection called necrotizing fasciitis. During your critical illness you sufferred a heart attack (myocardial infarction). You also suffered a severe bleed from your esophagus. You had an upper endoscopy where clips were placed to stop the bleeding. You did not have any further bleeding after that. You will need to eat a soft diet for one week so that your esophagus has time to heal. In addition to the surgery for your infection, you were also treated with antibiotics. You will need to be on oral antibiotics (last day [11-7]). You also had a device placed to help you heal from your surgery which is called a wound vac. You will need the wound vac for several weeks to ensure appropriate healing. When you see the surgeons for follow-up they will decide on the exact duration depending on how well you are healing. You were started on multiple new medications for your heart. These are to decrease your risk of having another heart attack and decrease complications from the heart attack that you had. START: Aspirin 81mg by mouth once per day START: Lisinopril 5mg by mouth once per day START: Atorvastatin 80mg by mouth once per day START: Linezolid 600mg by mouth twice per day, last day [11-7] START: Pantoprazole 40mg by mouth twice per day In addition you will need to complete your course of antibiotics START: Linezolid 600mg Twice Daily. Last dose in evening on [11-7]. You will need to see multiple doctors for follow-up appointments as detailed below. 1. Your primary care doctor 2. Surgery clinic to care for the wound from your infection 3. Cardiology clinic to address complications related to your heart attack 4. [Hospital ] clinic to address the bleeding you had in your esophagus. Followup Instructions: Department: Primary Care Name: Dr. [First Name8 (NamePattern2) 56281] [Last Name (NamePattern1) 19952] Location: [Hospital1 ] [Location (un) ] Address: [Doctor Last Name ], [Location (un) ],[Numeric Identifier 89216] Phone: [Telephone/Fax (1) 84402] When: Wednesday, [11-9] at 10AM Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2107-11-15] at 4:15 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: MONDAY [2107-12-5] at 9:20 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2385], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2107-12-14] 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	[ "428.0", "410.21", "693.0", "276.52", "997.1", "728.86", "414.01", "038.9", "428.21", "785.52", "530.7", "285.9", "E878.8", "V45.89", "041.01", "787.91", "584.9", "410.91", "V10.05", "995.92", "E930.0" ]	icd9cm	[ [ [] ] ]	[ "83.44", "42.33", "37.22", "38.97", "88.56" ]	icd9pcs	[ [ [] ] ]	14202, 14251	8568, 8860	327, 464	14446, 14446	2551, 2551	16509, 17812	1979, 2007		13377, 14179		14272, 14425		13348, 13354		8117, 8545	14596, 16486				3503, 8100					2022, 2532																13048, 13322							269, 289		8875, 13027				492, 1761					2567, 3487				14461, 14572						1783, 1850	1866, 1963
18,376	100,831	13371	Discharge summary	report	Admission Date: [2147-6-12] Discharge Date: [2147-6-22] Date of Birth: [2072-12-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: persantine MIBI cardiac stress test thoracentesis Chest Tube History of Present Illness: 74 yo M with lung cancer DVT who presents with 1 day of substernal chest pain. Patient developed chest pain the night prior to admission. The pain was substernal [6-21], did not radiate. He reports that the pain was similar to his prior MI. The patient had shortness of breath. . In the ED the patients pain resolved with NTG and morphine. he was given ASA and bblocker. At time of my evaluation, the patient denied nausea, vomitting, abdominal pain, dysuria, dizziness, changes in vision/hearing Past Medical History: - Lung cancer - Non-small cell lung cancer stage IIIA, status post weekly carboplatin and Taxol chemotherapy with XRT for seven weeks followed by surgery on [2147-3-28]. - CAD - s/p inferior STEMI [11-16], stent to L Cx - CHF(EF 55% on [4-17]) - HTN - paroxismal afib - CVA - Left LE DVT on coumadin - s/p IVC filter Social History: non-smoker, occasional etoh, no drugs Family History: father and mother with CAD Physical Exam: VS - 98.0 67 140/63 22 99% on RA Gen - A+Ox3, NAD HEENT - EOMI, OP clear Neck - supple, no LAD, no JVD Cor - RRR no murmurs Chest - R base with poor excursion and poor breath sounds. Clear otherwise. Abd - s/nt/nd +BS Ext - w/wp, no edema, R leg swollen compared to left Pertinent Results: [2147-6-12] 05:15PM CK(CPK)-67 [2147-6-12] 05:15PM CK-MB-NotDone cTropnT-<0.01 [2147-6-12] 09:55AM GLUCOSE-159* UREA N-17 CREAT-1.0 SODIUM-137 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [2147-6-12] 09:55AM CK(CPK)-76 [2147-6-12] 09:55AM cTropnT-<0.01 [2147-6-12] 09:55AM CK-MB-NotDone [2147-6-12] 09:55AM WBC-10.4 RBC-4.41# HGB-12.8# HCT-38.2# MCV-87 MCH-29.0 MCHC-33.5 RDW-15.9 [2147-6-12] 09:55AM NEUTS-86.1* LYMPHS-5.4* MONOS-5.7 EOS-2.2 BASOS-0.6 [2147-6-12] 09:55AM MICROCYT-1+ [2147-6-12] 09:55AM PLT COUNT-372 [2147-6-12] 09:50AM URINE HOURS-RANDOM [2147-6-12] 09:50AM URINE GR HOLD-HOLD [2147-6-12] 09:50AM PT-20.4* PTT-28.6 INR(PT)-2.0* [2147-6-12] 09:50AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2147-6-12] 09:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2147-6-12] 09:50AM URINE RBC-[4-16]* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 . CXR - Increased right pleural effusion and partial collapse of the right upper lung. . EKG - NSR 70, nl axis, nl int, old TWI III, F; old J pointing V [3-18] . [6-16] CT CT CHEST: The heart, pericardium, and great vessels are stable. There is a small amount of pericardial fluid. No definite axillary, mediastinal, or hilar lymphadenopathy is seen. Again seen is a moderate-to large-sized right pleural effusion. There has been interval development of moderate amount of high-attenuation fluid within the effusion consistent with hemorrhage. Patchy consolidation of the right lung is stable. Hazy patchy opacities are noted in the left lung field but no frank consolidation is seen. CT ABDOMEN: Within the limits of this non-contrast study, the liver, gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach, and small bowel loops are within normal limits. There is colonic diverticulosis most prominent at the hepatic flexure. There is no free air or free fluid. No mesenteric or retroperitoneal lymphadenopathy is identified. An IVC filter is seen. CT PELVIS: The bladder is unremarkable. The patient appears to be status post prostatectomy. The rectum is unremarkable. There is no free fluid and no pelvic or inguinal lymphadenopathy. BONE WINDOWS: A lytic area is again seen in the L5 vertebral body but unchanged from prior examination. Several subacute or chronic rib fractures are identified on the right. IMPRESSION: 1. Interval development of a moderate amount of hemorrhage within the right pleural effusion. 2. No acute intra-abdominal abnormalities identified. . [6-14] Stress MIBI New moderate and fixed inferior myocardial wall perfusion defect. Mild inferior wall hypokinesis. Calculated LVEF 42%. . Brief Hospital Course: A/P 74 yo M with lung cancer, DVT, CAD s/p MI presents with chest pain shortness of breath. . # Chest Pain/Ischemia - Patient with history of CAD a/p MI. Now with an episode of pain consistent with his anginal equivalent. No changes on EKG but not in pain at time of EKG. Patient was ruled out by enzymes. He also had a stress test which revealed an irreversible deficit from his prior known IMI. Continued on asa, bblocker, [Last Name (un) ], statin, plavix. BP meds held while was unstable. ASA, plavix held during hemothorax. . # CHF - patient does not seem volume overloaded at this time. He has no JVD, no edema in legs (other than swelling from DVT). Last Echo with EF 55%. Does have increased effusion although loculated. Continued on lasix, bblocker [Last Name (un) ]. BP meds held while unstable. . # Afib - In sinus during admission. Patients anticoag held during hemothorax. . # Shortness of Breath/loculated Effusion - patient with increaing loculated pleural effusion. Has chronic shortness of breath which has worsened over the past few days. No sign of infeciton at this time. Had thoracentesis by interventional pumonology on [2147-6-14] revealing almost 2 L of serous exudative fluid. Patient had improved breathing. Cytology was negative. However on [6-15] Hct dropped. CT revealed hemothorax. All anticoagulation stopped despite the risk of DVT, afib. Risk discussed with family. Thoracics consulted and chest tube placed. Frank blood was taken out. Patient continued to bleed in and around the tube. Patient sent to MICU for observation after Hct continued to drop. Patient spontaneously stablized and output of CT became more serous. Output resent for cytology which was pending at time of discharge. When output became <100 cc the tube was removed. Patient follwed with serial CXR that did not demonstrate reaccumulation. Hct also remained stable. . # DVT - patient therapeutic on heparin. Improving clots on LENI. CTA neg for PE. Anticoagulaiton held during hemothorax. Patient restarted on coumadin and will be discharged on 3mg coumadin qday. . # Lung Cancer - patient currently with no evidence of disease. s/p neoadjuvant chemo/XRT now s/p surgery. 1st cytology negative. 2ng cytology pending. WIll follow up tih outpatient oncologist. . Contacts - son [Telephone/Fax (1) 40633] Medications on Admission: Lipitor 80mg qday Asa 81mg qday bowel reg percocet prn plavix 75mg qday losartan 25mg qday coumadin 3mg qday lasix 20mg qday atenolol 25mg qday Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:100 Tablet(s) Refills:0 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:60 Capsule(s) Refills:3 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 14. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:QS 1 month ML(s) Refills:0 15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Angina Pleural Effusion Secondary HTN Non small cell lung cancer CAD DVT h/o afib Discharge Condition: stable, eating, on room air Discharge Instructions: Please take all medications as listed in the discharge paperwork. Please make all appointments listed in the discharge paperwork. If you have chest pain, shortness of breath, abdominal pain, nausea or other concerning symptoms please [Name6 (MD) 138] your MD or come to the emergency room. . I have changed some of your blood pressure meds. Your atenolol has increased to 50mg a day. Your losartan has increased to 50 mg a day. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[0-0-] Date/Time:[2147-7-20] 9:00 You should call Dr. [Last Name (STitle) ] to also see him again sooner [8-21] days. [0-0-]. Please see Dr. [Last Name (STitle) 2903] [Telephone/Fax (1) 2936] on monday and have your coumadin level checked.	[ "V58.61", "427.31", "E878.8", "511.9", "414.01", "412", "428.0", "401.9", "998.11", "V45.82", "285.1", "413.9" ]	icd9cm	[ [ [] ] ]	[ "34.04", "34.91", "99.04", "99.07", "99.05" ]	icd9pcs	[ [ [] ] ]	8621, 8679	4501, 6860	326, 389	8806, 8836	1691, 4478	9320, 9684	1351, 1380		7054, 8598		8700, 8785		6886, 7031			8860, 9297									1395, 1672																							276, 288						417, 925															947, 1279	1295, 1335
24,212	118,373	18271+18336+56930+56936	Discharge summary	report+report+addendum+addendum	Admission Date: [2193-3-8] Discharge Date: [2193-3-12] Date of Birth: [2124-5-30] Sex: M Service: [Last Name (un) 7081] HISTORY OF PRESENT ILLNESS: The patient is a 68 year-old male, with a history of stage 2-B melanoma, excised from his left upper arm in [2189]. He developed local recurrence. Subsequent biopsy with excision and resection. He underwent 14 cycles of chemotherapy and follow-up CT scans demonstrated two small pulmonary nodules on the left. Repeat CT scan was consistent with some enlargement of the pulmonary nodules. The patient presented at the time of admission for an elective wedge resection of pulmonary nodules by means of a video assisted thoracoscopy and bronchoscopy. MEDICATIONS ON ADMISSION: Furosemide, Lisinopril, Digoxin, Plavix, Atenolol and Lipitor. PAST MEDICAL HISTORY: Includes metastatic melanoma, status post multiple excisions and sentinel node biopsy; also history of coronary artery disease, status post stenting. HOSPITAL COURSE: The patient was admitted to the thoracic surgery service under the care of Dr. [Last Name (STitle) ]. On hospital day number one, he underwent a wedge resection of metastatic melanoma on the left upper and left lower lobes, along with bronchoscopy. He tolerated the procedure well with minimal blood loss and was transferred to the floor after surgery. His pain was well controlled with patient controlled anesthesia. On postoperative day number two, his chest tube was placed on water seal and a chest x-ray was stable. It was decided that this chest tube would be removed. A chest x- ray following removal of the chest tube revealed a pneumothorax on the left, of about 20% of the lung. The patient was satting well following this complication but it was decided that the chest tube should be replaced with a 20 French chest tube. This was accomplished. The patient tolerated the procedure well. Chest tube was placed on suction. The patient was placed on telemetry and oxygen as needed. Chest x-ray on postoperative day number three showed resolving pneumothorax. The chest tube was placed back to water seal. A repeat chest x-ray on postoperative day number four continued to be stable. It was decided that the chest tube would be removed, as the last chest x-ray was stable and the patient was discharged home. The patient was instructed to call the Emergency Room or surgery clinic if he observed any increasing pain, swelling, drainage, bleeding, shortness of breath, chest pain or elevated temperature. He was instructed to avoid driving while taking narcotic pain medications and was told to leave the dressing over the chest tube site for 2 to 3 days and then to remove and use bandages as needed. He was told to avoid soaking his wound. DISCHARGE DIAGNOSES: 1. Stage 2-B melanoma, metastatic. 2. Pulmonary nodules. 3. Status post bronchoscopy and left VAC. FOLLOW UP: Instructions included follow up with Dr. [Last Name (STitle) ] in one to two weeks. Call the thoracic surgery clinic for an appointment. At the time of discharge, the patient was stable, tolerating a regular diet and ambulating independently. DISCHARGE MEDICATIONS: 1. Lisinopril 20 mg p.o. q. day. 2. Plavix 75 mg p.o. q. day. The patient was instructed to start this after the chest tube was removed at the time of discharge. 3. Lasix 40 mg p.o. q. day. 4. Digoxin 250 mcg p.o. q. day. 5. Lipitor 40 mg p.o. q. day. 6. Atenolol 25 mg p.o. q. day. 7. Percocet 5/325 tablets, one to two tablets p.o. every four to six hours prn pain for five days. [Name6 (MD) 4667] [Name8 (MD) ], M.D. [MD Number(2) 39921] Dictated By:[Last Name (NamePattern1) 15009] MEDQUIST36 D: [2193-3-12] 09:01:49 T: [2193-3-12] 09:21:49 Job#: [Job Number 50405] Admission Date: [2193-3-8] Discharge Date: [2192-3-19] Date of Birth: [2124-5-30] Sex: M Service: NME ADDENDUM The patient complained of a headache and DICTATION ENDED [Name6 (MD) 4667] [Name8 (MD) ], M.D. [MD Number(2) 39921] Dictated By:[Last Name (NamePattern1) 15009] MEDQUIST36 D: [2193-3-19] 09:32:22 T: [2193-3-19] 09:38:45 Job#: [Job Number 50518] Name: [Known lastname 9338], [Known firstname ] Unit No: [Numeric Identifier 9339] Admission Date: [2193-3-8] Discharge Date: [2193-3-19] Date of Birth: [2124-5-30] Sex: M Service: As the patient was preparing for discharge, the nurses have observed that he complains of increased headache and his wife noted that his mental status did not seem at baseline for him. Therefore, a neurology consult is obtained and a head CT was completed, which showed a right frontal lobe hemorrhage. At that point, the patient was transferred to the neurology service for further management, and further hospital summary will be available to their documentation. [Name6 (MD) 9340] [Name8 (MD) 9341], M.D. [MD Number(2) 9342] Dictated By:[Last Name (NamePattern1) 9343] MEDQUIST36 D: [2193-3-19] 09:41:47 T: [2193-3-19] 09:54:00 Job#: [Job Number 9344] Name: [Known lastname 9338],[Known firstname ] Unit No: [Numeric Identifier 9339] Admission Date: [2193-3-8] Discharge Date: [2193-3-25] Date of Birth: [2124-5-30] Sex: M Service: NEUROLOGY Allergies: Aspirin Attending:[First Name3 (LF) 2013] Addendum: see all d/c summaries Chief Complaint: Transfer from thoracic surgery service for bleeding metastatic brain mass Major Surgical or Invasive Procedure: 1. Bronchoscopy 2. left VATS 3. Brain surgery History of Present Illness: HPI: This is a 68 yo RH man with h/o metastatic melanoma (to lungs) and CAD who was admitted to the thoracic surgery service on [3-8] for VATS/bronchoscopy of lung nodule. His post operative course was complicated by pneumothorax after removal of surgical chest tube. PTX is now resolved and chest tube has been removed. He became confused yesterday with headache and neurology consult service was consulted. They saw the patient, suggested CT, CT was performed today and showed a single hemorrhagic lesion in the right frontal lobe with mass effect on the lateral ventricle, blood in the occipital horns, hydrocephalus. History obtained from wife and patient. Patient has been having fatigue and "imbalance" walking for the past 3-4 months. No falls although has had to catch himself at times. Occasional light headedness. Is able to feel the ground beneath him. Also c/o memory loss for recent things. He was admitted on [3-8] for surgery, did well immediately post op but then yesterday (POD #4) began to have confusion, a "disinterest" in the people around him, acting "spacey", talking about the need to attend his father's funeral (who is long dead), having day/night confusion, aggitation at night (pulling at lines, etc.) He also had an "excruciating" headache. He "never" has headaches baseline and so this was unusual for him. Constant, all over his head (points to the front of head), [2198-3-29], but relieved with tylenol. No visual changes or nausea. He denies incontince. Currently has a foley in place as a UA was needed last night. No falls. Was given plavix today but no other blood thinners (other than SC heparin). ROS is otherwise negative for chest pain, SOB, palp, belly pain, weakness, numbness, difficulty speaking or swallowing, etc. Past Medical History: 1. Melanoma stage IIB, originally diagnosed in [7-26] with left arm lesion, excised. Recurred two more times in [8-26] and [4-27], both excised. Underwent 14 cycles of ECOG 4697 (? vaccine vs. placebo). Had CT torso which showed pulm nodules [9-27], then repeat CT that showed enlarging pulmonary nodules [12-29], now s/p VATS for lung nodule on [2193-3-8]. Non contrast Head CT on [8-26] showed enlarged ventricles but no masses. Followed by Dr. [Last Name (STitle) 9365]. 2. CAD s/p stent [2189] 3. CHF, no echo in our records, ? EF 4. "borderline diabetes" - HBA1c 6.0 [2193-3-11] No h/o strokes or seizures. Social History: SHx: Married x 43 yrs, 4 kids, retired from telephone company. + cigars one a day x 40 yrs, quit drinking 4 yrs ago but used to drink 4-6 beers/day. No IVDA Family History: FamHx: Mom - CHF, DM. Dad - lung disease. Kids healthy. Physical Exam: PHYSICAL EXAM: VITALS: 97.3, 124-139/60's, 52, 18, 99% RA, FS 168 GEN: no acute distress, cooperates HEENT: NC/AT, anicteric sclera, mmm NECK: supple, no carotid bruits CHEST: normal respiratory pattern, CTA bilat CV: regular rate and rhythm without murmurs ABD: soft, nontender, nondistended, +BS, no HSM EXTREM: no edema NEURO: Mental status: Patient is alert, awake, blunted affect. Little facial expression. Oriented to person, place, time and president. Poor attention - gets confused around [Month (only) ]/[Month (only) ]. Language is fluent with good comprehension, repitition, naming, able to read and write, no dysarthria. No apraxia, agnosias, no neglect. Able to calculate, no left/right mismatch. Registration [1-24] objects. Recalls [12-27] objects after 3 minutes, [1-24] with a cue. Normal luria sequencing. Upon attempting to draw a complex figure, he draws the outline, but does not fill in the details. Cranial Nerves: I: deferred II: Visual fields: full to left/right/upper/lower fields. Fundoscopic exam: difficult to appreciate due to small pupils, but left disc appeared flat, no hemorrhages or exudates. Pupils:3->2 mm, consenual constriction to light. III, IV, VI: EOMS full, gaze conjugate. No nystagmus or ptosis. V: facial sensation intact over V1/2/3 to light touch and pin prick. VII: mild left nasolabial fold flattening VIII: hearing intact to finger rubs IX, X: Symmetric elevation of palate. [Doctor First Name 2237]: trapezius [3-28] bilaterally XII: [Known lastname ] midline without atrophy or fasciulations. Sensory: Normal touch, proprioception, pinprick. No extinction to double simultaneous stimulation. Motor: Normal bulk. Paratonia in the arms, increased tone legs bilaterally. No fasciculations. + left pronator drift. No adventitious movements. + bilateral asterixis. Strength: Delt Tri [Hospital1 ] WE WF FE FF IP QD Ham DF PF Toe LEFT: 5 5 5 5 5 5 5 4+ 5 4+ 5 5 5 Reflexes: No glabellar. [Hospital1 ] BR Tri Pat Ach Toes RT: 2 2 2 2 1 down LEFT: 2 2 2 1 1 up slightly brisker [Hospital1 ]/br on the left. Coordination: Normal finger-to-nose, heel-to-shin, RAMs. Gait: Retropulsion upon standing, unable to further investigate due to unsteadiness. Pertinent Results: CXR [3-22]: Disappearance of left-sided apical pneumothorax with 9 days interval for comparison. MRI post op [3-22]:Enhancement within the right frontal lobe tumor resection bed, in which the appearance is worrisome for residual tumor. cEEG [3-18]: This is a discontinuous 24-hour bedside EEG telemetry from [3-17] through [3-18]. The record shows a low voltage but symmetric background rhythm predominately in drowsiness. Occasional generalized delta frequency slowing that likely reflects drowsiness but may suggest dysfunction of deep, midline subcortical structures. No epileptiform abnormalities were seen in this recording. It did not change appreciably over the day's recording. [2193-3-25] 06:45AM BLOOD WBC-8.3 RBC-3.56* Hgb-11.6* Hct-31.2* MCV-88 MCH-32.5* MCHC-37.0* RDW-14.9 Plt Ct-220 [2193-3-25] 06:45AM BLOOD Plt Ct-220 [2193-3-25] 11:00AM BLOOD Glucose-237* UreaN-20 Creat-0.8 Na-131* K-4.3 Cl-98 HCO3-24 AnGap-13 [2193-3-25] 11:00AM BLOOD ALT-93* AST-40 TotBili-0.4 [2193-3-11] 12:04PM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [2193-3-22] 06:00AM BLOOD Osmolal-275 [2193-3-17] 03:10AM BLOOD TSH-0.44 [2193-3-16] 03:50AM BLOOD Digoxin-0.5* [2193-3-25] 06:45AM BLOOD Phenyto-2.5* Brief Hospital Course: Patient was transferred from thoracic surgery to neuro ICU x 1 week while awaiting neurosurgery for newly diagnosed right frontal brain mass. During his week in the ICU his mental status declined in that he became more inattentive, more abulic. Left hemiparesis was stable. He was started on dex and keppra, however, on keppra 500 [Hospital1 ] he had a seizure - head turned to right, dropped an item from his hand, was unresponsive. Keppra was increased and he was started on dilantin. Continuous EEG was obtained and showed right frontal slowing. He remained seizure free after this event. Keppra was increased slowly to 1500 [Hospital1 ] and dilantin eventually discontinued as it was impossible to maintain a theraputic level. He underwent resection of right frontal mass on [3-19] by Dr. [Last Name (STitle) 9366] of neurosurgery, and was transferred to the general neurology floor on POD #2. He recovered nicely on the floor. Exam upon discharge: still with mild abulia and frontal lobe dysfuction, A&O x3, inattentive (unable to say MOYB but can count backwards from 20), mild left hemipareisis. Sodium was low (120's) after mass removed, labs c/w SIADH. Placed on 1 L free water restriction and salt tabs, and sodium leveled out at 131. He was seen by neuroonc and has an appt with XRT and Dr. [Last Name (STitle) 9367] on [4-8]. His dex will be tapered to 4mg [Hospital1 ] over 2 weeks (currently on 8mg PO TID). Hyperglycemia - BL DM and dex, maintained on RISS. PTX resolved, CXR confirmed. NO thoracic issues. Mass removed came back as melanoma. (please see thoracic's d/c summ for further info). Being discharged to rehab. PCP was called and message left re: patient's status and discharge. It is unclear whether or not he should be maintained on digoxin. Needs to be verified with PCP. Medications on Admission: 1. Lisinopril 20 mg p.o. q. day. 2. Plavix 75 mg p.o. q. - had been stopped for 3 weeks prior to surgery 3. Lasix 40 mg p.o. q. day. 4. Digoxin 250 mcg p.o. q. day. 5. Lipitor 40 mg p.o. q. day. 6. Atenolol 25 mg p.o. q. day. 7. Percocet and Dilaudid prn Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): restart at discharge. 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours for 5 days. Disp:30 Tablet(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 11. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO TID (3 times a day): please monitor sodium and discontinue if sodium normalizes. 12. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 13. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 units Injection TID (3 times a day). 14. Dexamethasone Dexamethasone 6mg PO TID x 6 more days, then Dexamethasone 4mg PO TID x 6 days, then 4mg PO BID until Dr. [Last Name (STitle) 9367] appointment. 15. Insulin sliding scale per copy attached. Discharge Disposition: Extended Care Facility: [Hospital6 9368] of [Location (un) 9369] - [Location (un) 9369] Discharge Diagnosis: 1. Stage IIB melanoma 2. Pulmonary nodules 3. s/p bronchoscopy and left VATS 4. s/p brain mass removal Discharge Condition: stable medically,frontal (abulic) with left hemiparesis. Discharge Instructions: Call Surgery clinic ([Telephone/Fax (1) 1477]if you observe: increased pain, swelling, drainage, bleeding, shortness of breath, chest pain, or temp > 101.5. Followup Instructions: 1. F/up with Dr.[Last Name (STitle) ] in [11-25] weeks. Call [Telephone/Fax (1) 9370] to make appointment Provider: [Name10 (NameIs) 9371] [Last Name (NamePattern4) 9372], MD Where: [Hospital6 189] NEUROLOGY Phone:[Telephone/Fax (1) 190] Date/Time:[2193-4-8] 1:30 Provider: [Name10 (NameIs) ],MULTI CUTANEOUS ONCOLOGY Where: CUTANEOUS ONCOLOGY Date/Time:[2193-4-17] 9:00 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 3549] [Name Initial (NameIs) ]. [Telephone/Fax (1) 1477] Follow-up appointment should be in 1 week Please followup with Dr. [Last Name (STitle) 9373] of neurosurgery Wed [4-3] at 11:30, if you can't keep this appointment call [Doctor First Name ] [Telephone/Fax (1) 9374] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2016] MD, [MD Number(3) 2017] Completed by:[2193-3-25]	[ "253.6", "V10.82", "331.4", "250.00", "780.39", "197.0", "428.0", "438.22", "198.3", "V45.82", "512.1", "431" ]	icd9cm	[ [ [] ] ]	[ "33.22", "01.59", "32.29", "34.04" ]	icd9pcs	[ [ [] ] ]	15804, 15906	12189, 13145	5744, 5795	16057, 16115	10910, 12166	16324, 17257	8492, 8553	2815, 2916	14349, 15781		15927, 16036		14069, 14326	1025, 2794		16139, 16301									8583, 8906									2928, 3177														5630, 5706						5823, 7613	9538, 10891								8921, 9522						7635, 8299	8315, 8476			13166, 14043
20,836	169,490	9821	Discharge summary	report	Admission Date: [2139-12-7] Discharge Date: [2140-1-19] Date of Birth: [2070-9-14] Sex: M Service: LIVER TRANSPLANT SURGERY PREOPERATIVE DIAGNOSES: Hepatitis C. Hepatocellular carcinoma. Diabetes mellitus type 2. Hypercholesterolemia. Hypertension. Chronic low back pain. Status post hernia repair. DISCHARGE DIAGNOSES: Status post orthotopic liver transplant. Status post exploratory laparotomy with repair of fascial wound dehiscence. Ascites leak. Status post liver biopsy. Portal vein thrombosis/stenosis--status post thrombolysis and stenting. Blood loss anemia. Insertion of nasojejunal feeding tube via endoscopic guidance. Postoperative delirium. Postoperative pneumonia. Pleural effusions. Insertion of peripherally inserted central catheter. Hepatocellular carcinoma. Hepatitis C. Diabetes mellitus type 2. Hypertension. Malnutrition. Hypercholesterolemia. Status post hernia repair. Chronic low back pain. ADMISSION HISTORY AND PHYSICAL: Mr. [Known lastname ] is a 69-year-old male, with a history of end-stage liver disease secondary to hepatitis C cirrhosis with multiple hepatocellular carcinomas, who had been awaiting a liver transplant and had actually been admitted to the hospital towards the end of [Month (only) ] for elective orthotopic liver transplantation, but unfortunately secondary to an inappropriate donor, Mr. [Known lastname 17391] liver transplantation was cancelled. Notably, the patient had a heavy history of alcohol use and polysubstance abuse including IV drug abuse, but he had been free of these for at least 14 years. He represented on [12-6] after a suitable donor had been found for elective orthotopic liver transplantation. At the time of his admission, the patient's white blood cell count was 2.5 with a hematocrit of 32. His PT was 13.8. His INR was 1.2, and his PTT was 31.4. His platelet count was 118. His admission sodium was 144, with a potassium of 3.9. His chloride and bicarb were 109 and 25, respectively, with a BUN and creatinine of 20 and 1.0. His glucose was 124. His total bilirubin was 0.8 with an ALT and AST of 45 and 88. His alk phos was 92. HOSPITAL COURSE: The patient was admitted, and on the evening of the [12-6] he underwent an orthotopic cadaveric liver transplantation using the piggyback technique. The portal vein was anastomosed to the portal vein with a common bile duct to common bile duct anastomosis, and a celiac duct patch into the donor branch patch anastomosis. The patient tolerated the procedure well, and there was no note of intraoperative complication. The patient was taken to the Intensive Care Unit postoperatively for ventilatory support and intensive monitoring. The [Hospital 228] hospital course was as follows: 1. NEUROLOGIC: Neurologically, the patient's pain was controlled with a variety of combinations of intravenous and oral narcotics. His chronic low back pain continued to be an issue throughout his hospitalization, but prior to his discharge we were able to sustain him on a regimen of methadone 5 mg po bid, in addition to 5 mg of oxycodone q 6 h as needed for breakthrough pain on top of his Neurontin he had been taking. The patient's pain was controlled adequately with this regimen. Notably during late in the second week of his hospitalization, the patient developed mental status changes which were characterized by increased lethargy and difficulty in rousing the patient. He was transferred immediately to the Intensive Care Unit for further evaluation, and after a thorough work-up which included CT scan of the head which showed no evidence of intracranial hemorrhage, it was felt that this was most likely secondary to cyclosporin toxicity along with the narcotics that the patient had been receiving. The patient recovered from this quite well, and prior to his discharge he was alert and oriented, completely lucid, and otherwise had no neurologic deficits and, as noted, had good pain control. 1. RESPIRATORY: The patient was supported with a ventilator in the initial postoperative period from which he was able to wean successfully without complication. Notably, he did develop bilateral pleural effusions throughout the course of his hospitalization, but after diuresis, these effusions significantly improved. The patient otherwise had no significant pulmonary complications. 1. CARDIOVASCULAR: The patient's cardiovascular status was tenuous in the initial postoperative period requiring some vasopressor support with Neo-Synephrine, but after adequate volume resuscitation in the immediate perioperative period, we were able to wean off vasopressors, and the patient was able to maintain an adequate blood pressure with peripheral perfusion pressure without any sort of pharmacologic support. We were able to restart the patient's beta blockade for cardioprotection and management of his hypertension, and he tolerated his Lopressor doses well without any complication. 1. GI: The patient's liver transplant was actually quite successful. Follow-up biopsies evidenced no evidence of acute cellular rejection, and the patient's liver function tests continued to remain steady and within normal limits throughout the remainder of his hospitalization. His course was notably complicated by some stenosis and thrombosis of the portal vein which required angiography with thrombolysis and stenting secondary to acutely rising LFTs on [2140-1-3]. The patient tolerated this procedure well, and after successful stenting and balloon dilatation via angiography, the patient's liver function tests improved and stabilized. The patient's postoperative course was notably complicated by a persistent ascites leak which was discovered on [12-20], [2139] after bedside exploration, and a fascial wound dehiscence was discovered. This required reexploration in the operating room with repeat closure, which the patient again tolerated well. His wound was subsequently cared for with a combination of wet-to-dry dressing changes and placement of a wound VAC. 1. FEN: The patient's nutritional status continued to be a problem given his malnourished state at the onset, along with his postoperative complications of pneumonia and wound dehiscence. He was initially given TPN until return of bowel function, and subsequent to that time, as it was felt the patient could not take in adequate oral intake without supplementation to sustain himself, postpyloric feeding tubes were placed, and he was started on supplemental enteral nutrition via tube feeds, which he continued up until one day prior to the end of his hospitalization. These tube feeds were administered, as noted, through a postpyloric feeding tube. The patient's renal status remained steady, and his creatinine remained around its baseline of 1.0, although while in the Intensive Care Unit, in the second week postoperatively, he did develop acute renal failure which was felt to be secondary to drug toxicity and intravascular volume depletion. His renal function though did recover to its baseline without long-term complication. 1. HEMATOLOGIC: The patient did suffer from blood loss anemia for which he was transfused appropriately. His coagulopathy was corrected with a combination of fresh frozen plasma and cryoprecipitate. Prior to discharge, his PT and INR had normalized. 1. INFECTIOUS DISEASE: The patient's main infectious disease issues included a left lower lobe pneumonia, for which he was treated appropriately with broad-spectrum antibiotics including Zosyn. He never evidenced any sort of bacteremia, nor did he ever have a urinary tract infection. Notably, he was colonized with VRE, although there was never any focal infection with this, and patient's MRSA screens were negative. The patient's wound grew out E. coli. Regarding patient's immunosuppression, after the standard initial postoperative course, he was maintained on cyclosporin and CellCept, along with oral doses of prednisone. His cyclosporin levels had been stabilized on a dose of 150 mg of cyclosporin [Hospital1 ], along with CellCept 1 gram po bid, and 15 mg of prednisone once daily. As noted, the patient never evidenced any graft rejection. At the time of discharge, the patient was afebrile and otherwise hemodynamically normal, with a pulse in the 60s, a blood pressure in the 110s, satting 95 percent on room air, with blood sugars between the 70s and 130s. He was otherwise urinating adequately. He was in no acute distress, alert and oriented x 3. His lungs were clear bilaterally with only a slight decrease at the left base. He was otherwise irregular. His abdomen was soft and nontender. He had a 3 cm triangular wound underneath the subcostal margin at the bifurcation of the incision. This was granulating in well at the base, there was no purulence, and a VAC was applied with good seal. His abdomen was otherwise soft, mildly distended, but nontender, and he had only 1 plus peripheral edema. His white blood cell count was 6.2 prior to discharge with a hematocrit of 32, and a platelet count of 215. His PT was 12.6 with a PTT of 25.4, and an INR of 1.0. His BUN and creatinine were 37 and 1.3. His total bilirubin was 1.6 with an alk phos of 363, an ALT of 36 and AST of 22. His albumin was 3.4. The patient was discharged to rehab on the following medications: DISCHARGE MEDICATIONS: 1. Bactrim single strength 1 tab po once daily. 2. CellCept 1,000 mg po bid. 3. Guaifenesin 5-10 cc po q 4-6 h prn. 4. Prednisone 15 mg po once daily. 5. Albuterol/ipratropium nebulizer treatments. 6. Bisacodyl prn. 7. Lansoprazole 30 mg po once daily. 8. Colace 100 mg 1 po bid. 9. Aspirin 81 mg po once daily. 10.Plavix 75 mg po once daily. 11.Fluconazole 400 mg po once daily. 12.Neurontin 100 mg po bid. 13.Valganciclovir 450 mg po bid. 14.Methadone 5 mg po bid. 15.Oxycodone 5 mg po q 4-6 h prn pain. 16.Trazodone 25 mg po q at bedtime. 17.Lopressor 50 mg po bid. 18.Lasix 20 mg po bid. 19.Cyclosporin dose to be adjusted based on levels (150 mg po q 12 h at the time of discharge). 20.Glargine insulin 20 units q at bedtime with an insulin sliding scale. He was sent for discharge to rehabilitation facility on [2140-1-19] in fair condition with a follow-up scheduled for 1-2 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 12072] Dictated By:[Doctor Last Name 3763] MEDQUIST36 D: [2140-1-18] 11:14:04 T: [2140-1-18] 12:16:39 Job#: [Job Number 33042]	[ "997.3", "272.0", "996.82", "276.5", "070.70", "155.0", "293.9", "571.5", "401.9", "997.5", "263.9", "486", "584.9", "250.00" ]	icd9cm	[ [ [] ] ]	[ "99.10", "38.93", "00.93", "50.59", "39.90", "86.22", "96.6", "39.50", "50.11", "86.59", "45.13" ]	icd9pcs	[ [ [] ] ]								362, 2196	9639, 10794					2214, 9616
20,620	187,967	14646	Discharge summary	report	Admission Date: [2123-11-15] Discharge Date: [2123-11-26] Date of Birth: [2057-1-10] Sex: M Service: SURGERY Allergies: Penicillins / Erythromycin Base / Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2777] Chief Complaint: Right non healing heel ulcer Major Surgical or Invasive Procedure: [2123-11-16]: Right foot guillotine amputation [2123-11-22]: Right below knee amputation History of Present Illness: 66yoM with diabetes, ESRD on HD, and PVD s/p R SFA to DP bypass graft ([10/2115]) followed by RLE angiogram with angioplasty and SFA/AT stents ([2123-3-12]), with known chronic right heel ulcer, now presents with worsening right heel gangrene. He has been followed by podiatry (Dr [Last Name (STitle) 12636], last seen on [2123-10-8] and noted to have significant improvement since the last visit, instructed to continue with saline dressing changes, a Multipodus splint, and future plans to place an Apligraf to the right heel were discussed. He was subsequently seen in vascular surgery clinic and found to have worsening heel gangrene which prompted direct admission. Past Medical History: PMH: Noninsulin dependent diabetes mellitus x 16 years, Chronic renal insufficiency on HD (T, Thr, Sat at [Location (un) 2498] Kidney Center), hypertension, Osteoarthritis of the ankles and knees, Right cataract, Peripheral neuropathy [3-4] diabetes, blindness [3-4] diabetes, T8 vertebral fracture. . PSH: R SFA DP bpg 04, multiple angioplasties (last [2121-5-16]), Fibrosarcoma resection of the upper back in [2089], multiple debridements of the left lower extremity culminating in left BKA [2115], right 5th toe amputation [5-/2121] Social History: currently at [Hospital1 1501]; past 20PY smoking history. Social EtOH. Family History: Non-contributory Physical Exam: 97.9 97.9 89 99/54 18 96RA GEN: AAOx3 NAD. Cardiac: Irregular rhythm, Normal rate Resp: CTAB GI: Soft non-tender, non distended Ext: L-Old BKA stump well healed R- BKA stump non erythematous, closed with staples. No fluctuance or induration or drainage Pulses- Dopplerable femoral and PT b/l Pertinent Results: [2123-11-15] 10:00PM GLUCOSE-106* UREA N-39* CREAT-5.2# SODIUM-138 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-28 ANION GAP-17 [2123-11-15] 10:00PM estGFR-Using this [2123-11-15] 10:00PM estGFR-Using this [2123-11-15] 10:00PM ALT(SGPT)-42 AST(SGOT)-24 LD(LDH)-186 ALK PHOS-138* TOT BILI-0.5 [2123-11-15] 10:00PM %HbA1c-5.6 eAG-114 [2123-11-15] 10:00PM %HbA1c-5.6 eAG-114 [2123-11-15] 10:00PM PLT COUNT-223 [2123-11-15] 10:00PM PT-11.9 PTT-34.5 INR(PT)-1.1 [2123-11-15] STUDY: Eight total views of the right foot and ankle [2123-11-15]. COMPARISON: Right foot radiographs [2123-3-10]. INDICATION: Evaluate for osteomyelitis, gangrene right heel, known nonhealing ulcer. FINDINGS: Atherosclerotic vascular calcifications. Subcutaneous edema. Large posterior calcaneal ulcer with exposed bone, mild periostitis at the calcaneus and cortical irregularity. Plantar spur. Tibiotalar joint space narrowing. The mortise and syndesmosis are intact. Bone demineralization. Prior fifth toe amputation. Final Report STUDY: Eight total views of the right foot and ankle [2123-11-15]. COMPARISON: Right foot radiographs [2123-3-10]. INDICATION: Evaluate for osteomyelitis, gangrene right heel, known nonhealing ulcer. FINDINGS: Atherosclerotic vascular calcifications. Subcutaneous edema. Large posterior calcaneal ulcer with exposed bone, mild periostitis at the calcaneus and cortical irregularity. Plantar spur. Tibiotalar joint space narrowing. The mortise and syndesmosis are intact. Bone demineralization. Prior fifth toe amputation. [2123-11-15] IMPRESSION: Large posterior calcaneal ulcer with exposed bone and cortical irregularity, likely representing osteomyelitis. ECHO [11-17] The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed (biplane LVEF= 35 %) secondary to moderate global hypokinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([2-1]+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with moderate global systolic dysfunction. No LV thrombus. Mild-moderate mitral regurgitation. Compared to prior study dated [2115-7-2] (images not available for review), left ventricular systolic function and degree of mitral regurgitation are worse. IR GUIDED CENTRAL LINE PLACEMENT IMPRESSION: 1. Apparent complete occlusion of the left brachiocephalic, right brachiocephalic veins. 2. Collateral flow of blood via the left internal jugular into the accessory hemiazygos vein which communicates with the azygos and from there to the SVC. 3. Successful placement of a temporary triple-lumen central venous access line with the tip in the accessory hemiazygos. Brief Hospital Course: The patient was admitted to the Vascular Surgery service for concern of RLE non healing wound ulcer. X-rays were concerning for osteomyelitis. On HD#2 he was taken to the OR for RLE Guillotine amputation. Post op course was complicated by hypotension, pressor (neo) dependence and troponin leak. cardiology was not convinced that he had an ischemic event. He was taken to the CVICU and monitored there with daily weaning trials. On HD6, he was transferred from the CVICU to the VICU. On HD 7, he underwent a completion BKA and tolerated the procedure well. He received 4 sessions of HD, with up to 1.5L of fluid removed on his last session. For his atrial fibrillation, he was rate controlled on metoprolol. Per cardiology, Imdur and Labetalol were stopped, and a new regimen of metoprolol and lisinopril were started. Neuro: The patient's pain was well controlled on his home regimen. He was AAOX3, appropriate at all times. Cardio: On HD2, his preop ECG showed atrial flutter. He was seen by the cardiologist who recommended rate control and a post-op Echo. He also received cardiology clearance for the OR. He was taken to the OR on HD2 and underwent a RLE Guillotine ampuation. He tolerated the procedure well but became hypotensive in the PACU necessitating neo drip. He also had a troponin leak and stablized upon cycling. Cardiology was c/s and they were not impressed by the leak in the setting of ESRD. He also remained in rate controlled Atrial fibrillation. He was transferred to the CVICU and was on pressors for a few days afterwards. An Echo done showed EF 35% and global hypokinesis. His was weaned off the drip and transferred to the VICU. On HD#7, he was taken to the OR for completion BKA. He tolerated the procedure well, and was HD stable. He received 2 doses of coumadin [11-24], [11-25] but these were stopped and the decision was made to anticoagulate him one week after discharge. Pulm: No acute issues. Mild atelectasis b/l but maintained good O2 sats during stay GI: Tolerated diabetic diet, Ensure tid, nephrocaps and good bowel regimen Heme: Hcts were monitored and stable Renal: Histroy of ESRD HD dependent and anuria. Received HD (T,Th,Sat); [11-19], [11-20], [11-23] and [11-25]. ID: Pan culture was negative. He was treated empiricially with Vanc HD protocol, cipro, flagyl. These will be continued till [2123-11-29]. Endocrine: SSI was started in house, although he maintained good glycemic control during his stay so the decision was made to stop it. Wounds: His RLE stump was wrapped with kerlex and ACE wrap. His was placed in a knee immobilizer which was removed on the day of discharge. He acquired Stage 2 decibutus ulcer and shearing abraision in between his scapular. Medications on Admission: lisinopril 10'; asa 81'; oxycontin 30''; tylenol 650prn; ativan 0.5'''prn; colace; duoneb; imdur 60 '; labetalol 200'''; lipitor 80'; oxycodone 5prn; plavix 75'; protonix 40'; senna' simethicone' trazodone 50qhs Discharge Medications: 1. Warfarin 5 mg PO DAILY16 This will be started on [2123-12-3]. Please monitor INR daily. Goal [3-5]. dx: atrial flutter. There will be NO bridge. 2. Oxycodone SR (OxyconTIN) 30 mg PO Q12H 3. Lisinopril 2.5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN pain 6. Docusate Sodium 100 mg PO BID 7. Metoprolol Tartrate 25 mg PO TID 8. Vancomycin 1000 mg IV HD PROTOCOL 9. Pantoprazole 40 mg PO Q24H 10. Simethicone 40-80 mg PO QID:PRN gas 11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain 12. Ciprofloxacin HCl 500 mg PO Q24H Duration: 4 Days thru [11-29] RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp #3 Tablet Refills:0 13. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 4 Days thru [11-29] 14. Atorvastatin 80 mg PO DAILY 15. WE STOPPED THE FOLLOWING plavix, Imdur, labetalol 16. traZODONE 50 mg PO HS:PRN insomnia 17. Senna 2 TAB PO BID:PRN constipation Discharge Disposition: Extended Care Facility: [Hospital 169] Center- Wedgemere Discharge Diagnosis: Gangrene of the right foot & osteomyelitis s/p Right Lower Guillotine Amputation and Completion below the knee amputation. Atrial Flutter - rate controlled Diabetes Mellitus- Non insulin dependent 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: Weigh daily - evaluate for fluid overload You were admitted with a severe infection of the tissue and bone in the right heel. You were started on iv antibiotics and the decision was made that an amputation was neccessary. You underwent a guillotiene amp of your right lower extremity, followed by a below knee amputation several days later. We would like you to continue on vancomycin with HD, and cipro/flagyl by mouth through [11-29]. Your regular schedule is T/T/S. You should keep your right extremity elevated whenever possibly. You will need to have a dressing and light ace bandage to the stump. You have a Stage 2 decubitus Ulcer. Please place mepilex over it. Ensure tuning every 2 hours. You also have a shear injury on your back between your scapula, also place mepilex over that. ACTIVITY: ?????? On the side of your amputation you are non weight bearing for 4-6 weeks. ?????? You should keep this amputation site elevated when ever possible. ?????? You may use the opposite foot for transfers and pivots. ?????? No driving until cleared by your Surgeon. ?????? No heavy lifting greater than 20 pounds for the next 3 weeks. BATHING/SHOWERING: ?????? You may shower when you get home ?????? No tub baths or pools / do not soak your foot for 4 weeks from your date of surgery WOUND CARE: ?????? Sutures / Staples may have been removed before discharge. If they are not, an appointment will be made for you to return for staple removal. ?????? When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. CAUTIONS: ?????? If you smoke, please make every attempt to quit. Your primary care physician can help with this. Smoking causes narrowing of your blood vessels which in turn decreases circulation. CALL THE OFFICE FOR: [Telephone/Fax (1) 28502] ?????? Bleeding, redness of, or drainage from your foot wound ?????? New pain, numbness or discoloration of the skin on the effected foot ?????? Fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2123-12-20*] 3:00	[ "427.31", "V10.89", "V45.11", "440.24", "458.29", "715.37", "250.80", "369.4", "730.26", "V49.72", "357.2", "V49.75", "250.60", "715.36", "585.6", "403.91", "731.8", "427.32", "707.14", "250.40" ]	icd9cm	[ [ [] ] ]	[ "39.95", "84.12", "84.15", "38.93" ]	icd9pcs	[ [ [] ] ]	9458, 9521	5503, 8244	355, 454	9762, 9762	2218, 5480	12204, 12360	1868, 1886		8506, 9435		9542, 9741		8270, 8483			9938, 11234									1901, 2199																							287, 317					11246, 12181	482, 1170									9777, 9914						1192, 1757	1774, 1851
83,361	164,664	49500	Discharge summary	report	Admission Date: [2177-8-6] Discharge Date: [2177-8-11] Date of Birth: [2106-3-12] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Bactrim / Erythromycin Base / Penicillins / Prochlorperazine / Nalbuphine / Iodine / Phenothiazines / Aspirin Attending:[First Name3 (LF) 492] Chief Complaint: Malignant airway obstruction. Major Surgical or Invasive Procedure: [2177-8-7] Rigid bronchoscopy, flexible bronchoscopy, tumor destruction with mechanical forceps, tumor destruction with cryotherapy, Y-stent placement and therapeutic aspiration of secretions. History of Present Illness: Pt is a 71 yo F admitted to OSH on [7-17] w/ acute onset wheezing she attributed to asthma as well as epigastric pain. Endoscopy revealed a large esophageal mass & TE fistula w/ path of esoph SCCa. L M bronchus stent was placed on [7-26]. Also w/ Jtube, protocath this admission. Intubated for resp distress on [2177-8-5], and transferred to [Hospital1 ] [2177-8-6] for further care. Past Medical History: Breast cancer T2N0M0 s/p mastectomy left and 4 cycles of chemotherapy w/ Adriamycin/Cytoxan limited due to GI-toxicity and Tamoxifen 20mg for 5 years till [2170] Esophagitis, gastritis, Pyloroplastic CAD Hysterectomy Appendectomy, Cholecystectomy Social History: Married lives with husband. [Name (NI) 1139] quit [2148] Family History: non-contributory Physical Exam: VS: T: 99.1 HR: 104 ST BP: 152/89 Sats : 96% RA General: sitting up in bed no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: decreased breath sounds otherwise clear GI: benign. J-tube in place. Wound: mid-abdominal with staples Extr: warm no edema Neuro: non-focal Pertinent Results: [2177-8-7] WBC-11.0 RBC-3.60* Hgb-10.4* Hct-30.5* Plt Ct-610* [2177-8-6] WBC-11.6* RBC-3.64* Hgb-10.1* Hct-31.2 Plt Ct-616* [2177-8-10] Glucose-117* UreaN-9 Creat-0.5 Na-137 K-3.9 Cl-99 HCO3-29 [2177-8-6] Glucose-92 UreaN-15 Creat-0.4 Na-140 K-3.8 Cl-103 HCO3-31 [2177-8-10] Calcium-9.1 Phos-2.4* Mg-2.0 Esophageal: [2177-8-8] No evidence of esophageal fistulization with the airways. Chest CT IMPRESSION: Intended esophageal stent displaced to the right by large, gas containing retrotracheal mediastinal abscess and subcarinal mass. No tracheoesophageal fistula is defined by a tract, but cannot be excluded, and there are small gas collections adjacent to the stent that suggest transmural esophageal erosion. The precise location of the esophageal stent and the integrity of the esophagus are best examined by a contrast swallow, followed by mediastinal CT, if necessary. Left main bronchus stent is compromised by extrinsic compression by mass and abscess as well as soft tissue or secretions at its origin. The distal left main bronchus and right bronchial tree are patent. Probable aspiration pneumonia, right lower lobe. Left lower lobe atelectasisi adjacent to a loculated pleural fluid. Brief Hospital Course: Mrs. [Known lastname 3012] was transferred from N.E. [Hospital1 ] intubated for respiratory distress and left main stem obstruction. On [2177-8-7] she underwent Rigid bronchoscopy, flexible bronchoscopy, tumor destruction with mechanical forceps,tumor destruction with cryotherapy, Y-stent placement and therapeutic aspiration of secretions. She was successfully extubated. Aggressive pulmonary toilet and nebs continued. A barium swallow no evidence of esophageal fistulization with the airways. She was seen by speech and swallow for a video-swallow. With penetration of thin liquids during the swallow resulting in aspiration immediately after the swallow. There was a long conversation with patient and husband regarding risk for aspiration. She wishes to continue to eat a regular diet with thin liquids and will follow the aspirations precautions. Hem/Onc was consulted and she will follow-up with Dr. [Last Name (STitle) ] at [Hospital6 ] for her oncology treatments. She was seen by physical therapy who deemed her safe for home. Medications on Admission: fentanyl 125mc patch, metadone 40 mg tid, albuterol IH, Omeprazole 20 mg daily Discharge Medications: 1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for agitation or anxiety. Disp:30 Tablet(s) Refills:0 2. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO twice a day for 2 weeks. Disp:28 Tab, Multiphasic Release 12 hr(s) Refills:0 3. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for cough for 2 weeks. Disp:60 Capsule(s) Refills:0 4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal Q72H (every 72 hours). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal once a day: total 125 mcg/hr . 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezes or SOB. 7. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO TID (3 times a day). 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Esophageal fistula for 2 weeks. Disp:12 Tablet(s) Refills:0 10. Senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a day). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Acetylcysteine 10 % (100 mg/mL) Solution Sig: Three (3) mL Miscellaneous twice a day: for Y stent patency Mix w/albuterol to prevent bronchospasm. Disp:180 mL Refills:2 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation twice a day: mix w/mucomyst. Disp:180 mL Refills:2 15. Nebulizer Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Malignant airway obstruction. Discharge Condition: stable Discharge Instructions: Call Dr.[Name (NI) 5070] office [Telephone/Fax (1) 10651] if develops Fevers > 101 increased shortness of breath, cough or shortness of breath Followup Instructions: Follow-up with Medical Oncology Dr. [Last Name (STitle) ] as directed Follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Please call for an appointment [Telephone/Fax (1) 7769] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494] Completed by:[2177-8-13]	[ "197.0", "518.81", "507.0", "530.84", "V10.3", "158.0", "V44.4" ]	icd9cm	[ [ [] ] ]	[ "32.01", "96.71", "96.05", "96.6" ]	icd9pcs	[ [ [] ] ]	5947, 5996	3060, 4127	415, 614	6070, 6079	1810, 3037	6278, 6613	1423, 1441		4256, 5924		6017, 6049		4153, 4233			6103, 6255									1456, 1791																							345, 377						642, 1048															1070, 1323	1339, 1407
65,689	143,433	43765	Discharge summary	report	Admission Date: [2190-5-28] Discharge Date: [2190-6-8] Date of Birth: [2116-8-14] Sex: M Service: MEDICINE Allergies: Lipitor / Zetia / Rosuvastatin Attending:[First Name3 (LF) 2880] Chief Complaint: Arm Pain/Abdominal Pain - concern for anginal equivalent Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 73 y/o M with hx of CAD, CVA presents with intermittent chest pain/forearm pain x 1 week. The patient was seen by his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 838] in clinic today where he complained ot forearm/abdominal pain for the last 8 days - these symptoms were not associated with chest pain. Symptoms were intermittent and occasionally at rest. On the day prior to admission patient notes walking with his grand son and developing medial arm pain and abdominal pain as well as feeling fatigued. Patient sat in the air conditioning and rested and these symptoms resolved over 20 minutes. After dinner the day prior to admission the patient noted another episode with similar symptoms no chest pain, however also was associated with flushing, diaphoresis and headache. The patient reports his prior CAD presented as tooth pain. Today he has not had a recurrence of either the forearm pain or chest pain. No orthopnea, increased lower extremity swelling. . In the ED, initial VS were 98.4 58 147/75 16 97. He was given 325 mg aspirin. Labs were significant for no elevation of cardiac enzymes. EKG showed no ST changes, small q waves in lateral leads I, II, aVL, consistent with prior. He was seen by his outpatient cardiologist, Dr. [Last Name (STitle) ] who requested admission to [Hospital1 1516] service. On transfer the patient's VS were HR 56 BP 159/73 RR 17 O2 95% on RA. . On the floor this morning patient denies recurrence of symptoms and feels well. . On review of systems, he denies any 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 paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1) Cerebral Infarctions- Left fronto-parietal infarct ([2185]) presenting with right cortical hand symptoms, recent symptom of language deficit. 2) Coronary Artery Disease- has left circumflex stent 3) Dysphagia- found to have Schatzki ring 4) Left Renal Artery Stenosis- status post stent 5) Hypertension. 6) Hypercholesterolemia 7) Sleep apnea on CPAP 8) Abdominal Aortic Aneurysm s/p repair. 9) Lyme disease- treated with 10 day course of doxycycline Social History: He lives with his wife in [Name (NI) 8], he is retired. He smoked 1.5 packs per day for 25 years, quit 25 years ago. He does not drink alcohol at present. No history of drug or alcohol abuse. Family History: Brother- had an MI at age 32. Physical Exam: Vitals - T 97.7 HR 57 BP 143/76 RR 16 O2 97% on RA Gen: Oriented x3, Occasionally has difficulty with word finding HEENT: PERRL, EOMI. Neck: Supple with flat JVP. CV: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular tachycardic, normal S1, physiologically split S2. no murmurs. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, mild crackles at right base, decreased breath sounds at left base, no wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No edema, No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Labs on Admission: [2190-5-28] 07:00PM BLOOD WBC-4.4 RBC-4.74 Hgb-14.5 Hct-43.2 MCV-91 Plt Ct-228 [2190-5-28] Neuts-48.5* Lymphs-38.2 Monos-6.4 Eos-5.6* Baso-1.3 [2190-5-28] PT-29.4* PTT-29.3 INR(PT)-2.9* [2190-5-28] Glucose-112* UreaN-23* Creat-1.2 Na-142 K-4.3 Cl-108 HCO3-24 . [2190-5-29] CK(CPK)-607* [2190-5-29] CK(CPK)-591* [2190-5-29] CK(CPK)-563* [2190-5-30] CK(CPK)-456* [2190-5-30] CK(CPK)-505* [2190-5-31] CK(CPK)-390* [2190-5-28] cTropnT-<0.01 [2190-5-29] CK-MB-14* MB Indx-2.3 cTropnT-0.05* [2190-5-29] CK-MB-14* MB Indx-2.4 cTropnT-0.05* [2190-5-29] CK-MB-14* MB Indx-2.5 cTropnT-0.07* [2190-5-30] CK-MB-11* MB Indx-2.4 cTropnT-0.08* [2190-5-30] CK-MB-13* MB Indx-2.6 cTropnT-0.08* [2190-5-31] CK-MB-10 MB Indx-2.6 cTropnT-0.05* . Cardiac enzymes: Admission: [2190-5-28]: CK(CPK)-607* [2190-5-31] CK(CPK)-390* [2190-6-5] CK(CPK)-1451* [2190-6-7] CK(CPK)-381* [2190-5-28] CK (CPK)- <0.01 [2190-5-30] cTropnT-0.08* [2190-6-5] cTropnT-1.65* . Studies: Chest PA/Lat: FINDINGS: Frontal and lateral views of the chest were obtained. Lingular atelectasis/scarring is again noted. No new focal consolidation, pleural effusion or pneumothorax is seen. The aorta is tortuous and calcified. The cardiac silhouette is not enlarged. IMPRESSION: No acute cardiopulmonary abnormality. Cardiac Cath Study Date of [2190-6-1] COMMENTS: 1- [Date Range 18583] complex and high-risk PTCA and stenting of the culprit distal RCA ulcerated, thrombotic culprit lesion with a 3.0x15 mm Promus DES complicated by distal RCA dissection, treated with placement of three (2.5x8, 2.5x12 and 2.5x12 mm) overlapping MiniVision stents distal to and overlapping with the Promus stent and proximal dissection treated with an 3.0x12 mm Vision BMS proximal to and overlapping with the Promus stent. Final angiography shwoed excellent results (see PTCA Comments). 2- Vagal event related to urinary retention treated with placement of Foley catheter and supportive care 3- Brief hypotensive event related to # 5 and hypovolemia 4- Small and stable [Initials (NamePattern4) ] [Last Name (NamePattern4) ] venous hematoma (noted following urgent placement of venous sheath for RHC). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. [Name (NI) 18583] PTCA and stenting of the RCA with total of 5 overlapping stents (see comments for details) 3. Integrilin for 18 hours (renal dose) 4. IV rehydration 5. Plavix 150 mg po dialy x 2 weeks then 75 mg daily for minimum of 12 months 6. ASA 325 mg indefinitely 7. Secondary prevention of CAD . Portable TTE (Focused views) Done [2190-6-1] at 3:11:21 PM Focused study to exclude effusion: The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. . Cardiac catheterization ([6-4]): 1. Limited coronary angiography in this right dominant system demonstrated single vessel disease. The left system was not injected. The RCA had a proximal hazy 30% stneosis representing uncovered dissection from prior case, patent stents in the mid to distal vessel with TIMI 2 flow, subtotal 90% occlusion of the distal AV groove RCA into the major RPL, and a 50-60% stenosis in the proximal to mid RPDA. 2. Limited resting hemodynamics revealed normal central pressures with a systolic pressure of 127mmHg, diastolic of 59mmHg, and mean of 84mmHg. 3. Unsuccessful attempt to wire the true lumen of the RPL secondary to residual dissection from the previous catheterization. Final angiography revealed a 90% residual stenosis in the RPL, a grade III dissection in the RPL, and TIMI 2 flow. (see PTCA comments for details) FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. 3. Unsuccessful attempt to wire the true lumen of the RPL due to residual dissection from the prior PCI procedure. 4. Supraventricular tachycardia. . ECHO [2190-6-8]: The left atrium and right atrium are normal in cavity size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with probable basal to mid lateral akinesis/hypokinesis (LVEF ?45-50%) but views are technically suboptimal for assessment of regional wall motion. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2190-6-1], regional wall motion abnormality is now detected but studies are technically suboptimal for comparison. Brief Hospital Course: 73M with h/o CVA on coumadin, CAD s/p DES->LCx [4-15], s/p L renal artery stent [11-14], infrarenal AAA s/p repair admitted with forearm, chest, and tooth pain (prior anginal equivalent) who went to cardiac catheterization for NSTEMI, s/p PCI complicated by mid vessel RCA dissection, followed by STEMI [6-4] (distal RCA + RPL, felt to be secondary to dissection). . # NSTEMI and STEMI: The patient was admitted to the floor and his cardiac enzymes were trended peaking at 0.08 from <0.01 on admission. He was taken to cardiac catheterization, which revealed a RCA thrombus thought to be the culprit lesion that was treated with one DES. This was complicated by a distal RCA dissection requiring three overlaping BMS distal to and overlapping with the DES as well as one proximal BMS and overlapping with the DES with the final result being TIMI-3 flow. Bedside TTE was performed and was notable for the absence of pericardial effusion with normal wall motion. He was started on plavix 75mg, which he will take 75mg [Hospital1 ] for one week and then change to 75mg daily. He was continued on aspirin 325mg daily. He was maintained on an integrillin drip for 18hours post catheterization. He was started on rosuvastatin, as he had a history of poor tolerance to other statins. He was pain-free until afternoon [6-4] at which time he developed chest pressure, arm pain, and teeth pain. At that point he was noted to have ST-elevations in inferior leads and CODE STEMI was called. He was brought immediately to the cath lab at which time angiography showed occlusion of the RPL off the mid-distal RCA felt to be due to his prior dissection. The proximal PCA appeared patent. Given the dissection flap, a wire could not be passed into the vessel and no intervention was performed. He was chest pain free several hours later and remained so throughout the remainder of his hospital stay. Follow-up echocardiogram showed basal/midlateral akinesis/hypokinesis (although technically sub-optimal) that was new from priors. . # HISTORY OF CVA: Given his history of recent stroke, thought to be embolic, he was maintained on systemic anticoagulation with coumadin. Heparin was initiated while his INR was subtherapeutic. In consultation with his outpatient neurologist the goal INR is 1.8 to 2.5. The patient was discharge home with Lovenox injections twice daily until he began therapeutic again on his Coumadin. . # ATRIAL TACHYCARDIA: He was monitored on telemetry during the course of his hospitalization. He was primarily in sinus rhythm with a rate in the 80s although he did have asymptomatic episodes of atrial tachycardia to the 110s. His metoprolol dose was increased to 37.5mg q8hr. . # HAND CELLULITIS: This was thought to be due to an infiltrated IV site. There was a pustule that was lanced with culture growing MSSA. He was started on Keflex + Bactrim with plans for a 7 day course (Bactrim D/C'd once sensitivities available). He remained afebrile with a normal white count and site clinically improved prior to discharge. . # HYPERTENSION: He was continued on losartan and metoprolol. As above, metoprolol dose increased to 37.5 tid. Losartan held for ARF. . # ACUTE RENAL FAILURE: Creatinine trended up from baseline 1.2 -> 1.4 after cath [6-1]. It rose again from 1.4 -> 1.6 after second cardiac cath. This was felt to be due to potential contrast nephropathy as he received substantial contrast load for both procedures. [Last Name (un) ] was held with some improvement in his renal function. Creatinine at baseline for this patient is 1.1-1.2 and 1.4 upon discharge. . # HYPERLIPIDEMIA: He was initially continued on niacin and cholestyramine. This was changed to rosuvastatin 10mg daily, however he developed myalgias and he was changed back to home cholestyramine. Medications on Admission: CHOLESTYRAMINE-ASPARTAME 4 gram [Hospital1 ] CLOPIDOGREL 75 mg DAILY FEXOFENADINE 60mg [Hospital1 ] PRN LOSARTAN 25 mg QD METOPROLOL TARTRATE 25 mg TID NITROGLYCERIN 0.4 mg PRN WARFARIN 5 mg QD CALCIUM CITRATE 250 mg [Hospital1 ] CHLORHEXIDINE GLUCONATE 4 % Liquid - use once a day MAGNESIUM 250mg [Hospital1 ] MULTIVITAMIN qam NIACIN 250 mg SR QHS Discharge Medications: 1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Niacin 250 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QHS (once a day (at bedtime)). 5. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day for 5 days: Please continue Lovenox until your [Hospital3 ] informs you to stop. . Disp:10 qs Refills:1 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:135 Tablet(s) Refills:2 12. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day): Please take at a different time than your Warfarin to avoid interactions . 13. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q5min as needed for chest pain: Please go to the ER if your chest pain does not resolve after 3 tablets. Disp:100 tablets Refills:0 14. Magnesium 250 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: CAD HTN HLD Skin Infection of Right Hand Secondary: Hx of CVA Hx of Abdominal Aortic Aneurysm 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 caring for you while you were admitted with arm pain/abdominal pain thought to be related to your heart. A cardiac catheterization was performed which showed a blockage in one of the arteries surronding the heart. Stents were placed in this artery. The procedure was complicated by a dissection of this artery which was managed by placing other stents. Several days later you again developed chest pain and were brought emergently for cardiac catheterization. This showed a blockage in one of the smaller branches of the coronary arteries. You were monitored in the intensive care unit. An echocardigram was performed before your discharge and showed good heart function, similar to before you had the heart attack and stents placed. . During your stay you developed an infection of the skin on the top of your right head. You were treated with antibiotics and the hand surgeons drained a small amount of infected fluid; it is healing well. . You were tried on a new cholesterol medication - rosuvastatin (Crestor) but developed leg cramps so this was stopped. . Please follow up with Dr. [Last Name (STitle) 838] in the week following discharge for follow up regarding your skin infection and Dr. [Last Name (STitle) ] with cardiology on [6-16]. Furthermore, your INR (level of anticoagulation) will need to be checked at your appointment with Dr. [Last Name (STitle) 838]. Based on the INR, the Lovenox you were discharged on may be able to be stopped. . The following changes were made to your medication regimen: - START: Lovenox 100 mcg Twice Daily until your [Hospital 3052] informs you that you to discontinue your lovenox and take only your coumadin. - START: ASA 325mg Daily - CHANGE: Metoprolol Tartrate 25mg three times daily to 37.5 three times daily - STOP: Losartan 25mg as your blood pressures have been well controlled on Metoprolol only - ALSO, make sure to take your Cholestyramine and Warfarin at different times, as they can interact with each other and make Warfarin less effective at blood thinning. . Again it was a pleasure participating in your care. Followup Instructions: Primary Care: Please follow-up with Dr. [Last Name (STitle) ] on [Last Name (LF) 2974], [6-11]. Make sure you have your INR level checked prior/during that appointment to decide if you should continue Lovenox. . Cardiology: Dr. [Last Name (STitle) 9764], [Telephone/Fax (1) 8645], Wednesday, [2192-6-16]:20pm. [Location (un) 2790], [Location (un) ], [Numeric Identifier 4774] . Other Appointments. [Doctor Last Name ] WORTH, MS SLP Phone:[Telephone/Fax (1) 3731] Date/Time:[2190-6-15] 8:30 [Doctor Last Name ] WORTH, MS SLP Phone:[Telephone/Fax (1) 3731] Date/Time:[2190-6-8] 8:30 [Doctor Last Name ] WORTH, MS SLP Phone:[Telephone/Fax (1) 3731] Date/Time:[2190-6-1] 8:30 [First Name11 (Name Pattern1) 900] [Last Name (NamePattern1) 2882] MD, [MD Number(3) 2883]	[ "V12.54", "427.89", "477.8", "410.41", "327.23", "410.71", "E879.0", "V45.82", "745.5", "401.9", "997.5", "584.9", "V15.82", "041.11", "272.0", "428.21", "682.4", "998.12", "999.39", "998.2", "428.0", "458.29", "787.20", "788.20", "414.01", "E879.8", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "37.23", "00.40", "36.06", "86.04", "99.20", "00.66", "36.07", "88.56", "00.48" ]	icd9pcs	[ [ [] ] ]	14722, 14728	9008, 12816	347, 373	14876, 14876	3867, 3872	17198, 18078	3072, 3103		13231, 14699		14749, 14855		12842, 13208		7755, 8985	15027, 17175									3118, 3848																			4697, 6134				251, 309						401, 2362								3886, 4680	14891, 15003						2384, 2843	2859, 3056
50,353	191,522	41760	Discharge summary	report	Admission Date: [2174-9-3] Discharge Date: [2174-9-3] Date of Birth: [2089-10-28] Sex: F Service: CARDIOTHORACIC Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 1406] Chief Complaint: chest and back pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 90713] is an 84 year old female with a history of congestive heart failure, aortic stenosis, atrial fibrillation and hypertension who presented to an outside hospital complaining of chest pain. She had no palpable pulses and she was hypotensive. A subsequent CT scan showed a Type A dissection with pericardial effusion. She transferred to [Hospital1 18] for further evaluation and treatment. Past Medical History: congestive heart failure, aortic stenosis, atrial fibrillation and hypertension Social History: unknown Family History: unknown Physical Exam: PE: BP - 111/90 HR 112 (ST) General - intubated, cachectic, patient moving RUE HEENT - PERRLA, ETT in place Neck - supple Lungs - few scattered rhonch Cardio - heart sounds distant, cannot appreciate murmur Abdomen - +BS, soft, nontender Extremities - +2 pitting edema, pulses are not palpable in UE or LE but present by doppler Neuro - intubated, opens eyes occassionally spontaneously, has moved RUE, no purposeful movement Brief Hospital Course: Ms. [Known lastname 90713] was admitted to cardiac surgery for surgical evaluation of her type A aortic dissection. As she recently had a prolonged admission for a congestive heart failure and is a frail 82 year-old, it was felt that she would not tolerate what would likely become a prolonged post-operative course. She progressively became hypotensive despite high doses of neosynepherine. A bedside echocardiogram revealed an increasing pericardial effusion. After multiple discussions with her health care proxy and multiple family members, comfort measures only were instituted. She was given fentanyl and extubated. She expired at 14:23 on [2174-9-3]. Medications on Admission: unknown Discharge Medications: not applicable Discharge Disposition: Expired Discharge Diagnosis: type a dissection Discharge Condition: expired Discharge Instructions: not applicable Followup Instructions: not applicable Completed by:[2174-9-3]	[ "V66.7", "V64.1", "441.01", "785.50", "423.0", "424.1", "428.0", "427.31", "401.9", "276.2" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	2158, 2167	1389, 2061	311, 317	2228, 2237		2300, 2344	912, 921		2119, 2135		2188, 2207		2087, 2096			2261, 2277									936, 1366																							252, 273						345, 768															790, 871	887, 896
23,182	119,037	51151	Discharge summary	report	Admission Date: [2169-3-26] Discharge Date: [2169-3-30] Date of Birth: [2101-1-28] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: trach placement trach decannulation History of Present Illness: Ms. [Known lastname 951] is a 66 year old female with multiple medical problems, including COPD (6L home O2), squamous cell laryngeal cancer (s/p resection, XRT, and trach), large cell lymphoma, tracheobronchomalacia, squamous cell lung ca, and hepatitis C who was in her usual state of health until about a week ago when she developed the onset of progressive dyspnea. She was using her albuterol and mucomyst more frequently and also had been suctioning tannish sputum. She denied fevers or chills, nausea or vomitting. . On day of admission, she was in her bathroom heading out to her chair when she became unconscious, falling to the floor. Her roommate heard the crash and called 911. She was found unresponsive, cyanotic, and diaphoretic. She became responsive during nebulizer treatment. She is unable to recall this period until she awoke in the ED. . At the ED, she was cultured and started on methylprednisolone 125 mg, and levaquin 500 mg. Combivent was administered x 3. Her trachea stoma was accessed with a 6.0 trach and she was started mechanically ventilated. Her initial PH was 7.2 with a pCO2 of 66. Past Medical History: 1. severe COPD on home O2. 2. Squamous cell laryngeal cancer status post resection in [2149], XRT to neck. Patient is tracheostomy dependent. 3. Large-cell lymphoma status post CHOP x5 cycles in [2160]. 4. Tracheobronchomalacia requiring periodic stenting, the last stent to the trachea and bronchus, multiple months ago. 5. History of tracheoesophageal fistula. 6. History of Pseudomonal pneumonia. 7. Esophageal stricture status post dilation in [10-24]. 8. Squamous cell carcinoma of right lower lobe status post wedge resection [12-23]. 9. History of endocarditis secondary to IV drug use. 10. Hepatitis C positive. 11. Chronic renal insufficiency (baseline creatinine 1.4-1.6) Social History: History of heavy tobacco use. Denies alcohol history of IV drug use. Lives in apartment with a roomate. On disability Family History: mother with [Name2 (NI) 499] ca father died of prostate ca brother with asthma sister with AIDS Physical Exam: Physical Exam: VS: BP=131/55; HR=85; RR=16; 02=94% (FiO2 60%) GEN: elderly female, lying in bed, NAD HEENT: EOMI, Dry MM, edentulous, OP Clear NECK: [Last Name (un) 295] trach in place CV: RRR, Normal S1S2, no M/R/G appreciated RESP: No accessory muscle use. Not tachypneic. + crackles bilaterally (R>L); diffuse wheezes. ABD: Normo active BS, non-tender, no rebound, non-distended EXT: trace edema in lower ext bilaterally; no cyanosis/clubbing, DP/PT not palpable but dopplerable. Left anterior aspect of tibia with 1.5 cm ulcer with clean base. SKIN: changes of venous stasis on lower extremities bilaterally NEURO: CN II-XII intact bilaterally; strength 5/5 upper and lower extremities bilaterally, decreased sensation bilaterally in hands and feet Pertinent Results: [2169-3-26] 09:07PM POTASSIUM-4.4 [2169-3-26] 09:07PM MAGNESIUM-2.1 [2169-3-26] 11:25AM CK(CPK)-183* [2169-3-26] 11:25AM CK-MB-8 cTropnT-0.01 [2169-3-26] 11:25AM WBC-4.2 RBC-3.50* HGB-10.5* HCT-29.9* MCV-86 MCH-30.0 MCHC-35.0 RDW-14.9 [2169-3-26] 11:25AM PLT COUNT-190 [2169-3-26] 05:44AM TYPE-ART RATES-16/ TIDAL VOL-500 PEEP-5 O2-40 PO2-67* PCO2-55* PH-7.35 TOTAL CO2-32* BASE XS-2 INTUBATED-INTUBATED VENT-CONTROLLED [2169-3-26] 05:44AM LACTATE-1.2 [2169-3-26] 05:11AM GLUCOSE-196* UREA N-28* CREAT-1.3* SODIUM-138 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16 [2169-3-26] 05:11AM CK(CPK)-155* [2169-3-26] 05:11AM CK-MB-7 cTropnT-0.04* [2169-3-26] 05:11AM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-2.1 [2169-3-26] 05:11AM WBC-5.7 RBC-3.58* HGB-10.2* HCT-31.2* MCV-87 MCH-28.6 MCHC-32.8 RDW-14.8 [2169-3-26] 05:11AM PLT COUNT-170 [2169-3-26] 12:29AM TYPE-ART TEMP-37.2 PO2-470* PCO2-66* PH-7.20* TOTAL CO2-27 BASE XS--3 INTUBATED-INTUBATED [2169-3-26] 12:29AM GLUCOSE-288* LACTATE-4.2* NA+-140 K+-5.0 CL--100 [2169-3-26] 12:29AM freeCa-1.15 [2169-3-26] 12:03AM LACTATE-6.4* [2169-3-26] 12:02AM GLUCOSE-311* UREA N-29* CREAT-1.6* SODIUM-137 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-22 ANION GAP-22* [2169-3-26] 12:02AM CK(CPK)-150* [2169-3-26] 12:02AM CK-MB-5 cTropnT-<0.01 [2169-3-26] 12:02AM IRON-37 [2169-3-26] 12:02AM calTIBC-321 VIT B12-420 FOLATE-7.4 FERRITIN-83 TRF-247 [2169-3-26] 12:02AM WBC-9.2# RBC-3.82* HGB-11.1* HCT-35.2* MCV-92 MCH-29.0 MCHC-31.4 RDW-14.8 [2169-3-26] 12:02AM NEUTS-53.0 LYMPHS-41.8 MONOS-2.4 EOS-2.6 BASOS-0.2 [2169-3-26] 12:02AM HYPOCHROM-3+ [2169-3-26] 12:02AM PLT COUNT-260 [2169-3-26] 12:02AM PLT COUNT-260 [2169-3-26] 12:02AM PT-13.4* PTT-26.6 INR(PT)-1.2* TTE: The left atrium is normal in size. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. ECG: Sinus tachycardia. Since the previous tracing of [2168-8-4] the rate is more rapid. The electrocardiogram is otherwise, normal and unchanged. Intervals Axes Rate PR QRS QT/QTc P QRS T 116 168 86 338/407 71 48 36 LENI: [Doctor Last Name ]-scale and Doppler son[Name (NI) 1417] of the bilateral common femoral, superficial femoral, and popliteal veins were performed. These show normal compressibility, augmentation, and Doppler flow and waveforms. No intraluminal thrombus is identified. IMPRESSION: No evidence of deep vein thrombosis. AP PORTABLE UPRIGHT VIEW OF THE CHEST: There is a metallic tracheostomy tube. Left and right main stem bronchus stents are seen. There are bilateral lower lobe opacities There are bilateral interstitial opacities with perihilar fullness. No evidence of pneumothorax. Mediastinal contour is stable. IMPRESSION: Perihilar fullness and interstitial opacities consistent with volume overload/CHF pattern. Bilateral lower lobe opacities are also present and superimposed infectious process cannot be excluded. Brief Hospital Course: Ms. [Known lastname 951] is a 68 y.o. woman with unwitnessed loss of consciousness and evidence of ?PNA vs. CHF on CXR. * SYNCOPAL EVENT: The patient's loss of consciousness was attributed to a hypoxic event from a mucus plug. Her cardiac enzymes were negative x 3. LENI's were negative making PE less likely. No V/Q was done because her CXR was poor quality because of the finding of consolidation vs atelectasis. CTA was not obtained because the patient has renal failure and PE was not high on the differential. Echo showed preserved EF and no wall abnormalities, making a cardiac process unlikely as etiology for the event. Her telemetry showed no events that might have indicated a rhythm abnormality. When the patient was transferred to the medicine service, her course was complicated by a 38 beat run of NSVT. EP was consulted and they felt that this was artifact. * RESPIRATORY FAILURE: At home, the patient is on 6L of 02 at baseline. Her failure was thought to be secondary to aspiration vs. mucus plug in setting of increased secretions likely [2-23] pna. Her trach was changed to an 8 [Last Name (un) 295]. She has no teeth so less likely to have anaerobes. She also is at risk of post obstructive PNA as she's had lung CA and had bronchial stents placed. LENI's were negative for DVT making PE less likely. She was treated with levofloxacin. Her mucomyst was continued although the patient needs to be educated about reducing the amount of mucomyst she uses given that it can cause bronchospasm. She was gently diuresed as some of her CXR findings and exam were consistent with CHF. Her respiratory status improved with all these measures and she was feeling markedly better on hospital day 2. * COPD: The patient had wheezes on exam and evidence of infection. Albuterol and ipratropium nebs were administered. She was also started on methylprednisolone 125 Q6, which was transitioned to prednisone taper. * H/O TRACHEOBRONCHOMALACIA: pt was scheduled to have an outpt bronchoscopy with Dr. [Last Name (STitle) ] today (Mon [3-27]) for routine followup of stents. Instead, the patient was bronched while in house with samples sent for culture. * HYPOTHYROIDISM: The levothyroxine was continued * HYPERGLYCEMIA: As the patient was on steroids, her high sugars were attributed to the excess glucocorticoids. She was covered with humalog sliding scale. * PAIN CONTROL: Continued on MS contin and percocet for home pain control. * DEPRESSION: Continued on Zoloft. * UTI: The patient was discharged on Levaquin for UTI. On the day of discharge the patient's urine culture came back positive E.coli resistant to Levaquin. The patient's PCP was [Name (NI) 653] and the final micro senstivities report was faxed to her office. After speaking to the PCP she said that she would call in another precription. The patient was also [Name (NI) 653] at home about the change in antibiotics. * RENAL INSUFFICIENCY: Now at baseline cr around 1.5. - Renally dose meds. * ANEMIA: Pt has low Hct at baseline likely due to anemia of chronic disease. Her normal range is 27-30. She have been hemoconcentrated. Iron studies did not show iron, B12, or folate deficiency * DISPO: The patient was discharged home with close follow up. Medications on Admission: .Tolterodine Tartrate 2 mg QD 2. Sertraline HCl 200 mg PO QD 3. Pantoprazole Sodium 40 mg Tablet PO Q24H 4. Morphine Sulfate 100 mg Tablet SR PO Q12H 5. Oxycodone-Acetaminophen 1-2 Tablets PO Q4-6H PRN 6. Acetylcysteine 20 % 1-2 MLs Q4-6H PRN 7. Docusate Sodium 100 mg PO BID 8. Senna 8.6 mg [Hospital1 ] PRN 9. Fluticasone Propionate 110 mcg [Hospital1 ] 10. Albuterol 90 mcg2 QID 11. Ipratropium Bromide 2 Puffs QID 12. Levothyroxine Sodium 200 mcg QD * Allergies: NKDA Discharge Medications: 1. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 6-10 MLs Miscell. Q4-6H (every 4 to 6 hours) as needed. Disp:500 ML(s) Refills:1 2. Albuterol Sulfate 0.083 % Solution Sig: [1-23] vials Inhalation four times a day as needed for shortness of breath or wheezing. Disp:qs vials Refills:3 3. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3 times a day). Disp:qs tubes Refills:2 5. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:0 7. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. Disp:30 Tablet(s) Refills:0 8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once () for 1 days. Disp:1 Tablet(s) Refills:0 9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once () for 1 days. Disp:1 Tablet(s) Refills:0 10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once () for 1 days. Disp:1 Tablet(s) Refills:0 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 12. Detrol LA 2 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:qs device Refills:2 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 15. 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 16. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:2 18. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: Three (3) ml Inhalation Q6: PRN. Disp:qs ampules/ solution Refills:2 19. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 20. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:qs inhaler Refills:0 21. Portable Nebulizer Please provide patient with portable nebulizer machine 22. Humidifed Oxygen Please provide patient with humidified oxygen. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary Diagnosis Hypoxic Respiratory Failure Secondary to Mucus Plug . Secondary Diagnosis 1. severe COPD on home O2. 2. Squamous cell laryngeal cancer status post resection in [2149], XRT to neck. Patient is tracheostomy dependent. 3. Large-cell lymphoma status post CHOP x5 cycles in [2160]. 4. Tracheobronchomalacia requiring periodic stenting, the last stent to the trachea and bronchus, multiple months ago. 5. History of tracheoesophageal fistula. 6. History of Pseudomonal pneumonia. 7. Esophageal stricture status post dilation in [10-24]. 8. Squamous cell carcinoma of right lower lobe status post wedge resection [12-23]. 9. History of endocarditis secondary to IV drug use. 10. Hepatitis C positive. 11. Chronic renal insufficiency (baseline creatinine 1.4-1.6) Discharge Condition: Good, vitals stable Discharge Instructions: Please seek medical services immediately if you should have any chest pain, shortness of breath, fevers, chills or any other worrisome symptom. . Please take your medications as prescribed. . Please keep all follow up appointments. . Your are being discharged on a prednisone taper. [2169-3-31] 30mg [2169-4-1] 20mg [2169-4-2] 10mg then stop Followup Instructions: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [4-11] at 3pm Please follow up with your primary care physician [Name Initial (PRE) 176] 1 week of discharge [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] Completed by:[2169-5-15]	[ "518.81", "070.70", "585.9", "200.00", "V10.21", "519.09", "V10.11", "491.21" ]	icd9cm	[ [ [] ] ]	[ "96.71", "33.21" ]	icd9pcs	[ [ [] ] ]	13164, 13221	6721, 9978	333, 370	14055, 14077	3291, 6698	14479, 14819	2396, 2497		10509, 13141		13242, 14034		10004, 10486			14101, 14456									2527, 3272																							275, 295						398, 1522															1544, 2244	2260, 2380
31,622	182,185	31622	Discharge summary	report	Admission Date: [2154-6-22] Discharge Date: [2154-6-25] Date of Birth: [2090-4-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 64 year old male with CAD s/p anterior MI [2150], h/o recurrent DVT, recent DVT RLE s/o IVC filter admitted to OSH for TKR done 6 days prior developed chest pain, found to have myocardial infarction and transferred to [Hospital1 18] urgently for cardiac cath. Patient staes on [6-21] (one day prior to transfer to [Hospital1 18]), he developed SSCP which gradually worsened with associated shortness of breath. He states this was similar to his heart attack pain from [2150] (cath at [Hospital1 2025]). . Patient was originally supposed to have bilateral total knee replacement, left was performed, however, the right side was aborted as the air-conditioning in the OR was malfunctioning. On further evaluation, per patient a DVT was found in the RLE and decision was made to anticoagulate first (coumadin/lovenox) and plan for future TKR. He was supposed to go to rehab on [6-21], the day he developed chest pain. . [6-21] OSH EKG: NSR HR 65, Nl axis/intervals, poor R wave progression, 1mmST elevated V2-3, TWIs II-III, aVF [6-22] OSH EKG: sinus bradycardia HR 53 Nl axis/intervals, poor R wave progression (resolved TWIs) . baseline EKG shows sinus rhythm, poor R-wave progression consistent with antecedent anterior MI . Past Medical History: PAST MEDICAL HISTORY: CAD s/p MI [2150] (2 stents placed at [Hospital1 2025]) hypertension chronic deep venous thrombosis s/p 2 ivc filters (one prior to TKR) renal calculi GERD hiatal hernia depression osteoarthritis chronic low back pain bowel adhesions and intermittent SBO DJD . PAST SURGICAL HISTORY: s/p Total knee replacement [5-/2154] In [2150], he had two stents placed in his heart. GI surgery unspecified in [2149] s/p cervical fusion in [2139] hemorrhoid surgery in [2133] [2132] a lumbar fusion with complications of DVT . Cardiac Risk Factors: - Diabetes, Dyslipidemia, + Hypertension . Percutaneous coronary intervention, in [2150] anatomy as follows: unknown - done at [Hospital1 2025] LAD [Name Prefix (Prefixes) ] [Last Name (Prefixes) 10157] . Stress ECHOCARDIOGRAM performed on ?[3-/2154] demonstrated: Per NEBH reports prior to surgery: His baseline echo shows mild left ventricular hypertrophy, disproportionate to the septum, normal wall motion, and ejection fraction greater than 55%. He had no significant Doppler lesions. He was able to walk for 5 minutes 45 seconds and heart rate of 132, which is 85% max. He had no chest pain, no ST depression. Echo showed augmentation of wall motion in all regions of the left ventricle. . Social History: Retired, lives at home with his wife. < 1 drink EtOH/day. Quit tobacco in [2114]. Family History: non-contributory Physical Exam: VS: afebrile HR 64 BP 114/62 RR 19 100%/2L O2 Gen: WDWN middle aged male in NAD. Oriented x3. Appear in some discomfort (back pain). HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple, obese. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB - anteriorly, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Left knee dsg C/D/I groin: angioseal in place in right groin Skin: No stasis dermatitis, ulcers, or xanthomas. . Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ . Pertinent Results: OSH RECORDS: RLE - Ultrasound [2154-5-13]: occlusive thrombus in right proximal superficial femoral vein and non-occlusive thrombus extending into the distal superficial femoral and proximal popliteal vein compatible with chronic DVT (seen prior) . LABS PRIOR TO TRANSFER CK 929(0-200) MB 140.20(0-5) MBI 15.1(0-2.5) TropI 30.49(-0-0.4) [6-21] Na 140 4.7 102 26 14 1.1 119 . ADMISSION LABS: [2154-6-22] 08:19PM BLOOD WBC-9.9 RBC-3.92* Hgb-11.5* Hct-34.1* MCV-87 MCH-29.4 MCHC-33.8 RDW-14.5 Plt Ct-420 [2154-6-22] 08:19PM BLOOD PT-15.4* PTT-27.9 INR(PT)-1.4* [2154-6-22] 08:19PM BLOOD Glucose-95 UreaN-16 Creat-1.0 Na-137 K-4.4 Cl-102 HCO3-27 AnGap-12 [2154-6-23] 03:40AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.1 Cholest-144 [2154-6-23] 03:40AM BLOOD Triglyc-154* HDL-22 CHOL/HD-6.5 LDLcalc-91 . CARDIAC ENZYMES: [2154-6-23] 03:40AM BLOOD ALT-25 AST-99* CK(CPK)-708* [2154-6-23] 03:40AM BLOOD CK-MB-43* MB Indx-6.1* cTropnT-6.01* [2154-6-24] 05:40AM BLOOD CK(CPK)-283* [2154-6-24] 05:40AM BLOOD CK-MB-9 . DISCHARGE LABS: [2154-6-25] 06:41AM BLOOD WBC-8.8 RBC-3.52* Hgb-10.1* Hct-31.3* MCV-89 MCH-28.7 MCHC-32.3 RDW-14.6 Plt Ct-455* [2154-6-25] 06:41AM BLOOD PT-15.5* PTT-31.8 INR(PT)-1.4* [2154-6-25] 06:41AM BLOOD Glucose-101 UreaN-14 Creat-1.1 Na-139 K-4.7 Cl-103 HCO3-30 AnGap-11 . [2154-6-22] CARDIAC CATH: 1. Access was obtained via the right CFA in a retrograde directionto the right and left coronary arteries. 2. HEMODYNAMIC EVALUATION - The central aortic pressure was 111/77 (Systolic/diastolic) 3. Angiography of this right dominant system revealed one vessel disease with an occluded LAD stent. The RCA had a mid 50% lesion. the LMCA was free of disease. The LAD had proximal stent occlusion. with some collaterlization. The LCX had only minor disease. 4. The LAD stent thromosis was predilated with a 2.5 mm balloon and thrombectomy was performed with an export catheter followed by stenting with a 3.0 X 18 mm Taxus stent with lesion reduction to 0% The distal spasm/thrombus was treated with a 2.0 mm balloon. The final angiogram showed TIMI III flow with no residual stenosis, no dissection, no perforation and no embolisation. The patient left the lab in a stable condition. 5. After femoral angiography with hand contrast injection, the femoral arteriotomy was closed successfully with a 6F angioseal device. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal central aortic pressure 3. Successful stenting of the LAD (Drug eluting) . TTE [2154-6-24]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta and arch are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. IMPRESSION: Normal biventricular cavity size and regional/global systolic function. Dilated ascending aorta and arch. Trace aortic regurgitation. . Brief Hospital Course: #) CAD: The patient presented with acute coronary syndrome due to LAD stent thrombosis. He went urgently to the cath lab where he underwent thrombectomy and received [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Last Name (Prefixes) 74329] stebt to his proximal LAD. Cardiac enzymes peaked prior to addmission (prior to transfer from OSH records-- CK 929, MB 140.20, MBI 15.1, TropI 30.49). After the catheterization, the patient was treated medically with ASA, plavix, valsartan (at half of his home dose to start a beta blocker), metoprolol, and his home dose of zetia. He initially refused lipitor/statins (states severe myalgias) but was started on low dose pravastatin (20mg qd). He has been chest pain free since the catheterization. . #) Rhythm: Tele revealed the patient to be in NSR/sinus brady with occasional ectopy and one episode of 4 beats of NSVT. . #) Pump: EF >55% on previous stress Echo report from OSH. TTE on [6-24] revealed normal biventricular cavity size and regional/global systolic function with EF>55%. Dilated ascending aorta and arch. Trace aortic regurgitation. He was treated with valsartan and metoprolol to prevent remodeling s/p MI. . #) Hyperlipidemia: The patient was on zetia as an outpatient for hyperlipidemia. This was continued in house and low-dose pravastatin was initiated as well. Would consider starting a fibrate for his low HDL as an outpatient. . #) HTN: The patient was treated with valsartan and metoprolol for his hypertension. . #) s/p TKR: The patient had a L TKR 6 days prior to admission. Pt c/o L sciatica s/p surgery and was treated with Lyrica which had been started at the OSH. He was followed by Physical Therapy who assisted him in using the continuous passive motion machine. The patient complained of intermittently severe L knee pain that was only resolved with 2mg IV morphine. Pt was on standing oxycodone SR 40mg PO q12 for pain control. He is being discharged to a rehab facility for intensive knee rehab. Will follow up with orthopedist as an outpatient. . #) DVT RLE: The patient was found to have a RLE DVT s/p L TKR surgery so the decision was made to anticoagulate first before pursuing TKR for the R knee. He had been on coumadin 3mg daily prior to admission. After his cardiac catheterization he was initially on heparin drip. Upon discharge, he is on lovenox and coumadin. The coumadin was started on [6-23] with goal INR [1-26]. His INR on morning of discharge ([6-25]) is 1.4. . The patient was full code for this admission. Medications on Admission: HOME MEDICATIONS: Omeprazole 20 mg daily sular 10 mg daily Zetia 10 mg b.i.d. Percocet 5/325 t.i.d. ASA 325 iron [Hospital1 ] . MEDICATIONS ON TRANSFER: nitro gtt heparin gtt coumadin 3mg po qhs lovenox 100mg sc bid celebrex 200mg po bid diovan 160mg qday lyrica 75mg po q8hr MVI oxycodone 5-10mg po q4-6hrs prn oxycontin 40mg po bid senna/dulcolax ambien prn phenergan prn/tigan prn lidoderm patch 5% low back daily valium 5mg po q8hrs prn . Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HOURS ON/12HRS OFF () as needed for back pain. 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please address with cardiologist. 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours): for DVT treatment until therapeutic on coumadin. 11. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 14. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO q8hrs (). 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): to adjusted according to his INR. 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital 12414] Healthcare Center - [Location (un) 12415] Discharge Diagnosis: Primary Diagnoses: ST Elevation Myocardial Infarction with stenting to LAD Hypertension Hyperlipidemia Deep Vein Thrombosis status post total knee replacement Discharge Condition: Good, hemodynamically stable. Chest pain free Discharge Instructions: The patient was diagnosed with a heart attack and occlusion of his prior stent. He was taken to the cardiac cath lab where he received a stent to his LAD coronary artery ([Name Prefix (Prefixes) ]-[Last Name (Prefixes) 74329]). Because of this he has been started on various heart medications which must be taken daily. In particular, the patient has been started on Plavix for his stent. It is very important that he continue this medication indefinitely until follow up with his cardiologist Dr. [Last Name (STitle) ]. . The patient is also on lovenox for his DVT. We have started him on coumadin as well. He must continue his lovenox until his INR is therapeutic between [1-26]. He will need frequent INR checks until he is therapeutic. . The patient will need to follow up with his cardiologist as soon as possible. In addition, the patient will need to follow up with his orthopedic surgeon for further care of his knees, as well as physical/occupational therapy. . Followup Instructions: Follow up appointment with his primary cardiologist/primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in the next 2-3 weeks. [Telephone/Fax (1) 48293] . Follow up appointment with his orthopedic surgeon Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 53181] within the next 4 weeks. [Telephone/Fax (1) 29119] .	[ "272.4", "724.2", "715.36", "311", "414.01", "410.01", "530.81", "996.72", "553.3", "401.9", "V43.65", "E878.8", "453.41" ]	icd9cm	[ [ [] ] ]	[ "00.45", "00.66", "36.07", "88.56", "00.40", "88.53", "37.22" ]	icd9pcs	[ [ [] ] ]	12186, 12279	7351, 9895	324, 349	12482, 12531	4007, 4391	13573, 13986	3095, 3113		10392, 12163		12300, 12461		9921, 9921		6408, 7328	12555, 13550				5066, 6391				1979, 2974	3128, 3988					9939, 10053														4842, 5050				274, 286						377, 1643					4407, 4825									10078, 10369	1687, 1956	2990, 3079
15,258	175,382	8934	Discharge summary	report	Admission Date: [2154-2-7] Discharge Date: [2154-2-14] Date of Birth: [2102-3-25] Sex: F Service: MEDICINE Allergies: Amoxicillin / Tetracycline Attending:[First Name3 (LF) 297] Chief Complaint: tracheal stenosis Major Surgical or Invasive Procedure: balloon dilation of trachea History of Present Illness: HPI: 51 yoF w/ widely metastatic NSCLC ([Last Name (LF) 500], [First Name3 (LF) ], liver, kidney) p/w tracheal narrowing. She presented to her oncologist this a.m. c/o right shoulder pain X 2 days, intermittent dysphagia (solids >liquids) X 1 week, and "difficulty breathing in" X 5 days. She was noted to have stridor (concerning for tracheal compression) and elevated JVP (concerning for early SVC syndrome) and was admitted for further evaluation/management. She had a total spine MRI which showed collapse of T1 c/w a pathological fracture with anterior edema as well as evidence of metastases at T10, T12, left L5 lamina, and left sacral ala. However, there was no evidence of significant cord compression or neural foraminal narrowing. She also had a chest CT which showed marked progression of disease with a large mass invading the right aspect of the mediastinal with significant narrowing of the distal trachea (and possible invasion), encasement of the lateral aspect of the SVC, esophagus, and right SC vessels, as well as evidence of lymphagitic spread within the lungs. She received dexamethasone 10 mg IV X 1 and was admitted to the ICU for close monitoring to ensure airway stability prior to planned bronchoscopy/tracheal stenting in a.m. In [Location 31038] rigid bronch [2-13] vertebral issues, and no flex bronch-trach stent given nickel allergy(stent is nickel), therefore had balloon dilatation. Ortho-spine following---recommended brace, intervention only if neuro changes, no signs cord compression now. Past Medical History: PMHx: 1) Metastatic NSCLC: dx [7-15]; mets to brain (right parietal, left parietal, right pontine, right subfalcine), liver (caudate with biliary compression/dilitation), [Month/Year (2) 500] (spinal, left ileum, right proximal femur) -- s/p carboplatin & taxol X 2 cycles; Iressa X 5 weeks, Navelbine X 1 cycle (held last week for low blood counts) 2) Arthritis 3) Sciatica 4) MVP 5) Right hip pathologic fx s/p ORIF Social History: Former payroll assistant in a high school, 1-1.5 ppd x 20 yrs, social etoh, married, 2 daughters Family History: Mother and brother with DM and CAD Physical Exam: VS: 98 80 127/74 18 97% RA GEn: chronically ill-appearing, comfortable, without stridor HEENT: PERRL, EOMI, pale conjunctiva, + JVD to angle of jaw Cardiac: RRR, 2/6 SEM at apex Lungs: CTA bilaterally Abd: NABS, soft, nt/nd, no masses Extr: no c/c/e, 2+ DP bilaterally Pertinent Results: Labs on admission: [2154-2-7] 11:39PM PH-7.54* [2154-2-7] 11:39PM freeCa-1.10* [2154-2-7] 10:19PM GLUCOSE-192* UREA N-7 CREAT-0.5 SODIUM-138 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17 [2154-2-7] 10:19PM ALT(SGPT)-20 AST(SGOT)-17 LD(LDH)-315* ALK PHOS-114 TOT BILI-0.2 [2154-2-7] 10:19PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-2.9 MAGNESIUM-1.8 [2154-2-7] 10:19PM WBC-2.6# RBC-6.41# HGB-17.9# HCT-54.4# MCV-85 MCH-28.0 MCHC-33.0 RDW-15.4 [2154-2-7] 10:19PM NEUTS-83.7* LYMPHS-11.7* MONOS-4.1 EOS-0.2 BASOS-0.3 [2154-2-7] 10:19PM PLT COUNT-275# [2154-2-7] 10:19PM PT-13.4 PTT-30.0 INR(PT)-1.1 Brief Hospital Course: A/P: 51 yo female, with widely metastatic non-small cell lung cancer, presenting with tracheal narrowing and ?cord compression, no invervention tried, pt eventually made CMO and passed away. 1. Metastatic Lung cancer: On presentation, she had ?cord compression and tracheal narrowing. Steroids were initially administered for ?cord compression (no definite evidence on spinal MRI). She had balloon dilation of her trachea, but flexible and rigid bronchoscopy with stenting could not be performed. Rigid could not be performed [2-13] spinal disease, and flexible could not be performed [2-13] nickel allergy to stent that would be used. Radiation oncology was consulted for possible radiation of the trachea for the narrowing. The decision was made, however, to make the patient DNR/DNI and CMO (made by her family). She was then put on a morphine drip with the dose titrated up as necessary. Scolopamine patch was also used. She passed away on [2154-2-14] at 1:35 pm. As per her husband, autopsy will be performed. Medications on Admission: Meds on admission: Ativan MS [First Name (Titles) ] [Last Name (Titles) 31039] B12 [Name (NI) ] Sonata Celebrex ASA Percocet Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: metastatic lung cancer Discharge Condition: expired Discharge Instructions: none Followup Instructions: none	[ "197.1", "336.9", "198.3", "V10.11", "733.13", "424.0", "198.0", "519.1", "198.5", "197.7" ]	icd9cm	[ [ [] ] ]	[ "31.99" ]	icd9pcs	[ [ [] ] ]	4772, 4781	3516, 4556	303, 332	4847, 4856	2837, 2842	4909, 4916	2487, 2523		4743, 4749		4802, 4826		4582, 4587			4880, 4886									2538, 2818																							246, 265						360, 1907								4601, 4720							1929, 2357	2373, 2471
66,095	164,232	48555	Discharge summary	report	Admission Date: [2120-9-4] Discharge Date: [2120-9-11] Date of Birth: [2054-11-17] Sex: F Service: MEDICINE Allergies: Augmentin Attending:[First Name3 (LF) 1377] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Therapeutic Paracentesis ([2120-9-9]) Esophagogastroduodenoscopy ([2120-9-10]) History of Present Illness: 65 year old female with PMH of ETOH cirrhosis c/b ascites recently discharged from [Hospital1 18] on [9-1] after hospitalization for acute liver decompensation, present with thrombocytopenia, hematemesis, and epistaxis. During prior hospitalization, patient was evaluated for hepatic decompensation with bilirubin rising from 1.1 to 10.1 over 2 months. Although no definitive etiology was identified, an enterococcus UTI and hepatotoxic drugs were felt to be partially responsible. Of note, patient developed progressive thrombocytopenia while in the hospital with platelets falling from baseline of 148 on admission to 37 prior to discharge. She was discharged on 10 day course of macrobid for treatment of her UTI. Shortly after discharge from hospital on [9-1] had nausea with nonbloody emesis x 5. The next day, she continued to feel nausea with dry heaves accompanied by small amounts of bloody phlegm. On Monday, she developped vaginal spotting and frequent epistaxis which resolved with held pressure. She also noted loose dark, tarry stools x 2. She had slight dizziness with ambulation. Denies any syncope, chest discomfort, or worsened dyspnea from baseline. No confusion, abdominal discomfort, or other complaints. This morning, patient presented to her PCP who drew blood work. Platelets returned at 10,000 and she was referred to [Hospital1 18] ED for further evaluation. In ED, initial VS were T 98, BP 126/44, HR 72, RR 18, SpO2 98% on RA. Hepatology was consulted and recommended NG lavage which was not performed. Initial labs were remarkable for Hct at baseline of 26, platelets of 11,000 and worsening hyponatremia to 121 from baseline of 130s. Patient received Protonix 80mg IV and vitamin K 5 mg x 1. Two PIVs were inserted, and patient admitted to the MICU. ROS: pertinent +: see above; c/o significant chronic H/A, stable chronic exertional dyspnea pertinent -: denies any fevers, chest discomfort Past Medical History: Alcoholic cirrhosis with stage 4 fibrosis c/b ascites Heterozygotic hemochromatosis Hypertension Depression Alcohol abuse Social History: Currently living with granddaughter, retired -- ETOH: stopped drinking 1 month ago, used to drink 4-5 [Hospital1 17963] daily -- denies IVDA or tobacco Family History: Daughter with hemochromatosis. Denies family history of liver disease. Physical Exam: VS: Temp: BP:98/79 HR: 79 RR: 23 O2sat 97% RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, scleral icterus, small amt crusted blood around nares, MMM, op without lesions NECK: supple, JVP @ 10cm RESP: CTA b/l with good air movement throughout CV: RRR S1 and S2 wnl, grade II/VI systolic murmur best heard LSB ABD: +b/s, soft, nt, moderate amount ascites with shifting dullness to percussion EXT: trace edema b/l NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. RECTAL: trace guiac + per ED exam Pertinent Results: Labs On Admission: [2120-9-4] 11:10AM PT-21.1* PTT-37.3* INR(PT)-2.0* [2120-9-4] 11:10AM PLT SMR-RARE PLT COUNT-11# [2120-9-4] 11:10AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [2120-9-4] 11:10AM NEUTS-70 BANDS-4 LYMPHS-17 MONOS-6 EOS-2 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2120-9-4] 11:10AM WBC-14.8# RBC-2.41 HGB-9.0* HCT-26.0* MCV-108* MCH-37.6* MCHC-34.8 RDW-16.7* [2120-9-4] 11:15AM HAPTOGLOB-39 [2120-9-4] 11:15AM ALBUMIN-2.7* CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-1.3* [2120-9-4] 11:15AM LIPASE-26 [2120-9-4] 11:15AM ALT(SGPT)-69* AST(SGOT)-101* LD(LDH)-254* ALK PHOS-197* TOT BILI-10.2* [2120-9-4] 11:15AM GLUCOSE-103* UREA N-12 CREAT-0.8 SODIUM-121* POTASSIUM-3.1* CHLORIDE-88* TOTAL CO2-28 ANION GAP-8 [2120-9-4] 11:28AM LACTATE-2.3* . Labs On Discharge: [2120-9-11] 04:45AM BLOOD WBC-6.8 RBC-3.01* Hgb-10.4* Hct-30.3* MCV-101* MCH-34.6* MCHC-34.3 RDW-20.2* Plt Ct-74* [2120-9-11] 04:45AM BLOOD PT-24.7* PTT-44.8* INR(PT)-2.4* [2120-9-11] 04:45AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-128* K-3.2* Cl-94* HCO3-28 AnGap-9 [2120-9-11] 04:45AM BLOOD ALT-35 AST-67* LD(LDH)-245 AlkPhos-165* TotBili-6.1* [2120-9-11] 04:45AM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.9 Mg-1.3* . Urinalysis: [2120-9-5] 12:40AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.004 [2120-9-5] 12:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG [2120-9-5] 12:40AM URINE Hours-RANDOM UreaN-217 Creat-24 Na-<10 K-8 Cl-<10 [2120-9-5] 12:40AM URINE Osmolal-140 . Ascites: [2120-9-5] 03:34PM ASCITES WBC-125* RBC-5200* Polys-41* Lymphs-16* Monos-0 Eos-1* Mesothe-5* Macroph-37* [2120-9-5] 03:34PM ASCITES TotPro-1.3 Glucose-97 Albumin-LESS THAN . [2120-9-9] 04:43PM ASCITES WBC-250* RBC-[Numeric Identifier 54848]* Polys-48* Lymphs-16* Monos-21* Mesothe-3* Macroph-12* [2120-9-9] 04:43PM ASCITES TotPro-1.8 LD(LDH)-65 Albumin-LESS THAN . . CHEST (PORTABLE AP) Study Date of [2120-9-4] 5:59 PM Cardiac size is top normal. There is no evidence of pneumonia, CHF or aspiration. There is no pneumothorax or pleural effusion. . . CHEST (PORTABLE AP) Study Date of [2120-9-7] 10:33 PM Lordotic positioning. Low inspiratory volumes. Allowing for this, there is possible cardiomegaly and mild prominence of the upper zone vessels, without overt CHF. Minimal patchy opacity at both bases likely reflects atelectasis. No definite consolidation. No effusion. No pneumothorax detected. . . Cardiology Report ECG Study Date of [2120-9-4] 12:50:06 PM Sinus rhythm. Within normal limits. Compared to the previous tracing of [2120-8-26] leads V1-V2 are placed differently. Read by: [Last Name (LF) ],[First Name3 (LF) ] Intervals Axes Rate PR QRS QT/QTc P QRS T 65 164 92 458/466 76 -13 36 . . Procedure date Tissue received Report Date Diagnosed by [2120-9-6] [2120-9-9] [2120-9-10] DR. [Last Name (STitle) ] [Last Name (NamePattern4) 21496]/vf FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: CD2, CD3, CD5, CD7, CD10, CD19, CD20, FMC7, HLA-DR, Kappa, Lambda, CD45, CD23. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. CD45-bright, low side-scatter, lymphoid gated events are approximately 10% of total analyzed events. CD19 and CD20 co-expressing B cells comprise approximately 18% of lymphoid-gated events, and do not express aberrant antigens (CD5 or CD10). Surface immunoglobulin expression is extremely dim and clonality cannot be reliably assessed. T cells comprise 67% of lymphoid gated events, and express mature lineage antigens. INTERPRETATION Cell marker analysis demonstrates a non-specific T-cell dominant lymphoid profile. B-cell clonality could not be reliably assessed due to extremely dim expression of surface immunoglobulin light chain antibodies. Correlation with clinical findings is recommended. Flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. . . EGD Report Findings: Esophagus: Mucosa: Mild esophagitis was noted. Stomach: Mucosa: Patchy erythema and mosaic appearance of the mucosa with no bleeding were noted in the pylorus and whole stomach. These findings are compatible with gastritis and portal hypertensive gastropathy. No gastric or esophageal varices were seen. Duodenum: Normal duodenum. Other findings: There was a slightly raised appearance of the pyloric tissue. This was soft, it was easy to pass the scope, and flattened with insufflation. It likely represents a more prominent area of normal tissue. . Impression: Esophagitis in the lower third of the esophagus. Erythema and mosaic appearance in the pylorus and whole stomach compatible with gastritis and portal hypertensive gastropathy. No gastric or esophageal varices were seen. There was a slightly raised appearance of the pyloric tissue. This was soft, it was easy to pass the scope, and flattened with insufflation. It likely represents a more prominent area of normal tissue. Otherwise normal EGD to third part of the duodenum Recommendations: Recs per primary liver team. . . Brief Hospital Course: The patient is an 65 year old female with alcoholic cirrhosis c/b ascites who presented with thrombocytopenia, hematemesis, epistaxis, vaginal bleeding, melena, and BRBPR. . # Thrombocytopenia: Her thrombocytopenia may be due to liver disease, but the acute drop is more likely due to autoimmune causes, infection, or a medication effect. She did not receive Heparin during her last admission per POE orders, and platelets as low as 11 are unlikely to be due to HIT. Augmentin and Macrobid can cause thrombocytopenia, but the Macrobid was not started until after her platelets started to drop. She was given multiple platelet transfusions while in the MICU with continued thrombocytopenia. Further evaluation for HIT was not pursued. Hematology consult was called and recommended IVIg, flow studies for immunophenotyping, and H pylori serology. Her H pylori antibody testing was positive. The immunophenotyping was unremarkable. Her Plt count increased to the mid 60s after receiving IVIg, and had risen to the 70s by discharge. She did not require additional platelets after receiving IVIg. . # Hematemesis: The etiology of her initial hematemesis is unclear. It may have been [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear versus vomiting from epistaxis draining down the posterior pharynx. Variceal bleeding, portal gastropathy, and PUD were also possible. The patient's daughter reported that she had a recent EGD that was negative for varices, but documentation of this was not obtained during the MICU stay. She was given an IV PPI, but Octreotide gtt and antibiotics were not given. Her Hct slowly trended down in the MICU, requiring multiple RBC transfusions. Her bleeding slowed considerably and she remained hemodynamically stable. An EGD was performed on [2120-9-10] which showed only mild esophagitis and gastritis. She was continued on Pantoprazole 40 mg IV Q12H. On discharge, she was switched to Omeprazole 20 mg PO BID. . # Helicobacter pylori: Her H pylori serology was found to be positive and her EGD showed patchy gastritis and gastropathy. She was started on a 14 day course of Flagyl, Clarithromycin, and Omeprazole for eradication. Amoxicillin was avoided given the possible relationship of Augmentin with her recent thrombocytopenia. . # Hyponatremia: She presented with Na of 121 from baseline of 130s with no signs of altered mental status. Her Na improved and remained fairly stable in the mid 120s. Lasix and Spironolactone were restarted on [2120-9-6] without significant electrolyte abnormalities. . # ESLD: Diagnostic paracentesis was negative for SBP. Her MELD was 23 on transfer from the ICU and remained stable. She had significant ascites which is increasingly uncomfortable for her. She had a therapeutic tap for 4L on [2120-9-9] which had [Numeric Identifier 54848] RBCs, but only 250 WBCs and 48% polys. Her diuretics were restarted on [2120-9-6] with Lasix 40 mg PO daily and Spironolactone 50 mg PO daily. She tolerated these well. . # Epistaxis: She continued to have epistaxis overnight after admission. ENT was consulted and cauterized her left nostril with Surgicel placement. Packing was not required. The patient was written for PRN oxymetazoline spray. Her epistaxis largely resolved after cautery by ENT. She was continued on epistaxis precautions (No nose-blowing, no straining, no heavy lifting). . # Hypertension: Her BP remained stable in 130s-140s. Her Atenolol was held in the setting of her recent bleeding, but restarted at discharge. . Medications on Admission: furosemide 40 mg Tablet daily spironolactone 50 mg Tablet daily atenolol 50 mg Tablet daily folic acid 1 mg Tablet daily thiamine HCl 100 mg Tablet daily multivitamin daily Macrobid 100 mg PO twice a day for 10 days Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain: Do not take more than [2109] mg in 24 hours. 6. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 7. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:15 Tablet(s) Refills:0 9. Outpatient Lab Work Please draw blood on [2120-9-16] and check CBC/diff, Chem10, PT, PTT, INR, AST, ALT, and TBili. Please forward results to Dr [First Name4 (NamePattern1) 8369] [Last Name (NamePattern1) ] (phone: [Telephone/Fax (1) 20035], fax:[Telephone/Fax (1) 40472]). 10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:28 Tablet(s) Refills:0 11. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:28 Tablet(s) Refills:0 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Thrombocytopenia Ascites Helicobacter pylori Infection Secondary Diagnoses: Alcoholic Cirrhosis Hypertension 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 a low platelet count and bleeding from multiple parts of your body. You were initially sent to the Intensive Care Unit, where you were given transfusions of blood, platelets, and clotting factors. Your blood pressure and other vital signs remained stable, and you were transferred to the Liver service. You received additional platelet transfusions and evaluation of your liver disease. You were also seen by the Hematology department to help determine why your platelets were low. They recommended starting treatment with intravenous immunoglobulins. After receiving this treatment, your platelet count started increasing, and you did not require any additional platelet transfusions. The bleeding stopped, and your blood counts also started increasing. Since your low platelets may have been caused by taking the antibiotic Augmentin, you should avoid taking this medication in the future unless absolutely necessary. While on the Liver service, you had a therapeutic paracentesis to remove ascites fluid from your abdomen and help make you more comfortable. Several liters of fluid were removed. The fluid was tested and showed no evidence of infection. Your medications were adjusted to slow the further accumulation of fluid in your abdomen. You also had an upper endoscopy (EGD) to check for possible sources of bleeding in your esophagus, stomach, and the first part of the small intestine. The endoscopy showed some inflammation of the esophagus and stomach, but no major source of bleeding. A blood test was also sent which showed possible infection with bacteria called Helicobacter pylori, which can lead to ulcers and inflammation in the stomach. You were started on medications to treat this infection and eradicate the bacteria. START: Furosemide 40 mg by mouth daily START: Spironolactone 100 mg by mouth daily START: Omeprazole 20 mg by mouth twice daily START: Metronidazole 500 mg by mouth twice daily for 14 days START: Clarithromycin 500 mg by mouth twice daily for 14 days START: Lorazepam 0.5 mg by mouth at bedtime as needed for insomnia. Do not drive or operate machinery while taking this medication since it can make you sleepy and slow your reaction times. You should continue taking your other medications as indicated on your discharge medication sheet. You have several followup appointments scheduled as indicated below. You will need to have blood drawn for lab work prior to your visit with your PCP on [Name9 (PRE) 766]. A prescription has been provided which you can use for this lab work. Followup Instructions: You have a followup appointment scheduled with your PCP on [Name9 (PRE) 766] [9-16] at 12:30pm. You should review your lab results at this visit. The clinic can be reached at [Telephone/Fax (1) 20035] if you have any questions or concerns. You have a visit scheduled with Dr [Last Name (STitle) 696] in a few weeks. Department: TRANSPLANT When: TUESDAY [2120-10-1] at 9:40 AM With: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 3688] [Name8 (MD) ], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379]	[ "535.50", "401.9", "530.10", "276.1", "572.3", "578.1", "537.89", "278.00", "784.7", "275.01", "626.8", "287.49", "303.93", "599.0", "041.04", "571.2", "789.59", "578.0", "414.01", "286.9", "572.8", "041.86", "311" ]	icd9cm	[ [ [] ] ]	[ "54.91", "21.03", "45.13", "99.14" ]	icd9pcs	[ [ [] ] ]	13998, 14004	8672, 12261	283, 372	14177, 14177	3311, 3316	16943, 17758	2692, 2765		12528, 13975		14025, 14100		12287, 12505			14328, 16920									2780, 3292			14121, 14156																				231, 245				4200, 8649		400, 2356								3330, 4181	14192, 14304						2378, 2502	2518, 2676

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